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Colitis Associated with Variant Clostridium difficile
- Stuart Johnson, MD;
- Dale N. Gerding, MD; and
- Lance R. Peterson, MD
- Veterans Affairs Chicago Health Care System, Lakeside Division; Chicago, IL 60611 Northwestern University Medical School; Chicago, IL 60611
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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).
Stuart Johnson, MD
Dale N. Gerding, MD
Veterans Affairs Chicago Health Care System, Lakeside Division; Chicago, IL 60611
Lance R. Peterson, MD
Northwestern University Medical School; Chicago, IL 60611
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
