REPLY
Colitis Associated with Variant Clostridium difficile
Stuart Johnson, MD;
Dale N. Gerding, MD; and
Lance R. Peterson, MD
20 August 2002 | Volume 137 Issue 4 | Page 298
IN RESPONSE:
We appreciate the comments by Drs. Deming and Hyman and agree that laboratory testing should not replace clinical judgment. As we pointed out in our report, there were ample clinical clues to the diagnosis of C. difficile colitis that were ignored in light of the laboratory test results. We also agree that empirical therapy should be initiated in a seriously ill patient if the epidemiologic and clinical features are consistent with the diagnosis. Cholestyramine, however, is not recommended as a first-line therapy for C. difficile–associated diarrhea. Although there are anecdotal reports of success (1), binding resins such as colestipol did not appear more effective than placebo in a comparative clinical trial (2). Furthermore, these resins may also bind antibiotics such as vancomycin (3) and should therefore not be used in combination for treatment of C. difficile–associated diarrhea.
It is important to perform diagnostic tests for C. difficile to confirm clinical diagnoses and guide the clinical management of patients, particularly because response to appropriate therapy often takes several days and relapse or recurrent infections are common (4). As highlighted by our report, it is important to recognize the limitations of diagnostic testing or, to put it another way, the "tyranny of the test result," and use clinical judgment when laboratory test results deviate from clinical evidence. It is also important to appreciate the potential presence of variant strains of C. difficile to explain why toxin A test results may be unexpectedly negative. Since the publication of our report, we have been contacted by clinicians from two different states who also reported fatal cases of pseudomembranous colitis in which stool specimens were toxin A–negative and specific therapy for C. difficile was not initiated. Genotypic and phenotypic analyses of these strains are being conducted.
We agree that clinical judgment remains critical to optimum patient care. For practitioners, it is imperative to remember that even the best of immunologic assays for C. difficile toxins remain no more than 80% sensitive for laboratory confirmation of this disease (5).
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Author and Article Information
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Veterans Affairs Chicago Health Care System, Lakeside Division; Chicago, IL 60611
Northwestern University Medical School; Chicago, IL 60611
1. Kreutzer EW, Milligan FD. Treatment of antibiotic-associated pseudomembranous colitis with cholestyramine resin Johns Hopkins Med J. 1978;143:67-72. [PMID: 691920].[Medline]
2. Mogg GA, Arabi Y, Youngs D, Johnson M, Bentley S, Burdon DW, et al. Therapeutic trials of antibiotic associated colitis. Scand J Infect Dis Suppl. 1980; :41-5. [PMID: 7010533].
3. Taylor NS, Bartlett JG. Binding of Clostridium difficile cytotoxin and vancomycin by anion-exchange resins J Infect Dis. 1980;141:92-7. [PMID: 7365273].[Medline]
4. Gerding DN, Johnson S, Peterson LR, Mulligan ME, Silva J Jr. Clostridium difficile-associated diarrhea and colitis Infect Control Hosp Epidemiol. 1995;16:459-77. [PMID: 7594392].[Medline]
5. O'Connor D, Hynes P, Cormican M, Collins E, Corbett-Feeney G, Cassidy M. Evaluation of methods for detection of toxins in specimens of feces submitted for diagnosis of Clostridium difficile-associated diarrhea J Clin Microbiol. 2001;39:2846-9. [PMID: 11474001].[Abstract/Free Full Text]
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