Gastroenterology Book

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Clostridium difficile

Aka: Clostridium difficile, Pseudomembranous colitis, Pseudomembranous Enterocolitis
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  1. See Also
    1. Diarrhea
    2. Infectious Diarrhea
    3. Chronic Diarrhea
  2. Epidemiology
    1. Dramatic increase in cases in last decade
  3. Pathophysiology
    1. Obligate, anaerobic, Gram Positive, spore-forming bacillus
      1. Causes Secretory Diarrhea via 2 toxins (A and B)
    2. New virulent strain: NAP1/B1/027
      1. Toxin A/B levels are >16 fold higher than other strains
      2. Produces binary toxin in addition to typical toxins A and B
      3. Higher rate of associated toxic Megacolon
    3. Sequence of infection
      1. Normal colonic bacteria disturbed (e.g. antibiotics)
      2. Exposure to C. difficile
        1. C. difficile is commensal in only 3% of patients
        2. C. difficile survives in hospital room >40 days
        3. Occurs in 50% of those hospitalized >4 weeks
      3. Colonization with Clostridium difficile
        1. Results in carrier state (asymptomatic) or
        2. Mild Diarrheal illness or
        3. Severe illness (Pseudomembranous colitis)
  4. Risk Factors
    1. Highest risk patients
      1. Elderly
      2. Debilitated patients
      3. Immunocompromised patients
      4. Cystic Fibrosis patients (high risk for fulminant infection)
    2. Acid suppression
      1. Proton Pump Inhibitors (e.g. Omeprazole)
        1. Highest risk as they raise gastric pH most significantly
      2. H2 Blockers (e.g. Ranitidine)
        1. Less risk than with Proton Pump Inhibitors
      3. Consider stopping indefinately following diagnosis of Clostridium difficile (due to higher risk of recurrence)
    3. Corticosteroid use
    4. Recent antibiotic use (especially last 7-10 days)
      1. General
        1. All antibiotics can cause C. difficile Diarrhea
        2. Broad-spectrum agents are highest risk
      2. Most common antibiotic causes
        1. Quinolones (e.g. Ciprofloxacin, Levofloxacin)
          1. Emerging as very common cause
        2. Ampicillin or Amoxicillin (most common cause in United States)
        3. Cephalosporins
        4. Clindamycin
          1. More common cause again since resurgence for MRSA management
      3. Less common antibiotic causes
        1. Macrolides (e.g. Erythromycin, Azithromycin)
        2. Tetracyclines antibiotics (e.g. Doxycycline)
        3. Sulfonamides (e.g. Bactrim)
        4. Trimethroprim
      4. Rare antibiotic causes
        1. Parenteral Aminoglycosides
        2. Metronidazole (used for treatment)
        3. Vancomycin (used for treatment)
  5. Symptoms
    1. Asymptomatic carrier state is common
    2. Megacolon may be present without Diarrhea
    3. Diarrhea (variably present)
      1. Timing
        1. Incubates for 2-7 days after colonization
        2. Most cases occur on days 4-9 of antibiotic course
        3. Onset <14 days after antibiotics in 96% of cases
        4. All cases occur within 3 months of antibiotics
        5. Olson (1994) Infect Control Hosp Epidemiol 15:371
      2. Characteristics
        1. Frequent, watery Bowel Movements to profuse Diarrhea up to 20-30 stools daily
        2. Mucus and occult blood often present
        3. Crampy Abdominal Pain
      3. Associated findings
        1. Fever
        2. Asymmetric oligoarticular large joint arthralgia
  6. Labs
    1. Hypoalbuminemia
    2. Complete Blood Count
      1. Leukocytosis variably present
