Intraperitoneal Extra-Intestinal Clostridium Difficile: A Rare Case

Author(s):
Serena Murphy; Megan Barnett ; Christos Colovos; Margaret Tandoh; Ajai Malhotra; Gary An

Background:

Clostridium difficile is a gram positive, spore forming anaerobic bacteria that causes opportunistic infections. C. difficile infections (CDI) overwhelmingly affect the intra-luminal colon; however, extra-intestinal infections have been reported in the blood, wounds, and peritoneum. Taken together CDI result in healthcare costs of $6.3 billion annually. Risk factors associated with extra-luminal CDI include recent antibiotic use, surgery that violates the gastrointestinal tract, and proton pump inhibitors.

Methods:

A 49 year old male with decompensated alcoholic cirrhosis presented with acute perforated diverticulitis and septic shock. He underwent a Hartmann’s procedure and received a course of broad spectrum IV antibiotics. A persistent leukocytosis prompted a CT scan on POD#26, which revealed a perisplenic abscess. The abscess was drained percutaneously and cultures from the abscess were significant for C. difficile. Concurrent and subsequent fecal tests were negative for C. difficile. He was started on IV Metronidazole and subsequently discharged to physical rehabilitation with a continued course of PO Metronidazole.

Results:

In this review of previously published case reports and available literature, it is clear that extra-luminal CDI is a rare clinical entity. The pathophysiology of extra-luminal CDI is not well understood. Patients may seed extra-intestinal sites from active colonic C. difficile, which is more frequently reported in patients with peritoneal dialysis. Alternatively in cases of colonic perforation, the peritoneal cavity is seeded with non-pathogenic colonic C. difficile.

Conclusions:

The clinical consequences of extra-luminal C. difficile are unclear and result in uncertain antibiotic treatment duration and isolation precautions. With increasing comorbidities in the surgical population, more research needs to be done to clarify clinical treatment guidelines for this entity in order to avoid unnecessarily prolonged treatment courses with attendant risks of antimicrobial resistance.