CLOSTRIDIUM-DIFFICILE COLITIS ASSOCIATED WITH CHRONIC-RENAL-FAILURE

Background. Clostridium difficile-associated diarrhoea (CDAD) is a pot entially life-threatening illness which has been shown to be more comm on and more severe in patients with chronic renal failure (CRF) than i n other groups. A review of CDAD in our nephrology unit was carried ou t. Methods. A review of microbiology and histology records identified 32 cases of CDAD in the nephrology unit over a 24-month period. Patien t notes were reviewed to identify risk factors, clinical features and outcome. Available isolates of C. difficile underwent 16S ribosomal RN A typing. Results. The incidence of CDAD in the nephrology unit was 10 .7 per 1000 admissions, compared to 2.7 per 1000 in other areas of the hospital (P < 0.0001). CDAD was considered the sole or principal caus e of death in six (19%) and was considered a contributing factor in a further seven (22%). Mortality was significantly higher among patients with established CRF (P = 0.04). Seven cases occurred as a cluster, o ver a 1-month period. Isolates from this cluster, along with comparati ve strains from other areas of the hospital, were found to be PCR type 1. Diarrhoea occurred in 28 (89%) of cases, pyrexia in 17 (53%) and i leus or abdominal pain in 14 (44%). Six patients responded to disconti nuation of antibiotics alone and 22 required metronidazole and/or vanc omycin. Three patients had colectomy and one caecostomy because of tox ic megacolon. Four patients died before specific therapy could be give n and in two of these cases the diagnosis was made at autopsy. Twenty- six patients had a record of recent antibiotic therapy. Of these, 15 h ad at least one agent considered to be inappropriate (excessively broa d spectrum agent in 11, excessive duration of therapy in four). Nine p atients had only received antibiotics prior to admission. Conclusions. CDAD carries a high mortality in nephrology patients, especially thos e with established CRF. The diagnosis may be missed if a careful antib iotic history is not taken, including agents received prior to admissi on. Rational antibiotic prescribing and adherence to infection control measures are vital to reduce the incidence of this serious condition.