A Case of Community-acquired C. difficile colitis

Clostridium difficile is a gram-positive anaerobic bacterium that is commonly implicated as a cause of infectious diarrhea in the inpatient setting especially in patients with a recent history of antibiotic use, hospitalizations, and proton-pump inhibitor use as well as patients of advanced age. However, recent literature and epidemiologic studies have shown an increase in C. difficile infections (CDI) in the community setting as well as those without the classic aforementioned risk factors. This case highlights an acute presentation of community-acquired CDI.

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Case Presentation:

A 38-year old Caucasian male with a history of ADHD presented to the ED because he was abruptly awoken by sharp abdominal pain that led to the expulsion of a large amount of blood per rectum. In addition, he also experienced an episode of vomiting. He continued to have at least eight episodes blood per rectum, vomiting, and lower abdominal cramping throughout the rest of the morning and into the day. He also admits to subjective fevers and chills since the onset of symptoms. Patient was admitted with the diagnosis of acute C. difficile colitis as evidenced by positive C. difficile toxin on PCR, which was also, of note, negative for other sources of colitis. Patient was started on oral Vancomycin 125 mg four times daily and completed three days of out of ten days of this antibiotic regimen upon discharge.

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Discussion:

Health care-associated CDI has increased in incidence and severity in recent years. As such, further evaluation for CDI in the inpatient setting has increased. Interestingly, community-associated CDI has also risen and accounts for 20-28% of all CDI cases. Community-associated CDI has previously been associated with mild illness severity, but several case reports have highlighted severe CDI in “low risk” patients. Given the increasing incidence of CDI in the nosocomial and community settings, the absence of traditional risk factors should not exclude the diagnosis of CDI. Maintaining a clinical suspicion for CDI in patients who present without traditional risk factors and understanding the sources of CDI in the community can lead to better outcomes as well as guide strategies in the prevention of community-acquired CDI.