CASE LEARNING OBJECTIVES
Identify the signs and symptoms of Clostridium difficile–associated diarrhea (CDAD)
List the risk factors for CDAD
Select an appropriate treatment and monitoring plan for antimicrobial therapy
Consider the role of adjunctive agents and supportive care
"Please give me something for this cramping, diarrhea, and nausea."
History of Present Illness
Shannon Rasmussen is a 69-year-old woman who is brought to the emergency department for a 3-day history of diffuse abdominal pain, fever/chills, frequent, voluminous, foul-smelling stools, and lethargy. Her husband reports that "she has not been able to keep anything down" since her recent discharge and has had 5–10 profuse, watery bowel movements per day. The patient was in her usual state of health until 1 week ago when she developed severe, acute abdominal pain. She was admitted at that time with a small bowel obstruction and received an urgent exploratory laparotomy with resection. Her postoperative course was complicated by a polymicrobial intra-abdominal abscess. She was empirically treated with cefepime and clindamycin, which was changed to ampicillin–sulbactam on the basis of the culture/-susceptibility results. She was discharged on amoxicillin–clavulanate to complete a 14-day course.
Father died of bone cancer at age 66 years. Mother died of MI at age 72 years.
Married and lives with her husband, aged 65 years.
Social drinker (1–2 glasses of wine daily); (−) tobacco or illicit drug use
Allergies/Intolerances/Adverse Drug Events
"Sulfa drugs" cause a rash.
Metformin 500 mg PO twice daily
Metoprolol 50 mg PO twice daily
Lisinopril 40 mg PO at bedtime
Ibuprofen 200–400 mg PO q 3–4 h as needed
Amoxicillin–clavulanate 875/125 mg PO twice daily (day 13/14)
Loperamide 4 mg PO followed by 2 mg after each loose stool (max 16 mg/day)
Esomeprazole 40 mg PO twice daily (husband's prescription)
In addition to her symptoms noted in the History of Present Illness section, the patient reports that her husband gave her some of his prescription-strength esomeprazole for her abdominal pain; however, it did not help. Also, the patient states that she thinks she has lost several pounds over the last month, "since this all began and that the pain in all around her belly is sharp."
Elderly woman in acute distress