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Recurrence of Clostridium difficile infection after total colectomy in an allogeneic stem cell transplant patient

Bone Marrow Transplantation volume 47, pages 610–611 (2012)Cite this article

Clostridium difficile (C. difficile) is a bacterium that causes pseudomembranous colitis that often manifests as diarrhea, abdominal distention and pain, fever and leukocytosis.1 Sometimes the infection can be life-threatening because of toxic megacolon and septic shock that may require emergent colectomy.1 C. difficile infection is commonly associated with recent or prolonged antibiotic use that facilitates the modification of normal colonic flora. The infection is almost always limited to the colon, but there have been rare case reports of C. difficile enteritis.2, 3, 4, 5 We present an allogeneic transplant recipient with chronic GvHD who developed recurrent C. difficile infection after total colectomy.

A 56-year-old woman with Ph chromosome-positive ALL underwent allogeneic hematopoietic SCT (allo-HCT) from a sibling donor following a myeloablative-conditioning regimen in February 2008. In October 2010, she experienced respiratory failure due to Pneumocystis jirovecii (P. jirovecii) pneumonia while on prednisone 10 mg daily for chronic GvHD. She was treated with IV high-dose trimethoprim/sulfamethoxazole for 21 days, and then changed to oral prophylaxis with one double-strength tablet twice daily, every Monday and Tuesday. One month later, she presented with confusion, diarrhea, abdominal pain and distention, hypotension, tachycardia and hypoxemia. Laboratory evaluation revealed a WBC count of 52.8 × 109/L and an abdominal computed tomography scan showed significant bowel wall thickening and dilation, primarily in the rectosigmoid colon. C. difficile toxin B testing was positive. Lactic acid level was 1.8 mmol/L. The patient underwent emergency total abdominal colectomy with ileostomy placement. She was treated with a combination of 125 mg oral vancomycin, four times daily and 500 mg IV metronidazole, every 8 h (equal to 8 mg/kg q8 h), correlating closely with the recommended dosing of 7.5 mg/kg q8 h for 2 weeks. Repeat C. difficile toxin testing was negative after colectomy and antibiotic therapy. The patient's hospital course was complicated by a vancomycin-resistant enterococcus urinary tract infection, for which she was treated with 600 mg linezolid twice daily for 14 days. Upon discharge, she resumed our institution's standard post transplant antibiotic prophylaxis including 250 mg levofloxacin once daily, 100 mg fluconazole once daily and 400 mg acyclovir twice daily. Levofloxacin was given to prevent streptococcal infections while she was using steroids for control of chronic GvHD. Her prophylaxis was changed to inhaled pentamidine every 28 days for P. jirovecii while recovering from the C. difficile infection and colectomy; the patient's prophylaxis was later changed back to trimethoprim/sulfamethoxazole on discharge. The patient was discharged to a rehabilitation facility and later to a nursing home. Two months after discharge, she was readmitted to the hospital with altered mental status and hypercapnea. As part of an infectious work-up, C. difficile toxin assay was completed and was found positive, despite a total colectomy. She was treated with 125 mg oral vancomycin four times daily for 2 weeks. Her hypercapneic respiratory failure was thought secondary to respiratory muscle weakness. No other infection or etiology was found. The effect of C. difficile infection on her hospitalization was unclear. She recovered in 4 days and was discharged. Oral vancomycin therapy was to continue until steroid and prophylactic antibiotic therapy ended. Her levofloxacin prophylaxis was changed to 250 mg penicillin VK four times daily on discharge in attempt to decrease recurrence of C. difficile infections.

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Authors and Affiliations

  1. Department of Medicine, University of Minnesota, Minneapolis, MN, USA

    K Chang

  2. Division of Hematology-Oncology and Transplantation, Department of Medicine, Minneapolis, MN, USA

    L M B Kreuziger, K Angell & C Ustun

  3. Division of Infectious Disease, Department of Medicine, Minneapolis, MN, USA

    J-A Young

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  1. K Chang
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  2. L M B Kreuziger
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Correspondence to C Ustun.

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Chang, K., Kreuziger, L., Angell, K. et al. Recurrence of Clostridium difficile infection after total colectomy in an allogeneic stem cell transplant patient. Bone Marrow Transplant 47, 610–611 (2012). https://doi.org/10.1038/bmt.2011.132

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