      2. White Blood Cell count may be greater than 20,000
      3. White Blood Cell count greater than 30,000 is related to C. difficile in 25% of cases
  7. Radiology: Abdominal XRay
    1. Dilated colon: >7 cm in greatest diameter
    2. Small Bowel dilation or air-fluid levels may be present
    3. Mucosal edema or thumbprinting may also be present
  8. Diagnosis
    1. Clostridium difficile A and B toxin ELISA
      1. Preferred over Clostridium difficile culture
      2. High Test Sensitivity and Test Specificity
      3. Available within 2 hours of obtaining sample
      4. Aldeen (2000) Diagn Microbiol Infect Dis 36(4): 211-3
    2. Endoscopy (Flexible Sigmoidoscopy or Colonoscopy)
      1. Not recommended in most cases
      2. May be indicated if diagnosis is unclear
      3. Findings: Mucosal lesions with pseudomembranes
  9. Differential Diagnosis
    1. Antibiotic intolerance (resolves off antibiotics)
    2. Infectious enteritis
      1. Acute Gastroenteritis
      2. Amebic dysentary
    3. Inflammatory Bowel Disease
    4. Ischemic Colitis
  10. Management: General Measures
    1. Discontinue antibiotic
      1. Diarrhea resolves in up to 25% of cases with stopping
      2. If antibiotic required, choose one with lower risk
    2. Indications to start antibiotics immediately (empiric)
      1. Older patients
      2. Multiple comorbid conditions
      3. Antibiotics can not be discontinued
      4. Severe disease
        1. Persistent Diarrhea
        2. Dysentary (fever, Leukocytosis)
    3. Avoid and stop medications that could worsen condition
      1. Proton Pump Inhibitors
      2. Opioid
      3. Antidiarrheal agents
    4. Do not retest for toxin post-treatment if asymptomatic
      1. May be positive, but does not require treatment
  11. Management: Adults
    1. Metronidazole
      1. Drug of choice due to low cost and high risk
        1. However resistance is growing and may approach 30% in some regions
      2. Dose
        1. Typical: 500 mg orally every 6-8 hours for 10-14 days
        2. Lower dose: 250 mg orally q6 hours for 10-14 days
        3. Parenteral dose: 500 mg IV q8 hours for 10-14 days
    2. Vancomycin
      1. Precaution: Only effective for C. Difficile if dosed orally
      2. Indications
        1. High risk patients of severe, fulminant disease (with 2 or more of the following risk factors)
          1. Age over 60 years
          2. Temperature >38.3 C
          3. Albumin <2.5
          4. Leukocytosis with White Blood Cell count >15,000
          5. Serum Creatinine >50% increase over baseline
        2. Second line agent to Metronidazole
          1. Risk of promoting Vancomycin resistance
          2. Very expensive ($800 per course)
            1. Inexpensive if pharmacist compounds the intravenous form into oral formulation
      3. Dose: 125-500 mg orally four times daily for 10-14 days
        1. Use low dose (125 mg) in most patients
        2. Consider high dose (500 mg) in severe illness
          1. Studies suggest 125 mg four times daily is as effective as higher doses
  12. Management: Child
    1. Mild to Moderate disease: Metronidazole (Flagyl)
      1. Metronidazole 7 mg/kg (maximum 500 mg) tid for 7 days
    2. Severe disease: Vancomycin
      1. Vancomycin 5 mg/kg (maximum 125 mg) q6 hours x7 days
  13. Management: Recurrence
    1. Recurrence risk doubles with each episode
      1. Initial recurrence risk is 20%
      2. After third episode, recurrence is virtually assured
    2. Recurrence risk factors
      1. Prolonged antibiotic use
