A 68-year-old woman is brought to the emergency department due to worsening diarrhea and abdominal pain. The patient has had watery diarrhea every 3-4 hours for the past 2 days, and today she also had mild nausea but has been tolerating oral fluids. The patient was discharged from the hospital 10 days ago after treatment for an Escherichia coli urinary tract infection. Other medical conditions include hypertension, type 2 diabetes mellitus, hyperlipidemia, and chronic kidney disease.
Temperature is 39.3 C (102.7 F), blood pressure is 90/60 mm Hg, and pulse is 120/min. On examination, the patient appears lethargic. There is moderate abdominal distension and diffuse tenderness but no rebound tenderness or rigidity.
Laboratory results are as follows:
CT scan of the abdomen reveals an 8-cm dilation of the ascending and transverse colon with mucosal thickening. Stool samples for analysis are obtained.
In addition to IV fluids, which of the following is the most appropriate next step in management of this patient?

Question

A 68-year-old woman is brought to the emergency department due to worsening diarrhea and abdominal pain.  The patient has had watery diarrhea every 3-4 hours for the past 2 days, and today she also had mild nausea but has been tolerating oral fluids.  The patient was discharged from the hospital 10 days ago after treatment for an Escherichia coli urinary tract infection.  Other medical conditions include hypertension, type 2 diabetes mellitus, hyperlipidemia, and chronic kidney disease.
Temperature is 39.3 C (102.7 F), blood pressure is 90/60 mm Hg, and pulse is 120/min.  On examination, the patient appears lethargic.  There is moderate abdominal distension and diffuse tenderness but no rebound tenderness or rigidity.
Laboratory results are as follows:
 CT scan of the abdomen reveals an 8-cm dilation of the ascending and transverse colon with mucosal thickening.  Stool samples for analysis are obtained.
In addition to IV fluids, which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_960a_caea_853d_01cd5f1df0b5_MD0002_00 This patient has fulminant Clostridium difficile infection, defined by the presence of hypotension, shock, or ileus or toxic megacolon on imaging (as in this patient). Patients with fulminant disease should be treated with high-dose oral vancomycin (ie, 500 mg 4 times daily) and intravenous (IV) metronidazole. If ileus is suspected, oral vancomycin can be switched to rectal vancomycin. Patients with signs of toxic megacolon, impending perforation, or septic shock require immediate surgical evaluation as they may benefit from subtotal colectomy or diverting loop ileostomy with colonic lavage. toxic megacolon Guidelines indicate that patients with non-fulminant primary infection should be treated with oral vancomycin or fidaxomicin for 10 days, regardless of whether the infection is severe (eg, white blood cell count ≥15,000/mm³ or creatinine >1.5 mg/dL) or non-severe. ³ (Choices B and C) Although admission to the intensive care unit, serial imaging, and high-dose vancomycin are appropriate, IV metronidazole is required in fulminant disease. Routine rectal tube placement is not recommended. IV corticosteroids are commonly used for ulcerative colitis or Crohn disease flares but are not indicated for treatment of C difficile. (Choice D) Oral vancomycin, not fidaxomicin, is indicated in conjunction with IV metronidazole for fulminant disease. (Choice E) Intracolonic vancomycin can be used in patients who are intolerant of oral therapy or in those with profound ileus preventing oral therapy from reaching the colon. This patient does not have evidence of an ileus and should receive oral vancomycin. Additionally, surgical evaluation in a patient with megacolon is required due to risk of colonic perforation. Educational objective: Fulminant Clostridium difficile infection is characterized by hypotension, shock, or the presence of ileus or toxic megacolon. Patients with fulminant disease should be treated with high-dose oral vancomycin and intravenous metronidazole. Patients with signs of toxic megacolon, impending perforation, or septic shock require immediate surgical evaluation as they may benefit from subtotal colectomy. __________ References: Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). (http://www.ncbi.nlm.nih.gov/pubmed/29462280)

A 68-Year-Old Woman Is Brought to the Emergency Department Due