A 67-year-old man comes to the emergency department due to abdominal cramps, diarrhea, and fever that started 3 days ago. The patient initially had 3 or 4 stools per day for 2 days but, today, had 7 watery stools; the stools have not had gross blood or mucus or black discoloration. The patient has also had generalized weakness and malaise. Two weeks ago, he was treated with oral antibiotics for acute cellulitis. Since then, the patient's appetite has decreased, and he has had mild bloating. He has no history of recent travel, unusual foods, or sick contacts with similar symptoms. Other medical conditions include type 2 diabetes mellitus, hypertension, and hyperlipidemia. Temperature is 38.7 C (101.7 F) , blood pressure is 110/70 mm Hg, and pulse is 95/min. Physical examination shows moderate abdominal tenderness. The cellulitis has resolved. Leukocytes are 26,000/mm³, serum creatinine is 1.9 mg/dL (increased from 1.2 mg/dL 2 months ago) , and serum albumin is 2.9 g/dL. The patient does not want to be admitted to the hospital and would like to be treated as an outpatient.
Stool PCR testing for Clostridioides difficile PCR is positive. The patient is adamant about going home. He is given a prescription for oral fidaxomicin and discharged home against medical advice. The patient returns 2 days later feeling much worse. He says, "I just got the pills today and have taken only one dose." Temperature is 38.9 C (102 F) , blood pressure is 90/60 mm Hg, pulse is 114/min, and respirations are 24/min. The patient appears uncomfortable. The abdomen is distended, and bowel sounds are decreased; there is tenderness and guarding to palpation. CT scan of the abdomen shows diffuse colonic wall thickening and dilation. In addition to the appropriate oral pharmacotherapy, what is the most appropriate next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf90_2d2f_8f63_d9358770af6c_MD0005_00 This patient with PCR-confirmed Clostridioides difficileinfection (CDI) had evidence of severe infection (ie, leukocytes >15,000/mm³and serum creatinine >1.5 mg/dL) prior to leaving the hospital against medical advice. Now, after inadequate treatment (eg, only a single dose of oral antimicrobial therapy), he has findings (eg, hypotension, colonic dilation) concerning for progression to fulminant infection with possible toxic megacolon. A minority of patients with CDI develop severe complications such as toxic megacolon, which is characterized by nonobstructive colonic dilation. Toxic megacolon generally presents with the following: Severe systemic toxicity (eg, fever, hypotension, tachycardia) Abdominal distension and pain (diarrhea may cease due to lack of colonic motility) Leukocytosis (usually >15,000/mm³) Radiographic evidence of large-bowel dilation (eg, >6 cm in colon, >9 cm in cecum) Treatment of fulminant infection includes bowel rest, nasogastric tube placement, and aggressive antibiotic therapy against C difficile, which may include the addition of vancomycin enemas if ileus is present. In addition, surgical consultation should be initiated; surgical intervention (eg, colectomy) may be necessary if the patient develops peritonitis or colonic necrosis/perforation or if his condition clinically deteriorates despite medical therapy (Choice D). (Choice A) Colonoscopic decompression may be used in the management of sigmoid volvulus, which typically causes a single, closed loop of dilated bowel (vs colonic wall thickening and dilation) on CT scan. Colonoscopy is generally avoided in toxic megacolon because air insufflation and instrumentation within the inflamed, dilated colon carry a high risk of perforation. (Choice B) Intravenous corticosteroids are commonly used to treat flares of inflammatory bowel disease (IBD) and even IBD-induced toxic megacolon. However, they are not typically used in the management of toxic megacolon due to CDI; such use may be associated with increased mortality. (Choice C) Intravenous vancomycin therapy is not used in the management of CDI. In contrast, oral vancomycin is used; its poor absorption by the gastrointestinal tract allows it to be delivered to the colon, where it can treat C. difficile. If ileus is present, vancomycin enemas may be used. Educational objective: Clostridioides difficile infection can cause toxic megacolon, which is characterized by nonobstructive colonic dilation, severe systemic toxicity, abdominal pain and distension, and leukocytosis. Toxic megacolon requires aggressive antibiotic therapy, as well as surgical consultation. Surgical intervention may be necessary if the patient develops peritonitis or colonic necrosis/perforation or if the patient's condition clinically deteriorates despite medical therapy. References: ACG clinical guidelines: prevention, diagnosis, and treatment of Clostridioides difficile infections. (http://www.ncbi.nlm.nih.gov/pubmed/34003176) Toxic megacolon: background, pathophysiology, management challenges and solutions. (http://www.ncbi.nlm.nih.gov/pubmed/32547151) Clostridium difficile disease: diagnosis, pathogenesis, and treatment update. (http://www.ncbi.nlm.nih.gov/pubmed/28267992)

A 67-Year-Old Man Comes to the Emergency Department Due to Abdominal