Abstract

Clostridium difficile bacteremia (CDB) is a rare complication of C. difficile gastrointestinal colonization. CDB typically occurs in patients with recent surgical manipulation or trauma to the bowel, systemic immunosuppression, inflammatory bowel disease, or malignancy. Extra-colonic C. difficile is characterized by poor outcomes with high mortality rates. We present a case of fecal peritonitis with C. difficile abscess formation and bacteremia. 

We present a 72-year-old male with a past medical history of COPD, coronary artery disease, hypertension, hyperlipidemia, and colon cancer post colectomy with ileostomy who presented to the emergency department with a chief complaint of rectal bleeding. CT abdomen w/o contrast on admission revealed a sigmoid colon diverticulosis and an umbilical hernia containing a distended loop of transverse colon with no signs of obstruction. During his hospital course, he developed hypoxemia in the setting of acute abdomen in which a repeat CT abdomen revealed free air. He was subsequently taken for emergent exploratory laparotomy. During surgery, he was found to have a perforated colon with feculent peritonitis. Intraoperative cultures at that time grew pan sensitive E. Coli, which was managed with Zosyn and Diflucan. Despite appropriate therapy, the patient went into sepsis. Blood cultures were drawn which grew Clostridium Difficile and repeat CT abdomen revealed multiple intra-abdominal abscesses. Patient underwent multiple IR guided drainage of the intraabdominal abscesses and culture data revealed multi-drug resistant (MDR) enterococcus, pseudomonas, and C. difficile. The patient was managed with 3 weeks of IV ceftazidime/avibactam, metronidazole, vancomycin, and 10 days of PO vancomycin. Repeat blood cultures were negative at time of discharge and repeat CT abdomen showed complete resolution of intra-abdominal abscesses. 

CDB is rare and reported in roughly 137 cases between 1962 and 2016. Literature review shows those with underlying conditions such as perforation/trauma to bowel wall, malignancy, inflammatory bowel disease, immunosuppression, and recent surgical manipulation of the colon increases the risk of CDB. It is essential that clinicians know the appropriate management for CDB as it differs when compared to colonic C. difficile infections. Early treatment with IV vancomycin or metronidazole is the mainstay of treatment for CDB and should be used along with PO vancomycin if colonic C. difficile is also still suspected. Additionally, positive C. difficile blood cultures should include sensitivities due to the rising rate of C. diff resistance to metronidazole and vancomycin. While extracolonic manifestations of C. diff are rare, CDB is associated poor mortality even with aggressive treatment. With the growing prevalence of C. diff inoculation within hospital settings, it is imperative to monitor and tailor treatments of infections with proper sensitivities and cultures.