Advertisement
Mayo Clinic Proceedings Home

Extraintestinal Clostridium difficile Infections: A Single-Center Experience

Published:September 20, 2014DOI:https://doi.org/10.1016/j.mayocp.2014.07.012

      Abstract

      Objectives

      To evaluate the clinical burden of extraintestinal Clostridium difficile infection (CDI) seen at a single institution and to characterize the management and outcomes of these rare infections.

      Patients and Methods

      A retrospective medical record review was conducted to identify patients with isolation of C difficile from extraintestinal sites from January 1, 2004, through December 31, 2013. Medical records were reviewed and data, including demographic characteristics, microbiology, clinical associations, management, and infection outcomes, were abstracted.

      Results

      Overall, 40 patients with extraintestinal CDI were identified: 25 had abdominopelvic infections, 11 had bloodstream infections, 3 had wound infections, and 1 had pulmonary infection. C difficile was isolated with other organisms in 63% of cases. A total of 85% of infections were nosocomial. Factors associated with extraintestinal CDI included surgical manipulation of the gastrointestinal tract (88%), recent antibiotic exposure (88%), malignant tumors (50%), and proton pump inhibitor use (50%). Diarrhea was present in 18 patients (45%), 12 of whom had C difficile polymerase chain reaction (PCR)–positive stool samples. All isolates tested were susceptible to metronidazole and piperacillin-tazobactam. Management included both antimicrobial therapy and guided drainage or surgical intervention in all but one patient. The infection-associated mortality rate was 25%, with death a median of 16 days (range, 1-61 days) after isolation of C difficile.

      Conclusion

      Extraintestinal CDI is uncommon and often occurs in patients with surgical manipulation of the gastrointestinal tract and well-recognized risk factors for intestinal CDI. Management of extraintestinal CDI includes both antimicrobial and surgical therapies. Extraintestinal CDI is characterized by poor outcome with high mortality.

      Abbreviations and Acronyms:

