M.M., a 72-year-old female patient is in the step-down unit. She is currently being treated for pneumonia with intravenous antibiotics and oxygen therapy but during her stay at the hospital has developed other symptoms. She is now complaining of abdominal cramping, loss of appetite and nausea.  Vital signs are as follows: heart rate 85, Blood pressure 130/70, respirations 20, oral temperature 100.7˚F.  The patient’s abdomen is tender to the touch and hyperactive bowel sounds are auscultated in all four quadrants. Stool is watery and seedy and bowel movements are increasing in frequency, currently at six per day.

In terms of differential diagnoses, this patient’s fever is likely indicative of infection. This infection could be accounted for by the pneumonia which the patient is currently being treated for. Given the fever, a practitioner may order a whole slue of cultures (urine, stool, sputum, blood, etc.). However, given the nature of these specific symptoms, it seems reasonable to believe that some sort of colitis has manifested. For this reason, the practitioner orders only the most suspicious culture, stool, before proceeding to others.

The nurse practitioner has a few options as far as diagnostic testing. She suspects that this patient has contracted a common nosocomial, intestinal infection known as clostridium difficile. She first orders a stool sample assay for c. difficile toxin which comes back positive for the spore. In some cases, practitioners will also perform a colon exam (flexible sigmoidoscopy) to confirm the diagnosis. Occasionally, the practitioner will order a computerized tomography (CT) to be performed. This test would show any thickening of the colon wall or the extent of the damage caused by the organism.

Even though it is often antibiotic therapy which contributes to the contraction of c. difficile, antibiotic therapy is also the preferred method of treatment. Metronidazole (Flagyl) is generally the drug of choice, to be administered orally or intravenously. In severe cases, vancomycin (Vancocin) may be needed. These antibiotics will not only attack the c. difficile spore, but they will also diminish the normal intestinal flora. For that reason, practitioners will also prescribe something like saccharomyces boulardii (Florastor) to help restore the healthy intestinal bacteria. The infectious disease team will decide if the current antibiotic being used to treat the pneumonia can be discontinued and replaced as well.