Case Studies

Case 23

A 73-year-old woman in a care of the elderly ward develops diarrhoea. There is no fever. She has been an inpatient for 3 weeks following a urinary tract infection that has caused a loss of control of her diabetes mellitus. She was treated with amoxicillin for her urinary infection.

• 1. What investigation should you send for now?

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  Stools should be sent for investigation of the diarrhoea. The investigation should be focused on the identification of Clostridium difficile.

• More info: The next day the nursing staff report that there are now three other patients on the ward with diarrhoea.

• 2. What additional possibilities for the diagnosis are there?

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  There is now the possibility of an outbreak of infectious diarrhoea. This may include a food-borne outbreak, such as salmonellosis, or a viral infection. Among the viral infections, norovirus is a common problem in hospitals.

• 3. How should this be investigated?

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  Samples should be sent from all of the involved patients for bacterial culture and viral NAAT.

• More info: The result of the first patient's stool sample comes back and shows that the patient has C. difficile toxin.

• 4. How does this fit in with the history that you have?

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  This is what was first anticipated. The previous antibiotics have provided the environment that has allowed the proliferation of C. difficile in the gut followed by release of toxins.

• 5. What is the significance of this result?

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  C. difficile may cause outbreaks in hospitals so it is important to find out what the other patients have. The clinician needs to contact the laboratory and ask to expedite the results.

• 6. What further investigations should the laboratory perform?

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  The stool should be cultured and the strains typed.

• 7. What needs to happen to control the outbreak?

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  There is a need to control antibiotic prescription throughout the ward. Enhanced cleaning of the ward area is required and the patients should be isolated. The importance of hand-washing for all staff should be re-emphasized.