Recurrent Pseudomembranous Colitis as a Cause of Recurrent Severe Sepsis

Abstract

Clostridium difficile (C. difficile) colitis accounts for nearly 15-20 % of antibiotic-associated diarrhea. Manifestations include asymptomatic carriage, self-limited diarrhea, and pseudomembranous colitis, which is sometimes life-threatening. Despite effective therapy with metronidazole and vancomycin relapse rates are 15-33 %. Although colitis is seen in critically ill patients treated with combinations of broad-spectrum antibiotics, reports describing severe sepsis as a result of C. difficile infection are limited. We describe the case of recurrent severe sepsis due to recurrent local intestinal C. difficile infection as the only identifiable etiology. The mechanism of severe sepsis may be a derangement of the gastrointestinal barrier function. This could result in absorption of microbes or endotoxin or activation of inflammatory cascades in the submucosa of the intestine or liver. In general, for successful treatment of C. difficile infections other than anticlostridial antibiotics should be discontinuated. However, in the present case bacterial translocation from the intestine is an attractive explanation for severe sepsis and therefore additional antibiotics had been administered.

Zusammenfassung

Clostridium difficile (C. difficile) verursacht ca. 15-20 % aller mit Antibiotika assoziierten Diarrhöen. Die Manifestationen reichen vom asymptomatischen Träger über die selbstlimitierende Diarrhö bis zur pseudomembranösen Kolitis, die manchmal lebensbedrohlich sein kann. Trotz effektiver Therapie mit Metronidazol und Vancomycin liegen die Rezidivraten bei 15-33 %. Obwohl Kolitiden bei kritisch kranken Patienten, die mit Kombinationen von Breitspektrumantibiotika behandelt werden, durchaus beobachtet werden, gibt es kaum Berichte über die schwere Sepsis als Folge von C.-difficile-Infektionen. Wir beschreiben den Fall einer rezidivierenden Sepsis auf dem Boden einer rezidivierenden, lokalen, intestinalen Infektion mit C. difficile als die einzige identifizierbare Ursache. Der Mechanismus der schweren Sepsis könnte eine gastrointestinale Schrankenstörung sein. Diese könnte in eine Absorbtion von Mikroorganismen oder Endotoxin oder eine Aktivierung von Entzündungskaskaden in der Submukosa des Darms oder der Leber resultieren. Im Allgemeinen sollten für eine erfolgreiche Therapie der C.-difficile-Infektion zusätzliche Antibiotika abgesetzt werden. Im geschilderten Fall ist jedoch eine bakterielle Translokation aus dem Darm eine plausible Erklärung für die schwere Sepsis, weshalb zusätzliche Antibiotika verabreicht wurden.

Key words

Adult Respiratory Distress Syndrome - Clostridium difficile - Pseudomembranous Enterocolitis - Recurrence - Sepsis

Schlüsselwörter

ARDS - Clostridium difficile - Pseudomembranöse Enterokolitis - Rezidiv - Sepsis

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