      2. Prolonged hospitalization course
      3. Diverticulosis
      4. Multiple comorbid illnesses
      5. Elderly patients
      6. Immunocompromised
    3. Vancomycin taper
      1. Starting dose 125 mg every 6 hours for 1 week
      2. Taper to 125 mg every 12 hours for 1 week
      3. Taper to 125 mg daily for 1 week
      4. Taper to 125 mg every other day for 1 week
      5. Taper to 125 mg every third day for 2 weeks
    4. Probiotics (e.g. Florastor)
      1. Saccharomyces boulardii (avoid if immunocompromised)
        1. Dose 250 mg PO bid to tid for 1 month
        2. Has also been used with Vancomycin 500 mg PO qid
    5. Fecal transfer
      1. Healthy donor (e.g. spouse) with normal fecal flora
      2. Sample typically introduced via rectal enema
      3. Small volume fecal amount (25 grams) sufficient to reestablish normal flora
  14. Management: Fulminant disease (high mortality rate)
    1. Indications
      1. Intractable colitis, toxic Megacolon or bowel perforation
      2. Severe Leukocytosis (e.g. White Blood Cell count to 30,000)
      3. Serum Lactate >5
      4. Multi-system organ failure or other shock-like state
    2. Management
      1. Metronidazole IV 500 mg every 8 hours and
      2. Vancomycin 500 mg PO qid and
      3. Vancomycin enema 500 mg in 100 cc NS q6 hours
        1. Delivered by foley in rectum, 30 cc balloon
        2. Balloon inflated for 60 minutes after dose
      4. Colectomy may be indicated in the most severe diseases
  15. Prognosis: Findings of improvement (assess on day 5)
    1. Fever resolves within first 2 days
    2. Diarrhea resolves within first 4 days
  16. Complications
    1. Toxic Megacolon
    2. Bowel perforation
    3. Dehydration
    4. Electrolyte abnormality
  17. Prevention
    1. Avoid Proton Pump Inhibitors unless absolutely indicated
    2. Avoid broad-spectrum antibiotic use
    3. Probiotics may be considered in recurrent cases
    4. Prevent Clostridium difficile spore spread
      1. Spores are resistant to Alcohol, antibiotics and antiseptics
      2. Contact isolation of patient
        1. Use personal protective gear including gloves
      3. Practice good hygiene
        1. Hand washing
        2. Hand santizers are not effective against Clostridium difficile
        3. Disinfect surfaces
          1. Bleach
          2. Alkaline glutaraldehyde
          3. Ethylene oxide
  18. References
    1. Majoewsky EM:RAP C3 2(4): 3
    2. Suntharam (2006) First 24 hours, Park Nicollet Lecture
    3. Jabbar (2003) Prim Care 30(1):63-80
    4. Kyne (2001) Gastroenterol Clin North Am 30(3):753-77
    5. Hookman (2009) World J Gastroenterol 15(13): 1554-80
    6. Schroeder (2005) Am Fam Physician 71(5):921-8

Clostridium difficile (bacteria) (C0079134)

Definition (NCI) A species of Clostridium that is the most significant cause of pseudomembranous colitis.
Definition (NCI) Any bacterial organism that can be assigned to the species Clostridium difficile.
Definition (NCI) A type of bacterium found in human and animal waste. Clostridium difficile is a common cause of diarrhea that occurs in hospitals. It can also cause diarrhea or other intestinal disorders in patients treated with antibiotics.
Definition (MSH) A common inhabitant of the colon flora in human infants and sometimes in adults. It produces a toxin that causes pseudomembranous enterocolitis (ENTEROCOLITIS, PSEUDOMEMBRANOUS) in patients receiving antibiotic therapy.
Definition (CSP) causes antibiotic-induced diarrhea or pseudomembranous colitis in humans; found in the colonic flora in 3% of healthy adults.
