The diagnosis of Clostridium difficile-associated disease should be considered in patients with severe diarrhea, even if they don't have traditional risk factors such as recent hospitalization or antimicrobial use, the Centers for Disease Control and Prevention advised.
During May and June 2005, a total of 10 peripartum and 23 C. difficile-associated disease (CDAD) cases from previously healthy individuals in the community were voluntarily reported from four U.S. states following a request from the CDC. The findings suggest that the epidemiology of the disease might be changing to include features that have been uncommon in the past, such as close-contact transmission, high recurrence rate, young patient age, bloody diarrhea, and lack of antimicrobial exposure, the CDC warned (MMWR 2005;54:1201–5).
All but 1 of the 33 cases occurred during 2004–2005. Hospitalization was required for 15 (46%), and relapses occurred in 13 (39%). Transmission to close contacts was evident in four cases. Eight of the 33 patients (24%)—including 5 children—reported no exposure to antimicrobial agents within 3 months prior to CDAD onset. Of those eight, two reported close contact with a person who had diarrheal illness.
Clindamycin was the most common antimicrobial exposure noted prior to CDAD, representing 10 (33%) of the 33 cases. These included two patients who had taken just one dose for group B streptococcal prophylaxis before CDAD onset.
Among the cases was a 31-year-old woman who was 14 weeks pregnant with twins whose only antimicrobial exposure during the previous year had been trimethoprim-sulfamethoxazole for a urinary tract infection 3 months before she developed severe diarrhea. Despite treatment with metronidazole, cholestyramine, and oral vancomycin, she spontaneously aborted her fetuses and died 3 days later, even after receiving subtotal colectomy, intubation, and inotropic medication.
Another case was a 10-year-old girl who had not taken antimicrobials in the previous year. She had been completely healthy until 2 weeks before developing intractable diarrhea, projectile vomiting, and abdominal pain. Her symptoms eventually resolved after she received intravenous fluids, electrolytes, and metronidazole in the hospital.