An elevated white blood cell count may be an important clue to impending fulminant C. difficile colitis. The rapid elevation of the peripheral white cell count (commonly as high as 30,000 to 50,000) with a significant excess of bands and sometimes more immature forms often precedes hemodynamic instability and the development of organ dysfunction. Even in patients who are mildly symptomatic for an extended period, sudden and unexpected progression to shock may occur. It is difficult to predict those patients who may not respond to medical treatment. Hence, early warning signs such as a leukemoid reaction may be invaluable.
Hypotension is a late finding and can be resistant to vasopressor support. Abdominal signs range from distention to generalized tenderness with guarding. Colonic perforation is usually accompanied by abdominal rigidity, involuntary guarding, rebound tenderness, and absent bowel sounds. Free air may be revealed on abdominal radiographs. Any suspicion of perforation in this setting should prompt immediate surgical consultation. Death generally occurs before free air and perforation can occur. In one study, contrary to most other literature, perforation was found to be rare (22).
Abdominal radiography may reveal a dilated colon (>7 cm in its greatest diameter), consistent with toxic megacolon. Patients with megacolon may have an associated small bowel ileus with dilated small intestine on plain abdominal radiographs, with air-fluid levels mimicking small intestinal obstruction or ischemia. CT without contrast and endoscopy can quickly diagnose or at least strongly suggest fulminant C.difficile colitis. CT scan findings include evidence of ascites, colonic wall thickening and/or dilatation. These findings may prove helpful in categorizing the severity of the colitis.
More aggressive intervention in medically unresponsive patients, including rapid identification of patients failing to respond to medical therapy, is crucial to a positive outcome, and early surgical intervention should be done in this group (Figures 1-3).
It is important that everyone involved with patient care in hospitals, nursing homes, and skilled nursing facilities be educated about the organism and its epidemiology, rational approaches to the treatment and care of patients with C. difficile diarrhea, the importance of hand washing between contact with patients, the use of gloves when caring for a patient with C. difficile diarrhea, and the avoidance of the unnecessary use of antimicrobials.
Conclusion
Recent years have raised concerns over rising incidence and serious complication rates of CDAD in North American hospitals (22,23). The Canadian Medical Association journal published a report in 2004 detailing an outbreak of CDAD involving several hospitals in Montreal. The introduction of new hypervirulent and highly transmissible strains of C. difficile has been postulated as the possible cause for the outbreak (24). A deteriorating infrastructure, inadequate infection control practices, the increasing number of debilitated patients, an aging population, and hypervirulent strains were all felt to be likely contributors to recent outbreaks in Canada (25).