      BSI (bloodstream infection), CDI (Clostridium difficile infection), GI (gastrointestinal), IBD (inflammatory bowel disease), ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification), MRSA (methicillin-resistant Staphylococcus aureus), PCR (polymerase chain reaction), PPI (proton pump inhibitor)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Mayo Clinic Proceedings
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Bartlett J.G.
        • Chang T.W.
        • Gurwith M.
        • Gorbach S.L.
        • Onderdonk A.B.
        Antibiotic-associated pseudomembranous colitis due to toxin-producing.
        Clostridia. N Engl J Med. 1978; 298: 531-534
        • Kelly C.P.
        • LaMont J.T.
        Clostridium difficile–more difficult than ever.
        N Engl J Med. 2008; 359: 1932-1940
        • Khanna S.
        • Pardi D.S.
        The growing incidence and severity of Clostridium difficile infection in inpatient and outpatient settings.
        Expert Rev Gastroenterol Hepatol. 2010; 4: 409-416
        • Loo V.G.
        • Poirier L.
        • Miller M.A.
        • et al.
        A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality.
        N Engl J Med. 2005; 353: 2442-2449
        • Magill S.S.
        • Edwards J.R.
        • Bamberg W.
        • et al.
        Multistate point-prevalence survey of health care-associated infections.
        N Engl J Med. 2014; 370: 1198-1208
        • Levett P.N.
        Clostridium difficile in habitats other than the human gastro-intestinal tract.
        J Infect. 1986; 12: 253-263
        • Feldman R.J.
        • Kallich M.
        • Weinstein M.P.
        Bacteremia due to Clostridium difficile: case report and review of extraintestinal C. difficile infections.
        Clin Infect Dis. 1995; 20: 1560-1562
        • Garcia-Lechuz J.M.
        • Hernangomez S.
        • Juan R.S.
        • Pelaez T.
        • Alcala L.
        • Bouza E.
        Extra-intestinal infections caused by Clostridium difficile.
        Clin Microbiol Infect. 2001; 7: 453-457
        • Lee N.Y.
        • Huang Y.T.
        • Hsueh P.R.
        • Ko W.C.
        Clostridium difficile bacteremia, Taiwan.
        Emerg Infect Dis. 2010; 16: 1204-1210
        • Libby D.B.
        • Bearman G.
        Bacteremia due to Clostridium difficile–review of the literature.
        Intl J Infect Dis. 2009; 13: e305-e309
        • Mattila E.
        • Arkkila P.
        • Mattila P.S.
        • Tarkka E.
        • Tissari P.
        • Anttila V.J.
        Extraintestinal Clostridium difficile infections.
        Clin Infect Dis. 2013; 57: e148-e153
        • Wolf L.E.
        • Gorbach S.L.
        • Granowitz E.V.
        Extraintestinal Clostridium difficile: 10 years' experience at a tertiary-care hospital.
        Mayo Clin Proc. 1998; 73: 943-947
        • Sloan L.M.
        • Duresko B.J.
        • Gustafson D.R.
        • Rosenblatt J.E.
        Comparison of real-time PCR for detection of the tcdC gene with four toxin immunoassays and culture in diagnosis of Clostridium difficile infection.
        J Clin Microbiol. 2008; 46: 1996-2001
        • Dineen S.P.
        • Bailey S.H.
        • Pham T.H.
        • Huerta S.
        Clostridium difficile enteritis: a report of two cases and systematic literature review.
        World J Gastrointest Surg. 2013; 5: 37-42
        • Navaneethan U.
        • Giannella R.A.
        Thinking beyond the colon-small bowel involvement in Clostridium difficile infection.
        Gut Pathog. 2009; 1: 7
        • Williams R.N.
        • Hemingway D.
        • Miller A.S.
        Enteral Clostridium difficile, an emerging cause for high-output ileostomy.
        J Clin Pathol. 2009; 62: 951-953
        • Prati C.
        • Bertolini E.
        • Toussirot E.
        • Wendling D.
        Reactive arthritis due to Clostridium difficile.
        Joint Bone Spine. 2010; 77: 190-192
        • Zheng L.
        • Citron D.M.
        • Genheimer C.W.
        • et al.
        Molecular characterization and antimicrobial susceptibilities of extra-intestinal Clostridium difficile isolates.
        Anaerobe. 2007; 13: 114-120
        • Elliott B.
        • Reed R.
        • Chang B.J.
        • Riley T.V.
        Bacteremia with a large clostridial toxin-negative, binary toxin-positive strain of Clostridium difficile.
        Anaerobe. 2009; 15: 249-251
        • Gravisse J.
        • Barnaud G.
        • Hanau-Bercot B.
        • et al.
        Clostridium difficile brain empyema after prolonged intestinal carriage.
        J Clin Microbiol. 2003; 41: 509-511
        • Stieglbauer K.T.
        • Gruber S.A.
        • Johnson S.
        Elevated serum antibody response to toxin A following splenic abscess due to Clostridium difficile.
        Clin Infect Dis. 1995; 20: 160-162
        • McGill F.
        • Fawley W.N.
        • Wilcox M.H.
        Monomicrobial Clostridium difficile bacteraemias and relationship to gut infection.
        J Hosp Infect. 2011; 77: 170-171
        • Sethi A.K.
        • Al-Nassir W.N.
        • Nerandzic M.M.
        • Bobulsky G.S.
        • Donskey C.J.
        Persistence of skin contamination and environmental shedding of Clostridium difficile during and after treatment of C. difficile infection.
        Infect Control Hosp Epidemiol. 2010; 31: 21-27
        • Roth A.
        • Wiklund A.E.
        • Palsson A.S.
        • et al.
        Reducing blood culture contamination by a simple informational intervention.
        J Clin Microbiol. 2010; 48: 4552-4558
        • Zerey M.
        • Paton B.L.
        • Lincourt A.E.
        • Gersin K.S.
        • Kercher K.W.
        • Heniford B.T.
        The burden of Clostridium difficile in surgical patients in the United States.
        Surg Infect. 2007; 8: 557-566
        • Daruwala C.
        • Mercogliano G.
        • Newman G.
        • Ingerman M.J.
        Bacteremia due to Clostridium difficile: case report and review of the literature.
        Clin Med Case Rep. 2009; 2: 5-9
        • Cohen S.H.
        • Gerding D.N.
        • Johnson S.
        • et al.
        Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA).
        Infect Control Hosp Epidemiol. 2010; 31: 431-455
        • Surawicz C.M.
        • Brandt L.J.
        • Binion D.G.
        • et al.
        Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections.
        Am J Gastroenterol. 2013; 108 (quiz 499): 478-498
        • Baines S.D.
        • O'Connor R.
        • Freeman J.
        • et al.
        Emergence of reduced susceptibility to metronidazole in Clostridium difficile.
        J Antimicrob Chemother. 2008; 62: 1046-1052
        • Huang H.
        • Weintraub A.
        • Fang H.
        • Nord C.E.
        Antimicrobial resistance in Clostridium difficile.
        Int J Antimicrob Agents. 2009; 34: 516-522
        • Johnson S.
        • Samore M.H.
        • Farrow K.A.
        • et al.
        Epidemics of diarrhea caused by a clindamycin-resistant strain of Clostridium difficile in four hospitals.
        N Eng J Med. 1999; 341: 1645-1651
        • Owens Jr., R.C.
        • Donskey C.J.
        • Gaynes R.P.
        • Loo V.G.
        • Muto C.A.
        Antimicrobial-associated risk factors for Clostridium difficile infection.
        Clin Infect Dis. 2008; 46: S19-S31
        • Bedimo R.
        • Weinstein J.
        Recurrent extraintestinal Clostridium difficile infection.
        Am J Med. 2003; 114: 770-771
        • Dubberke E.R.
        • Reske K.A.
        • McDonald L.C.
        • Fraser V.J.
        ICD-9 codes and surveillance for Clostridium difficile-associated disease.
        Emerg Infect Dis. 2006; 12: 1576-1579
        • Dubberke E.R.
        • Butler A.M.
        • Nyazee H.A.
        • et al.
        The impact of ICD-9-CM code rank order on the estimated prevalence of Clostridium difficile infections.
        Clin Infect Dis. 2011; 53: 20-25