Clinical Manifestation of <i>C Difficile</i> Infections

Peter Salgo, MD: Hello, and thank you for joining us for this MD Magazine^® Peer Exchange on updating best practices in the diagnosis and treatment of Clostridium difficile [C. diff] infections. Clostridium difficile is a common cause of infectious diarrhea. It is associated with a substantial clinical and economic burden across the entire spectrum of healthcare. Advances in understanding the optimal diagnosis and management of C. diff infections over the past several years led to notable clinical practice guideline revisions in the 2017 recommendations. This MD Magazine^® Peer Exchange panel of experts will walk through some of the most significant guideline changes. We’re also going to discuss how they translate to what you should do differently in everyday clinical practice.

I’m Dr Peter Salgo. I’m a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons. I’m an associate director of Surgical Intensive Care at New York-Presbyterian Hospital. I see far too much C. diff, so let’s figure out how to deal with this stuff.

Joining me for this discussion are: Dr Dale Gerding, a research physician at the Edward Hines Jr. Veterans Administration Hospital of Hines, Illinois; Dr Yoav Golan, an attending physician from Tufts Medical Center in Boston, Massachusetts; and Dr Darrell Pardi, professor of medicine and vice chair of the Division of Gastroenterology and Hepatology at the Mayo Clinic College of Medicine and Science and associate dean of the Mayo Clinic School of Graduate Medical Education in Rochester, Minnesota. I want to thank all of you for joining us. Let’s get going over here.

I guess the basic things are basic. Why don’t we start with C. diff itself? What do clinicians look for? How does it present?

Yoav Golan, MD: Well, thanks for the question. It’s a pleasure to be here. I think it’s important for us to realize that C. diff can present in both systemic symptoms and localized gastrointestinal symptoms. Obviously, the main symptom is diarrhea. It is important to remember that diarrhea is defined not just by the consistency of the stool but also by the frequency of the stool. You need to have enough diarrhea to be considered as someone who has C. diff—so, at least 3 episodes, if not more, of loose stools a day. You will also have some cramps, obviously, and even belly pain.

Peter Salgo, MD: I get this question all the time. "My gosh, this patient has 82 different antibiotics and he or she is getting cramps. The white count is 50,000, but there’s no stool. Is this C. diff?” Based on your definition, it’s not.

Yoav Golan, MD: Well, you have to have diarrhea in order to have C. diff, unless you have such complete C. diff that you have complete ileus. In this case, you may not have any bowel movements. But in this case, people are usually very, very sick and have many other symptoms.

Peter Salgo, MD: So, that’s not a secret anymore?

Yoav Golan, MD: I would say that if you have no diarrhea, and you’re not very sick and have ileus, then you probably don’t have C. diff.

Peter Salgo, MD: So, if you go to the nurse, as we often do, and ask, “What does the stool sample show,” because we think it’s C. diff, and the nurse says, “I haven’t gotten any stool,” that’s not C. diff?

Dale N. Gerding, MD: It could be C. diff.

Peter Salgo, MD: I knew you were going to say that.

Dale N. Gerding, MD: The high white count is really the key differentiator in someone like that. And when you have unexplained very high leukocytosis, that may be reason enough to look for C. diff.

Peter Salgo, MD: OK. Again, a white count of 50,000. But he said if there’s no diarrhea, this can’t be C. diff.

Dale N. Gerding, MD: He didn’t say that.

Peter Salgo, MD: Then tell me what he said.

Dale N. Gerding, MD: He said there’s an exception to that. When patients have high leukocytosis and have what’s called an “adynamic ileus,” then they can have C. diff. In fact, they might be at greater risk of mortality when they aren’t passing stool.

Peter Salgo, MD: That’s where I was going. Not every C. diff patient is going to present with explosive diarrhea, right then, up front.

Darrell S. Pardi, MD: But I think it’s very important to emphasize the point that both Yoav and Dale have made: If you don’t have diarrhea, and you have C. diff, you should be very sick.

Peter Salgo, MD: So, somebody who doesn’t look sick but has a white count and no diarrhea is less likely? By the time they get to that nondiarrheal stage, they are, to use a phrase we use, “sick as dirt,” and that’s different.

Yoav Golan, MD: Well, if you look at the guidelines that we’ll discuss later, this is one of the defining symptoms of a very severe episode.

Transcript edited for clarity.