Pseudomembranous colitis
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Pseudomembranous colitis, sometimes called antibiotic-associated colitis, is a swelling and irritation of the large intestine or colon. It is caused by an excess of the bacterium Clostridioides difficile, also known as C. diff, commonly induced by using antibiotics.
Antibiotics stimulate the bacterium Clostridium difficile (C. diff) to proliferate and infect the gut lining, resulting in inflammation. Pseudomembranous colitis is more common in adults over the age of 65. It is also frequently associated with a recent hospital stay. Treatments for this condition may include medication, fecal transplant, or surgery.
Symptom
Most people with pseudomembranous colitis experience symptoms 5 to 10 days after beginning antibiotic treatment. It can last for several months or longer after stopping the treatment.
Common symptoms may include:
- Watery stools
- Tenderness and pain in the stomach
- Fever
- Stomach cramps
- Loss of appetite
- Pus or mucous in the feces
- Nausea
- Dehydration
- Sepsis, in severe cases
In case you develop diarrhea after taking antibiotics, it is advisable to contact your healthcare provider, regardless of the severity of the symptoms. Moreover, if you experience severe diarrhea along with fever, painful stomach cramps, or if you observe blood or pus in your stool, it is important to consult your healthcare provider immediately.
Causes
The natural balance of bacteria in the colon is usually well-maintained by the body. However, taking antibiotics or other medicines can interfere with this balance. Pseudomembranous colitis can occur when certain bacteria, particularly C. difficile, grow rapidly and outcompete other bacteria that normally keep them in check. The harmful toxins produced by C. difficile can reach levels high enough to cause damage to the colon.
Pseudomembranous colitis can be caused by various antibiotics, but some antibiotics are more commonly associated with the condition than others. These include fluoroquinolones (e.g. ciprofloxacin and levofloxacin), penicillins (e.g. amoxicillin and ampicillin), clindamycin, and cephalosporins (e.g. cefixime).
A new strain of C. difficile has been identified that is more aggressive than other strains and produces a higher amount of toxins. This strain might have higher resistance to some medications, and it has been found in individuals who have not been hospitalized or received antibiotics.
Other causes of pseudomembranous colitis may include:
- Colon-related diseases: Some colon disease, such as ulcerative colitis or Crohn’s disease, can put people at risk for pseudomembranous colitis.
- Community-acquired C. difficile: C. difficile spores have strong resistance against various disinfectants and can spread from the hands of healthcare workers to patients. Recently, there has been an increase in cases of C. difficile infections among people who do not have any identifiable risk factors, including those who have not been in contact with healthcare facilities or taken antibiotics. Such cases are referred to as community-acquired C. difficile.
- Chemotherapy drugs: The administration of chemotherapy drugs for cancer treatment can potentially disturb the usual equilibrium of bacteria present in the colon.
Risk factors
There are several factors that affects one’s risk of developing pseudomembranous colitis, such as:
- Ageing, particularly after the age of 65
- Being a resident of a nursing home
- Having been in the hospital for an extended period
- Under antibiotics medication
- Having a compromised immune system, due to another serious medical condition
- Undergoing chemotherapy for cancer
- Having intestinal surgery
- Having inflammatory bowel disease, colorectal cancer, or other colon-related diseases
Diagnosis
Diagnosis of pseudomembranous colitis may require several tests and procedure. It may include:
- Blood tests. An unusually high white blood cell count, known as leukocytosis, may be revealed through these tests. This can be an indication of an infection like C. difficile if there is also the presence of diarrhea.
- Imaging tests: An abdominal X-ray or an abdominal computed tomography (CT) scan can check for issues like toxic megacolon or colon rupture in severe cases.
- Stool sample: Feces or stool sample is tested in a laboratory for toxins produced by C. diff. The bacterium can be detected using a variety of stool sample techniques.
- Colonoscopy or sigmoidoscopy: A thin, flexible tube (sigmoidoscope) is used to allow the doctor to observe the interior of the large intestine. The test will check for elevated, yellow plaques called lesions, as well as swelling which could indicate pseudomembranous colitis.
Treatment
Several treatments are available to resolve pseudomembranous colitis. Symptoms of pseudomembranous colitis may improve within a few days of starting treatment. Treatments may include one or more of the following:
- Stopping the antibiotic or other medication: The first thing the doctor may advise is to discontinue the drug that caused the pseudomembranous colitis infection. This action may be enough to heal the illness, or at the very least, alleviate symptoms.
- Antibiotic effective against C. difficile: If symptoms of C. difficile persist, a different antibiotic may be prescribed by your healthcare provider to restore the balance of healthy bacteria in your colon. Antibiotics can be administered orally, intravenously or through a nasogastric tube. The specific antibiotic chosen may depend on the severity of the condition and the patient’s ability to tolerate the medication. Vancomycin and fidaxomicin are commonly used, but if these are not available or not well-tolerated, metronidazole may be an alternative. For severe cases, a combination of oral vancomycin and intravenous metronidazole or a vancomycin enema may be prescribed.
- Fecal microbial transplantation (FMT): In cases where the infection is severe or has recurred multiple times, doctors may recommend a treatment called fecal microbiota transplant (FMT). FMT involves transplanting stool from a healthy donor to help restore a healthy balance of bacteria in the colon. The donor stool can be administered through a nasogastric tube, inserted directly into the colon, or taken in capsule form. In some cases, doctors may use a combination of antibiotics and FMT to treat the infection.
Treating recurring pseudomembranous colitis:
Pseudomembranous colitis recurs in up to 20% of those who have been treated. The chances of having another recurrence of increases with each recurrence. Treating pseudomembranous colitis has become challenging with the emergence of new, more aggressive strains of C. diff. Treatment for recurring pseudomembranous colitis may include:
- Repeat antibiotics: If the condition recurs, the doctor will give another antibiotic dose. The course of the treatment may be longer depending on the patients’ response to the treatment.
- Bezlotoxumab: Bezlotoxumab, a human monoclonal antibody, has been given the green light by the FDA for use in reducing the risk of C. difficile infection returning. Its combination with antibiotics has been found to be highly effective in reducing the likelihood of recurrence. Despite this, the cost of the drug may impede its widespread use.
- Fecal microbial transplantation (FMT): The treatment involves receiving a capsule containing sterilized and healthy stool, which can be administered through a tube inserted through the nose into the stomach or directly to the colon.
- Surgery: When someone’s organs start to fail, or their colon ruptures and the lining of their abdominal wall becomes inflamed (peritonitis), surgery may be considered as an option. The typical surgery for this situation involves the removal of either all or part of the colon, which is known as total or subtotal colectomy. However, a newer procedure known as loop ileostomy and colonic lavage has been developed, which is less invasive and has shown promising results. This procedure involves the creation of a loop of colon using laparoscopic techniques and cleaning it.
