CASE REPORT |
https://doi.org/10.5005/jp-journals-11006-0056 |
A Case Report on Fulminant Clostridium difficile Colitis Managed with Vancomycin Administered through Ileostomy
1,2,4,5Department of Critical Care Medicine, Iqraa International Hospital Calicut, Kerala, India
3Department of Gastrosurgery, Iqraa International Hospital, Calicut, Kerala, India
6-8Department of Clinical Pharmacy, Iqraa International Hospital, Calicut, Kerala, India
Corresponding Author: Faris Hussain, Kondotty, Kerala, India, Phone: +91 8848674731, e-mail: farishussain2@gmail.com
Received on: 14 April 2023; Accepted on: 15 May 2023; Published on: 23 June 2023
ABSTRACT
Clostridium difficile (CDF) is a widespread nosocomial infection, usually presented as diarrhea. In fulminant cases, paralytic ileus is common. In postoperative patients with a functioning ileostomy, it is rare. Here, we describe a patient who was admitted with features of septic shock secondary to ileal obstruction and perforation. Since the patient was in sepsis, not responding to broad-spectrum antibiotics and antifungals, and computed tomography (CT) showed edematous bowel loops, we suspected CDF. Investigations confirmed pseudomembranous enterocolitis and responded to treatment which included oral vancomycin along with intravenous (IV) metronidazole and vancomycin as retention enema through rectum, and ileostomy downwards using Foley’s catheter. This case report is a newer insight to prompt decision-making and intervention than those described in the conventional treatment algorithm of Clostridium difficile infection (CDI).
How to cite this article: Hussain F, P S, Babu N, et al. A Case Report on Fulminant Clostridiumdifficile Colitis Managed with Vancomycin Administered through Ileostomy. Indian J Crit Care Case Rep 2023;2(3):66-68.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
Keywords: Clostridium difficile, Ileostomy, Intensive care unit, Vancomycin retention enema, Sepsis.
INTRODUCTION
Postoperative sepsis results in significant morbidity and mortality.1 Clostridium difficile (CDF) is identified as gram-positive, anaerobic spore-forming bacilli, which present as nosocomial diarrhea.2 In fulminant cases, paralytic ileus is also common. In postoperative patients with a functioning ileostomy, it is rare. We report a case of postoperative sepsis, caused by CDF and its successful management with individualized interventions.
CASE DESCRIPTION
A male patient aged 44 years, with a history of an appendectomy 2 months back presented to the Department of Emergency Medicine with complaints of abdominal discomfort, vomiting, and constipation for 5 days. He had a history of surgical site infection during the postoperative period managed with the administration of IV antibiotics for around 2 weeks. During the time of admission, his blood pressure was shown 60/30 mm Hg and pulse rate to be 161 beats per minute. His lab investigations were unremarkable except for mildly elevated white blood cells (WBC) (11,480 cells/cumm) and C- reactive protein (8.77 mg/L).
Contrast-enhanced CT abdomen/pelvis is suggestive of mechanical small bowel obstruction in the mid-distal ileal region with the collapse of the distal ileal loops and colon, which was secondary to adhesions. He had undergone emergency laparotomy, adhesiolysis, and closure of perforation with a loop ileostomy. The patient was moved to the medical intensive care unit (ICU) in view of severe septic shock. He was managed with double vasopressor support and mechanical ventilation and initiated on meropenem. He required one session of hemodialysis (HD) when became anuric. The patient recovered after 4 days of management with antibiotics and other supportive measures. Meropenem was de-escalated to injection (Inj). Amoxicillin and potassium clavulanate as all cultures were sterile and the patient was shifted to step-down ICU. Despite the patient improving clinically, the very next day his condition worsened with high-grade fever, shock, and leukocytosis (19,360 cells/cumm). Once again, he was required vasopressors and antibiotics were escalated to Inj colistin along with Inj meropenem as a septic shock was worsening. Three sets of blood cultures were sent from the peripheral line, a central venous catheter (CVC), and an HD catheter site and blood from the HD catheter site grew carbapenem-resistant Acinetobacter baumannii. All other cultures from CVC to the peripheral line were sterile.
Since the patient’s clinical status was not improving, tigecycline was added and meropenem was stopped to cover carbapenem-resistant Acinetobacter. Despite getting treated with appropriate antibiotics and ruling out other common focuses of sepsis, the patient was progressively worsening with further leukocytosis (24,020 cells/cumm), persistent fever spikes, and shock. Two sets of fresh blood cultures were sent again. CVC was removed through which the patient was getting total parenteral nutrition. As the patient’s condition further deteriorated, Inj tigecycline was discontinued after 2 days, and Inj ampicillin/sulbactam was added to colistin to effectively manage Acinetobacter (carbapenem-resistant Acinetobacter baumannii). As there was no improvement in shock, fever or leukocytosis, and repeat cultures came sterile, Inj teicoplanin was added empirically. At this time, a CT abdomen/pelvis was repeated (Fig. 1) and it demonstrated diffuse edematous wall thickenings of the small and large bowel loops with mucosal hyper-enhancement; there was no obvious collection noted in the visualized part of the abdomen. Inj caspofungin was added since his condition worsened further. On postoperative day 11, it was noted that his stomal output through ileostomy was increasing and there were loose stools per annum, which was not expected as the patient had a functioning ileostomy. Hence, a stool glutamate dehydrogenase (GDH) and CDF toxin (enzyme-linked immunosorbent assay) were sent. The toxin assay came negative and GDH was positive.
