Is colonic ileus associated with Clostridioides difficile (C. diff) infection common?

From the Guidelines

Colonic ileus associated with Clostridioides difficile (C. diff) infection is a serious but relatively uncommon complication, occurring in severe cases where C. diff toxins cause significant inflammation and neuromuscular dysfunction of the colonic wall. This complication is more likely to occur in elderly patients, those with severe infections, or individuals with compromised immune systems. When C. diff causes ileus, patients may present with abdominal distension, reduced or absent bowel sounds, and paradoxically, a decrease in diarrhea despite worsening infection. According to the 2019 update of the WSES guidelines for management of Clostridioides difficile infection in surgical patients 1, the diagnosis of C. diff infection should be suspected in patients with acute diarrhea with no obvious alternative explanation, particularly in the setting of relevant risk factors such as recent antibiotic use, hospitalization, and advanced age. In cases where patients are unable to produce stool specimens due to ileus, testing of perirectal swabs may be an acceptable alternative to stool specimen analysis, as described by Kundrapu et al. in 2012, with a sensitivity of 95.7% and specificity of 100% 1. Treatment typically involves oral vancomycin (125-500 mg four times daily) or fidaxomicin (200 mg twice daily) for 10-14 days, with consideration for intravenous metronidazole (500 mg every 8 hours) as adjunctive therapy in severe cases, as recommended by the 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) 1. In cases of ileus where oral medications may not reach the colon effectively, vancomycin enemas (500 mg in 100 mL normal saline every 6 hours) may be added. Surgical consultation should be obtained promptly as colectomy may be necessary in cases of perforation, severe ileus, or toxic megacolon. Key considerations in the management of C. diff infection include:

• Prompt and accurate diagnosis using a combination of clinical symptoms and laboratory tests, such as nucleic acid amplification tests (NAATs) or toxin enzyme immunoassays (EIAs) 1
• Early initiation of treatment with oral vancomycin or fidaxomicin, and consideration of adjunctive therapy with intravenous metronidazole in severe cases 1
• Monitoring for complications such as ileus, toxic megacolon, or perforation, and prompt surgical consultation when necessary
• Implementation of infection control measures to prevent the spread of C. diff in healthcare settings, including proper hand hygiene, use of personal protective equipment, and environmental cleaning and disinfection 1.

From the Research

Colonic Ileus with C. Diff

• Colonic ileus is a potential complication of Clostridioides difficile (C. difficile) infection, which can range from mild to severe disease 2, 3.
• C. difficile infection is characterized by a wide range of symptoms, including diarrhea, pseudomembranous colitis, colonic ileus, toxic megacolon, sepsis, or death 3.
• The incidence of C. difficile-associated diarrhea (CDAD) is increasing due to the emergence of a hypervirulent strain known as NAP1/BI/027 2.
• Colonic ileus is a severe complication of C. difficile infection, which may require surgical intervention, including subtotal colectomy 4.

Treatment and Management

• Treatment of C. difficile infection depends on the severity of the infection and may include oral vancomycin, fidaxomicin, or metronidazole 2, 3.
• For patients with ileus, oral vancomycin with simultaneous intravenous (IV) metronidazole and intracolonic vancomycin may be given 2.
• Fecal microbiota transplantation (FMT) is a reasonable treatment option for patients with multiple recurrent episodes of C. difficile infection 3, 5.
• Adjunctive measures used for CDAD include probiotics, prebiotics, fecotherapy, adsorbents, and immunoglobulin therapy 2.

Prevalence and Outcomes

• The overall treatment response to intracolonic vancomycin for severe C. difficile colitis is around 70% 4.
• The success rate of a treatment protocol involving FMT and continued vancomycin in selected patients is high, with an overall treatment response of 93% 5.
• Fidaxomicin is associated with a lower risk of C. difficile recurrence compared to vancomycin, with a 31% reduction in the risk of recurrence 6.