Concepts Bacterium (T007)
MSH D016360
SnomedCT 5933001
English Clostridium difficile, Clostridium difficile (bacteria), CLOSTRIDIA DIFFICILE, Clostridium difficile (Hall and O'Toole 1935) Prevot 1938, [Clostridium] difficile, CLOSTRIDIUM DIFFICILE, CLOSTRIDIUM DIFFICILIS, clostridium difficile, clostridium difficile organism, difficile clostridium, clostridia difficile, clostridium difficiles, clostridium difficilis, Bacillus difficilis, Clostridium difficilis, Clostridium difficile (organism)
Swedish Clostridium difficile
Czech Clostridium difficile
Finnish Clostridium difficile
Polish Clostridium difficile
Spanish Clostridium difficile (organismo), Clostridium difficile
French Clostridium difficile
German Clostridium difficile
Italian Clostridium difficile
Russian CLOSTRIDIUM DIFFICILE
Dutch Clostridium difficile
Portuguese Clostridium difficile
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Pseudomembranous colitis (SMQ) (C1869076)

Definition (MDRCZE) Pseudomembránová kolitida je těžký nekrotizační proces, který zachvacuje tlusté střevo a k němuž dochází kvůli komplikaci léčby antibiotiky. Občas se objevuje za nepřítomnosti vystavení účinkům antibiotik, kdy je často přítomný predispoziční stav, jako např. nedávná operace střev, urémie, střevní ischémie, chemoterapie, transplantace kostní dřeně. Zodpovědný patogen je „clostridium difficile", příslušník normální flóry, která narůstá za přítomnosti jistých antibiotik nebo za nepřítomnosti normální bakteriální flóry způsobené jinými faktory. Zkoušky na kultury a toxiny mohou vést k potvrzení C. difficile, ale pozitivní mikrobiologický test nebo testy za nepřítomnosti klinických nálezů nepodporují definitivní diagnózu pseudomembránové kolitidy. Mnohé zprávy o průjmu spojovaném s léčbou antibiotiky nemusejí vést k definitivním diagnózám nebo specifickým testům pseudomembránové kolitidy. Nekomplikovaný průjem vyvolaný antibiotiky obvykle spontánně přestane během dvou týdnů od ukončení podávání antibiotika. U přetrvávajících symptomů nebo zřetelné kolitidy může být nutná agresivní léčba pro obnovení rovnováhy bakteriální flóry v lumenu střevního traktu.
Definition (MDRHUN) A pseudomembranosus colitis egy súlyos, necrotizáló folyamat, ami a vastagbelet érinti és antibiotikus kezelés mellékhatásaként jelentkezik. Időnként előfordul antibiotikum hatása nélkül is; hajlamosság előző állapot miatt gyakran megfigyelhető, vagyis például nemrég végzett bélműtét, urémia, intestinalis ischaemia, kemoterápia, csontvelő transzplantáció. A felelős pathogen a "Clostridium difficile", a normal flóra egy tagja, ami bizonyos antibiotikum jelenlétében, vagy az egyéb tényezők miatt a normál flóra hiánya miatt túlságosan megnövekszik. A tenyészet és toxin vizsgálatok a C. difficile meghatározásához rendelkezésre állnak, azonban a klinikai eredmények hiányában nincsenek pozitív mikrobiológiai tesztek, melyek alátámasztanák a pseudomembranosus colitis végleges diagnózisát. Az antibiotikumos kezelés mellékhatásaként megjelenő hasmenés számos esetében lehet, hogy nincs határozott diagnózis vagy specifikus teszt a pseudomembranosus colitis megállapítására. Komplikációmentes antibiotikum éltal kiváltott hasmenés rendszerint spontán módon két héten belül elmúlik az antibiotikum szedésének beszüntetése után. Megmaradó tünetek, vagy tényleges colitis esetében esetleg aggresszív terápiára lehet szükség a baktérium flóra béltraktus lumenén belüli egyensúlyának visszaállításához.
