A 67-year-old woman is hospitalized for sepsis secondary to a urinary tract infection. Medical history is significant for hypertension, type 2 diabetes mellitus, ischemic stroke, and neurogenic bladder with chronic indwelling Foley catheter. The patient is admitted to the intensive care unit and treated with intravenous fluids and broad-spectrum antibiotics. Blood and urine cultures grow Escherichia coli that are sensitive to all tested antibiotics. The patient's condition gradually improves with the treatment, and antibiotics are changed to oral ciprofloxacin on the 3rd day of hospitalization. On the 7th day of hospitalization, the patient progressively becomes confused, and she also has 6 watery bowel movements with lower abdominal pain. Temperature is 38 C (100.4 F), blood pressure is 111/89 mm Hg, and pulse is 108/min. The abdomen is soft and mildly tender in the left lower quadrant with normoactive bowel sounds. There is no guarding or rebound tenderness. Chest x-ray reveals no new infiltrates. Laboratory evaluation shows a white blood cell count of 14,200/mm³ compared to 8,700/mm³ 2 days earlier. A repeat urinalysis shows occasional yeasts. Which of the following is the best next step in management of this patient?

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11ec25c8_d3e2_8ffe_bc81_777941591593_MD0003_00 This patient presents with new-onset white blood cell elevation and confusion, in association with recent antibiotic use, watery diarrhea, and mild abdominal tenderness, suggesting possible Clostridioides (formerly Clostridium) difficile infection (CDI). Risk factors for CDI include recent hospitalization, advanced age, or antibiotic use (most commonly fluoroquinolones, penicillins, cephalosporins, and clindamycin). Unexplained leukocytosis in hospitalized patients should raise suspicion for CDI, even without diarrhea. CDI can range from mild watery diarrhea to fulminant colitis with toxic megacolon. Diagnosis is usually confirmed with stool studies for C difficile toxin (eg, polymerase chain reaction). Treatment options for initial infection include oral vancomycin or fidaxomicin. Patients with fulminant disease (eg, hypotension, ileus, megacolon) should be treated with high-dose oral vancomycin and intravenous metronidazole; if ileus is present, vancomycin may be given rectally. (Choice A) Asymptomatic funguria is common in patients with longstanding indwelling urinary catheters, but actual symptomatic fungal urinary tract infections are unusual. In cases of uncomplicated asymptomatic funguria, catheters can be replaced, but empiric antifungal agents are generally unnecessary. (Choice B) Aminoglycosides (eg, gentamicin) treat resistant gram-negative bacteria. However, this patient was improving clinically and had Escherichia coli sensitive to ciprofloxacin. This patient's antibiotic use and gastrointestinal symptoms make C difficile colitis more likely than worsening urinary tract infection. (Choice D) In patients with CDI, inciting antibiotics (eg, ciprofloxacin) should be stopped as soon as possible, with patients switched to antibiotics that are less frequently associated with CDI. Intravenous vancomycin is used to treat resistant gram-positive organisms. However, this would not treat her E coli bacteremia. In addition, intravenous vancomycin is not excreted into the colon and is not effective against CDI. (Choice E) Surgical consult is required in patients with fulminant CDI (eg, hypotension, ileus, toxic megacolon). However, this patient has mild to moderate colitis without acute peritoneal signs on examination. Educational objective: Clostridioides (formerly Clostridium) difficile colitis should be suspected in any patient who has been on antibiotics and has diarrhea and/or abdominal pain. Stool studies for C difficile toxin should be sent to confirm the diagnosis. Treatment options for the initial episode include oral vancomycin or oral fidaxomicin. Patients with fulminant disease (eg, hypotension, ileus, megacolon) should be treated with high-dose oral vancomycin and intravenous metronidazole; if ileus is present, vancomycin may be given rectally. 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 67-Year-Old Woman Is Hospitalized for Sepsis Secondary to a Urinary