TORONTO — Think C. difficile when evaluating severe or ongoing diarrhea in previously healthy young women, said Dr. Judith O'Donnell at the annual meeting of the Infectious Diseases Society of America.
Although healthy women of reproductive age in the community have traditionally been considered at low risk for infection with the Clostridium difficile bacteria, recent data from a Philadelphia hospital suggest a shifting epidemiology for C. difficile-associated disease.
From January to June of 2006, six otherwise healthy women between the ages of 18 and 47 were admitted to Hahnemann University Hospital for treatment of severe C. difficile infections. Of the six, three were pregnant, one had given birth three weeks before treatment, and two had recently undergone elective hysterectomies, said Dr. O'Donnell of Drexel University in Philadelphia. All of the women had taken antibiotics in the months before developing C. difficile infections, although in some cases, the antibiotic use was limited, she said.
The two women who underwent hysterectomy received two doses each of perioperative antibiotics. Two of the pregnant women had received outpatient antibiotic treatment for bacterial vaginosis and one received a single antibiotic dose following laparoscopic cholecystectomy. And the woman who had recently given birth was admitted for diarrheal disease 3 weeks after a caesarean delivery.
The absence of a common risk factor for infection suggests “these women likely contracted their infections outside of the hospital setting,” said Dr. O'Donnell. The severity of disease they experienced suggests their infections were caused by a newer, hypervirulent strain of C. difficile.
Five of the six women had evidence of severe diffuse colitis on abdominal CT scans, and two of the six developed sepsis requiring treatment in the intensive care unit. One of the two women treated for sepsis died of complications from C. difficile-associated disease after undergoing a total colectomy, subsequent resection of a large portion of ileum when the sepsis did not resolve, and 14 days of intensive antibiotic therapy with intravenous metronidazole and oral and rectal vancomycin. The second septic patient responded to continuous colonic vancomycin infusion.
The remaining four patients responded to dual antibiotic therapy, “although two were subsequently diagnosed with a recurrence of C. difficile [infection], and one required a second hospitalization,” she said.
Physicians treating women should be cognizant of the possibility of community-acquired C. difficile infection in this population, she said. Those providing obstetric and gynecologic care “should be thinking about this because it's not something they've seen very often, especially in pregnant patients.” Dr. O'Donnell said she had no financial conflicts of interest related to the presentation.