CDI is one of the main causes of healthcare associated infection and rising health care costs worldwide.1
The risk factors have been clearly highlighted in many previous studies of which prior hospital admission and antibiotic use are the most common. C difficile
is an anaerobic Gram positive bacillus and its presentation can range from asymptomatic carrier state to life threatening pseudomembranous enterocolitis.2
Fulminant CDI is increasing with an overall rise in mortality from CDI. The importance of patients developing CDI in the community is increasingly recognised even in healthy young individuals.3,8
Occurrences of CDI outside health care settings and in the paediatric population are the new emerging challenges.4
The infection is also occurring in the absence of the traditional risk factors. Use of the common gastric pH altering drugs and drugs delaying gut motility have been implicated more strongly in recent times,4
although the exact mechanism is unclear.
The pathological process of CDI involves colonisation with spores which germinate and multiply in the colon. The two toxins produced by C difficile
are toxins A and B which induce damage to the gut tissue and disrupt the cell-to-cell tight junctions.9
A new subtype of polymerase chain reaction (PCR) ribotype 027 has been isolated first in Canada, North America and later in Europe.10
In the UK, over 50% of CDI isolates typed by the reference laboratory between 1995 and 2003 were of ribotype 01.5,10
An analysis of 881 C difficile
isolates from all over England in 2007 revealed ribotype 027 strain in 25% of them.11
Newer studies specifically showed patients have a longer interval between admission and onset of diarrhoea and follows increased exposure to quinolones with ribotype 027 subtype. It is characterised by the production of binary toxin in addition to toxins A and B, needs a small inoculum, and has higher sporulation levels.5
The incidence of pseudomembranous colitis is up to 3% and is on the rise with the rapidly increasing prevalence of CDI.4
Toxic megacolon is characterised by the presence of toxicity and colonic distension (>6 cm). In a cohort of 70 patients with toxic megacolon, CDI accounted for 30% of cases.12
This is a highly lethal condition with a mortality nearing 30% and the management is urgent subtotal colectomy to prevent perforation and sepsis.12
Elective orthopaedic patients contracting CDI is not uncommon; this has been described traditionally after using cephalosporins and clindamycin for surgical prophylaxis and with prolonged period of prophylaxis.7
There is a positive correlation between the delay in diagnosis and the severity of illness.6
A severe infection in patients with CDI is described as a fever of 38.5°C and a WCC of 17.5×109
/l, or a WCC of 20×109
In the previous series, the mean duration of onset of diarrhoea in elective surgical patients was 7 days.6,7
Our patient had no risk factors and developed ileus and diarrhoea within 48 h of surgery. The postoperative pain and inflammation following knee replacement misdirected the clinician towards a septic knee, thereby delaying diagnosis and increasing the severity of sepsis. The patient was hypokalaemic at 3.0 mmol on the first postoperative day, prompting the surgeons to assume this was an ileus. The patient was started on metronidazole but he did not improve, and the fact that his subtype was of the hypervirulent ribotype 027 explains the rapid deterioration of his general condition.
This is a rare occurrence in a relatively healthy patient admitted for a routine total knee replacement. CDI is a differential diagnosis even in patients without risk factors, who are admitted from the community and develop sepsis within 48–72 h of elective surgery. Prompt suspicion, sampling, medical management and involvement of surgeons with critical care is essential, even with which this group has poor outcomes. The in-hospital mortality rate following fulminant CDI is around 50%.13
In spite of nationwide guidelines, alerts, infection control policies and barrier nursing, C difficile
is a new emerging threat all over the world.
- Clostridium difficile infection (CDI) can be contracted in the community and outside all healthcare settings without the risk factors.
- Clostridium difficile ribotye 027 is a hypervirulent strain which causes fatal CDI more frequently.
- Life threatening CDI is possible in an apparently healthy patient admitted in the hospital for a routine procedure within 48–72 h.
- Toxic megacolon should be suspected without any delay, as the extent of delay significantly affects the prognosis.
- Regular metronidazole administration may not be enough; oral vancomycin is more likely to stop the progress of fulminant CDI if infection with ribotype 027 is suspected.