ESTES PARK, Colo. — One of the major diagnostic challenges in community-acquired Clostridium difficile–associated disease is that it can present without diarrhea or a history of recent antibiotic use—and with symptoms closely mimicking acute appendicitis.
“I have actually seen a patient go to appendectomy when in fact the problem was unrecognized community-acquired C. difficile–associated disease,” Dr. Mary Bessesen recalled at a conference on internal medicine sponsored by the University of Colorado.
This is a high-stakes diagnostic dilemma. Patients with community-acquired C. difficile–associated disease (CDAD) who present without diarrhea are at the severe end of the disease spectrum. Moreover, if they present with ileus they can't produce a specimen for diagnostic testing, said Dr. Bessesen, chief of infectious diseases at the Denver VA Medical Center.
“These are the most difficult and lethal cases because the CDAD is not recognized and the patients are so ill,” she said.
The ileus can range in severity from mild to toxic megacolon requiring surgery. Under the latter circumstances, rectal vancomycin can be colon-saving. It is given by inserting a Foley catheter into the rectum, inflating the balloon, instilling 500 mg of intravenous vancomycin in 100 cc of normal saline, then clamping the catheter. This is repeated every 6 hours.
The negative predictive value of most lab tests for C. difficile is so poor that often the best strategy when suspicion runs high is to treat empirically for the infection while waiting 5-7 days for the results of culture, the most sensitive test available.