Clostridium difficile infection
Patient presentation:
E.S. is a 68 year old male admitted to the Intermediate Care Unit (IMC) status post Whipple procedure. Past medical history includes kidney stones in 2006, hyperlipidemia, and hypertension. He is a full code with no known drug allergies. The purpose of the Whipple procedure was to remove a benign tumor at the head of the pancreas. This required rearranging and rerouting the pancreas, gallbladder, small intestines, and stomach in order for the patient to digest food. The surgery was successful and the patient was admitted to the IMC for observation and started on IV antibiotics of Zosyn® and Rocephin®.
On post-op day three the patient was complaining of increased abdominal discomfort. Upon exam his abdomen was non-tender and soft with active-normal bowel sounds. The patient’s vitals signs were: BP 138/86, HR 106, RR 18, oxygen saturation 99% on room air, and temperature 99.9 oral. Morning labs showed an increase white blood cell count of 19,000 cells/µL. Additionally the patient had 8 liquid bowel movements in 24 hours.
Differential list:
Infection, electrolyte imbalance, malnutrition
Diagnosis:
A C. dif culture was collected, placed on ice, and sent to the lab for testing. A day later the patient was diagnosed with C. dif and placed on contact isolation. He was given oral vancomycin and Flagyl®. A rectal trumpet was placed to prevent frequent clean-ups and to decrease infection. Due to increased fatigue and nutritional intake, a corpacks was placed and he was given Promote® tube feeding at 60cc/hr around the clock. The patient was placed on an electrolyte replacement protocol in which a BMP is drawn every morning. Based on the lab results potassium, magnesium, and phosphate can be replaced daily without additional doctor’s orders.
Treatment:
On post-op day 9 the patient continued to have liquidy, seedy, green-brown bowel movements. The patient continued to be on IV antibiotics. Doses and medications of the antibiotics were manipulated to help fight the infection but to no avail. A vancomycin enema was ordered to allow the medication to go directly to the source. The patient received the enemas every 12 hours for 4 days, but the patient continued to have nonstop bowel movements. As a result of decreased sphincter tone the rectal trumpet was discontinued.
A Resident caring the patient researched treatment options and came across a fecal transplant. In the treatment a donor, preferably a family member, donates one stool sample daily for five days. Laxatives and other supplements cannot be used. The specimen is spun down in the lab and liquefied. The stool is then placed in an enema bag. Due to the patient’s lack of sphincter tone, he was placed in Trendelenburg during the enema and for an hour following the procedure. The idea behind the method is to replace the bad bacteria with good bacteria. The patient’s wife was unable to be a donor due to diverticulitis. Thus, the daughter who was in healthy condition was able to donate her stool.
Outcome:
Following the fecal transplant the number of bowel movements trended downward until the patient was back to his baseline. He was discharged from the hospital 4 days after the fecal transplant was completed.