Definition (MDR) Pseudomembranous colitis is a severe, necrotizing process that involves the large intestine and occurs as a complication of antibiotic therapy. It occasionally occurs in the absence of antibiotic exposure; a predisposing condition is often present, e.g., recent bowel surgery, uraemia, intestinal ischaemia, chemotherapy, bone marrow transplantation. The responsible pathogen is "Clostridium difficile", a member of the normal flora that overgrows in the presence of certain antibiotics or in the absence of normal bacterial flora due to other factors. Culture and toxin tests are available to identify C. difficile but a positive microbiology test(s) in the absence of clinical findings does not support a definitive diagnosis of pseudomembranous colitis. Many reports of diarrhoea associated with antibiotic therapy may not have definitive diagnoses or specific tests for pseudomembranous colitis. Uncomplicated antibiotic-induced diarrhoea usually subsides spontaneously within two weeks of antibiotic discontinuation. For persisting symptoms or frank colitis, aggressive therapy may be required to restore balance of the bacterial flora within the lumen of the intestinal tract.
Definition (MDRSPA) La colitis pseudomembranosa es un proceso grave y necrosante que afecta el intestino grueso y se produce como una complicación de tratamientos antibióticos. Se da ocasionalmente en ausencia de exposición a antibióticos; a menudo con presencia de un factor que predispone, p. ej. cirugía intestinal reciente, uremia, isquemia intestinal, quimioterapia, trasplante de médula ósea. El patógeno responsable es el "Clostridium difficile", un miembro de la flora normal cuyo sobrecrecimiento se produce ante la presencia de ciertos antibióticos o en ausencia de la flora bacterial normal debido a otros factores. Se cuenta con pruebas de cultivo y toxinas para identificar el C. difficile pero las pruebas microbiológicas positivas en ausencia de signos clínicos no respaldan un diagnóstico definitivo de colitis pseudomembranosa. Muchas notificaciones de diarrea asociadas con tratamiento antibiótico pueden no tener diagnósticos definitivos o pruebas específicas para colitis pseudomembranosa. La diarrea inducida por antibióticos no complicada suele aliviarse espontáneamente dentro de las dos semanas que siguen a la interrupción del tratamiento antibiótico. Para síntomas persistentes o colitis de Frank, puede ser necesaria una terapia agresiva para restablecer el balance de la flora intestinal dentro del tubo digestivo.
Definition (MDRITA) La colite pseudomembranosa è un grave processo necrotizzante che coinvolge l'intestino crasso e si manifesta come complicazione di una terapia antibiotica. Occasionalmente si manifesta in assenza di esposizione ad antibiotici, e in tal caso è spesso presente una condizione predisponente, ad es., recente intervento chirurgico intestinale, uremia, ischemia intestinale, chemioterapia, trapianto di midollo osseo. Il patogene responsabile è il "Clostridium difficile", componente della flora normale che cresce eccessivamente in presenza di certi antibiotici o in assenza della normale flora batterica a causa di altri fattori. Sono disponibili la coltura e i test delle tossine per identificare il C. difficile, ma un test microbiologico positivo in assenza di reperti clinici non supporta una diagnosi definitiva di colite pseudomembranosa. Molti eventi riportati di diarrea associati con terapia antibiotica possono non avere diagnosi definitive o test specifici per colite pseudomembranosa. La diarrea non complicata indotta da antibiotici generalmente si risolve spontaneamente entro due settimane dall'interruzione della terapia antibiotica. Per i sintomi persistenti, o colite ovvia, la terapia aggressiva potrebbe richiedere il ripristino dell'equilibrio della flora batterica nel lume del tratto intestinale.
Definition (MDRFRE) Une colite pseudomembraneuse est un processus nécrosant grave impliquant le gros intestin et résultant d'une complication d'antibiothérapie. Elle se produit occasionnellement en l'absence d'une exposition aux antibiotiques ; un état prédisposant est souvent présent, par exemple : intervention intestinale récente, urémie, ischémie intestinale, chimiothérapie, transplantation de moelle osseuse. Le pathogène responsable est « Clostridium difficile », un membre de la flore normale qui subit une croissance excessive en présence de certains antibiotiques ou en l'absence de flore bactérienne normale en raison d'autres facteurs. Des cultures et des tests de toxine sont disponibles pour identifier C. difficile mais des analyses microbiologiques positives en l'absence de constatations cliniques ne soutiennent pas un diagnostic définitif de colite pseudomembraneuse. Il arrive que beaucoup des rapports de diarrhée associée aux antibiotiques ne produisent pas un diagnostic définitif ou des tests spécifiques pour la colite pseudomembraneuse. Une diarrhée non compliquée associée aux antibiotiques disparaît en général spontanément dans les deux semaines suivant l'arrêt de l'antibiothérapie. Pour les symptômes qui persistent ou en cas de colite franche, un traitement agressif peut s'avérer nécessaire pour rétablir l'équilibre de la flore bactérienne à l'intérieur des voies intestinales.
