Diarrhoea during or after antibiotic treatment

Dr Wrishi Raphael
Mr Rashid, a 35 year old man got admitted to hospital with the complaints of dry cough and fever which was going on for a week. On examination in the emergency department, Mr. Rashid seemed irritable and toxic, with a fever of 103 ̊ F, pulse rate of 100 beats per minute and an increased respiratory rate of 35 breaths per minute. His blood pressure was pretty low, 90/60 indicating impending sepsis and shock. The examination findings of his chest and the emergency chest X ray showed pneumonia.  The doctors in the emergency department quickly admitted him for intravenous hydration and injectable antibiotics.
With the passage of time and adequate hydration his fever started to drop and his blood pressure began to stabilize. He was treated empirically with injectable amoxicillin and gentamicin which was later replaced by cefixime and amikacin in accordance to his blood culture reports.
The patient Mr Rashid was in complete remission within 5 days of antibiotic therapy. However within a day of discontinuing his antibiotics Mr Rashid developed loose motion which seemed to leave him listless and dehydrated again. Much to the dismay of Mr Rashid’s family he was later informed that he developed a condition known as pseudomembranous colitis.
Pseudomembranous colitis is a disease caused by Clostridium Difficile. Due to disturbances in the normal bacterial population in the colon because of the powerful antibiotics, colonies of Clostridium Difficile started to secrete harmful toxins into the Gastro Intestinal Tract causing diarrhea. Although Mr Rashid became lethargic again, the signs of dehydration were not severe enough for intravenous hydration. As suspected by the doctors, Mr Rashid’s stool culture results were positive for Clostridium Difficile. His treatment was resumed soon after loose motion started and metronidazole was the drug of choice.     
While almost any antibiotic can cause pseudomembranous colitis, some antibiotics are more likely to cause pseudomembranous colitis than others:
Fluoroquinolones, such as ciprofloxacin and levofloxacin
Penicillins, such as amoxicillin and ampicillin
Clindamycin
Cephalosporins, such as cefixime
Risk factors
Factors that may increase your risk of pseudomembranous colitis include:
Taking antibiotics
Staying in the hospital or a nursing home
Increasing age, especially over 65 years
Having a weakened immune system
Having a colon disease, such as inflammatory bowel disease or colorectal cancer
Undergoing intestinal surgery
Receiving chemotherapy treatment for cancer
Laboratory studies
Laboratory testing for evaluating patients includes the following:
Complete blood count: Leukocytosis may be present
Electrolyte levels, including serum creatinine: Dehydration and electrolyte imbalance may accompany severe disease

Albumin levels: Hypoalbuminemia may accompany severe disease
Serum lactate level: Lactate levels are generally elevated (≥5 mmol/L) in severe disease
Stool examination: Stool may be positive for blood in severe colitis, but grossly bloody stools are unusual; fecal leukocytes are present in about half of cases
Stool assays for C difficile, from the most to the least sensitive, include the following:
Stool culture: The most sensitive test but the results are slow and may lead to a delay in the diagnosis if used alone
Management
Treatment for Clostridium Difficile varies according to its severity. Interventions include the following:
Asymptomatic carriers: No treatment is necessary
Mild, antibiotic-associated diarrhea without fever, abdominal pain, or leukocytosis: Cessation of antibiotic(s) may be the only treatment necessary
Mild to moderate diarrhea or colitis: Metronidazole (oral or intravenous) or vancomycin (oral) for 10 days
Antibiotic usage can be a double edged sword. Although the injudicious use of antibiotics can easily cause pseudomembranous colitis, it must also be remembered that a patient with dehydration and sepsis must be treated with vigilantly with broad spectrum antibiotics to save life or limb.

Diarrhoea during or after antibiotic treatment

Dr Wrishi Raphael Mr Rashid, a 35 year old man got admitted to hospital with the complaints of dry cough and fever which was going on for a week. On examination in the emergency department, Mr. Rashid seemed irritable and toxic, with a fever of 103 ̊ F, pulse rate of 100 beats per minute and an increased respiratory rate of 35 breaths per minute. His blood pressure was pretty low, 90/60 indicating impending sepsis and shock. The examination findings of his chest and the emergency chest X ray showed pneumonia. The doctors in the emergency department quickly admitted him for intravenous hydration and injectable antibiotics. With the passage of time and adequate hydration his fever started to drop and his blood pressure began to stabilize. He was treated empirically with injectable amoxicillin and gentamicin which was later replaced by cefixime and amikacin in accordance to his blood culture reports. The patient Mr Rashid was in complete remission within 5 days of antibiotic therapy. However within a day of discontinuing his antibiotics Mr Rashid developed loose motion which seemed to leave him listless and dehydrated again. Much to the dismay of Mr Rashids family he was later informed that he developed a condition known as pseudomembranous colitis. Pseudomembranous colitis is a disease caused by Clostridium Difficile. Due to disturbances in the normal bacterial population in the colon because of the powerful antibiotics, colonies of Clostridium Difficile started to secrete harmful toxins into the Gastro Intestinal Tract causing diarrhea. Although Mr Rashid became lethargic again, the signs of dehydration were not severe enough for intravenous hydration. As suspected by the doctors, Mr Rashids stool culture results were positive for Clostridium Difficile. His treatment was resumed soon after loose motion started and metronidazole was the drug of choice. While almost any antibiotic can cause pseudomembranous colitis, some antibiotics are more likely to cause pseudomembranous colitis than others: Fluoroquinolones, such as ciprofloxacin and levofloxacin Penicillins, such as amoxicillin and ampicillin Clindamycin Cephalosporins, such as cefixime Risk factors Factors that may increase your risk of pseudomembranous colitis include: Taking antibiotics Staying in the hospital or a nursing home Increasing age, especially over 65 years Having a weakened immune system Having a colon disease, such as inflammatory bowel disease or colorectal cancer Undergoing intestinal surgery Receiving chemotherapy treatment for cancer Laboratory studies Laboratory testing for evaluating patients includes the following: Complete blood count: Leukocytosis may be present Electrolyte levels, including serum creatinine: Dehydration and electrolyte imbalance may accompany severe disease Albumin levels: Hypoalbuminemia may accompany severe disease Serum lactate level: Lactate levels are generally elevated (5 mmol/L) in severe disease Stool examination: Stool may be positive for blood in severe colitis, but grossly bloody stools are unusual; fecal leukocytes are present in about half of cases Stool assays for C difficile, from the most to the least sensitive, include the following: Stool culture: The most sensitive test but the results are slow and may lead to a delay in the diagnosis if used alone Management Treatment for Clostridium Difficile varies according to its severity. Interventions include the following: Asymptomatic carriers: No treatment is necessary Mild, antibiotic-associated diarrhea without fever, abdominal pain, or leukocytosis: Cessation of antibiotic(s) may be the only treatment necessary Mild to moderate diarrhea or colitis: Metronidazole (oral or intravenous) or vancomycin (oral) for 10 days Antibiotic usage can be a double edged sword. Although the injudicious use of antibiotics can easily cause pseudomembranous colitis, it must also be remembered that a patient with dehydration and sepsis must be treated with vigilantly with broad spectrum antibiotics to save life or limb.