Fig. 1: Computed tomography (CT) abdomen demonstrating the involvement of small bowel
He was taken for sigmoidoscopy, which confirmed pseudomembranous enterocolitis (Fig. 2). Polymerase chain reaction for Clostridium toxins A and B of stool came positive later.
Fig. 2: Sigmoidoscopy suggestive of pseudomembranous enterocolitis
All antibiotics were stopped. Oral vancomycin 250 mg q6h, Inj metronidazole 500 mg IV q8h, and vancomycin 500 mg retention enema q6h through rectum were started. In view of small intestine involvement and ileus, vancomycin 500 mg q6h was administered through ileostomy also. We administered it via Foley’s catheter. After this line of management, on the 2nd day itself, the patient had a significant improvement with reversal of shock and decreased WBC count (14,990 cells/cumm). We were able to taper down inotropes. Still, the patient was on minimal noradrenaline support. The culture from CVC-grown Elizabethkingia meningoseptica and Inj cotrimoxazole was added for 10 days.
Subsequently, after starting Inj cotrimoxazole, the shock was completely reversed and vasopressors were stopped.
Gradual improvement in the stomal output with good urine output was noted. As he responded well to the above-mentioned treatment for the CDF, it was continued for 14 days. After discharge his colonoscopy was clear and he underwent a reversal of loop ileostomy (Fig. 3).
Fig. 3: Colonoscopy after 1 month of discharge
DISCUSSION
Clostridium difficile (CDF) is an anaerobic, gram-positive, and rod-shaped bacteria. It is the most common cause of hospital-acquired infectious diarrhea and is generally considered a colonic pathogen.3 It displays the entire spectrum of symptoms ranging from no symptoms to fulminant colitis leading to systemic toxicity and ultimately death. In 1978, as per the literature, the strongest risk factor was due to the usage of antibiotics, with up to 98% age of patients, taking at least one dose of antibiotics within 2 weeks.4
According to the guideline definition of severe CDI is stated that at least either of the following factors is noted, the temperature of >38.5°C, WBC count of >15,000/µL, increased creatinine of >1.5, or increased albumin. In this case, all the above-mentioned factors were noted with prominent features in sigmoidoscopy suggestive of pseudomembranous enterocolitis.5
The incidence of CDI has been reported after the reversal of ileostomy. Skancke et al. report the incidence of CDI as 3.04% in stoma reversal and that it is higher than 1.25% in elective colectomy with p < 0.0001.2 In our case, this patient was infected with CDI after the emergency loop ileostomy.
For patients with CDI with ileus, the drugs that are given orally, do not reach the colon, in such patients, it is important to realize severe diseases that do not respond to metronidazole and vancomycin therapy when given orally. Therefore, in these cases, the vancomycin administration, in an intracolonic is an important alternate choice.
The American Society of Cataract and Refractive Surgery, guideline on CDI evaluated that antegrade instillation of vancomycin was preceded by antegrade colonic therapy with polyethylene glycol and was found to have low-quality evidence.6 But Brown et al. found that loop ileostomy with colonic lavage group patients has reduced mortality compared with historical population odds ratio 0.24, p = 0.0006.7
Intracolonoscopic and oral vancomycin therapy presents a convincing alternative in the presence of ileus. However, there is a need for various diagnostic strategies to differentiate patients, as to who shall benefit from this method of treatment.
Matsuda et al. reported a case where they salvaged a patient with severe CDF colitis status postileostomy reversal with vancomycin therapy through a transverse colostomy.8
The pathophysiology of CDF enteritis is not clearly described in the literature yet. Metaplasia of the terminal end of the ileum of patients with ileostomy-simulating colonic environment9 is one of the accepted causes. As operative management, the guidelines recommendation is the diversion of loop ileostomy and colonic lavage which is followed by intravenous administration of metronidazole and vancomycin through the efferent limb of ileostomy.10,11 In our case, we hypothesized that adjunct therapy of vancomycin through ileostomy, through the rectum as a retention enema, and the conventional treatment as oral vancomycin with IV metronidazole would benefit this patient as his CT is suggestive of the involvement of small bowel and pseudomembranous enterocolitis and management was very effective for this patient.
To our knowledge, this is the first case reported of complicated pseudomembranous enterocolitis after emergency laparotomy treated with vancomycin as retention enema and through ileostomy simultaneously with conventional therapy.
CONCLUSION
Clostridium difficile (CDF) infection is a differential diagnosis of sepsis in the ICU. Diarrhea may not be a feature of severe sepsis, but increased stomal output and loose stools, despite a functioning stoma made us think in favor of CDF infection. Vancomycin administration as retention enema is already known, but in this case, there was an involvement of the small bowel as per CT and ultrasound. We had given vancomycin through ileostomy which made the recovery faster.
This case report is a newer insight to prompt decision-making and intervention than those described in the conventional treatment algorithm of CDI.
ORCID
Faris Hussain https://orcid.org/0000-0002-3176-4279
Ashique EP https://orcid.org/0000-0003-2038-0736
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