Definition (MDRDUT) Pseudomembraneuze colitis is een ernstig necrotiserend proces in de dikke darm, dat optreedt als complicatie bij behandeling met antibiotica. Het treedt af en toe op in afwezigheid van blootstelling aan antibiotica; er is vaak een predisponerende aandoening aanwezig, bijv. een recente darmoperatie, uremie, intestinale ischemie, chemotherapie, beenmergtransplantatie. Het verantwoordelijke ziekteverwekkend organisme is 'Clostridium difficile', een lid van de normale flora die buitensporige groei vertoont in aanwezigheid van bepaalde antibiotica of in afwezigheid van normale bacteriële flora vanwege andere factoren. Er zijn kweken en toxinetests beschikbaar om C. difficile te identificeren, maar in afwezigheid van klinische bevindingen ondersteunt een positieve microbiologietest geen definitieve diagnose van pseudomembraneuze colitis. Vele meldingen van diarree die zich voordoet bij een behandeling met antibiotica bevatten wellicht geen definitieve diagnose of specifieke tests voor pseudomembraneuze colitis. Een ongecompliceerde door antibiotica opgewekte diarree verdwijnt gewoonlijk spontaan binnen twee weken na staking van antibioticabehandeling. Bij persisterende symptomen of uitgesproken colitis kan een agressieve behandeling nodig zijn om het evenwicht van de bacteriële flora binnen het lumen van het darmkanaal te herstellen.
Definition (MDRGER) Pseudomembranöse Kolitis stellt einen schweren, nekrotisierenden, den Dickdarm betreffendenr Prozess dar und erscheint als Komplikation bei der Behandlung mit Antibiotika. In manchen Fällen tritt diese Kolitis in Abwesenheit von Exposition gegenüber Antibiotika auf; oft besteht ein prädisponierender Zustand, z. B. vor kurzem durchgeführte Darmoperation, Urämie, Darmischämie, Chemotherapie, Knochenmarkstransplantation. Das verantwortliche Pathogen ist „Clostridium difficile", ein Mitglied der bakteriellen Normalflora, das in Gegenwart von Antibiotika oder in Abwesenheit bakterieller Normalflora verursacht durch andere Faktoren überhand nimmt. Kulturund Toxintests stehen zum Nachweis von C. difficile zur Verfügung, jedoch unterstützt selbst mehr als ein mikrobiologischer Test in Abwesenheit klinischer Befunde keine definitive Diagnose einer pseudomembranösen Kolitis. Viele Berichte einer Diarrhoe, die mit einer Therapie mit Antibiotika assoziiert werden, können möglicherweise keine definitiven Diagnosen oder spezifischen Tests für pseudomembranöse Kolitis enthalten. Gewöhnlich hört eine komplikationsfreie, durch Antibiotika verursachte Diarrhoe innerhalb von zwei Wochen nach Absetzen der Antibiotika spontan auf. Im Falle von persistenten Symptomen oder einer nicht-infektiösen Kolitis, kann eine aggressive Behandlung erforderliche sein, um das Gleichgewicht der bakteriellen Flora im Lumen des Gastrointestinaltraks wieder herzustellen.
Definition (MDRPOR) A colite pseudomembranosa é um processo grave e necrosante que afecta o intestino grosso e ocorre como uma complicação de tratamento com antibiótico. Ocasionalmente, ocorre na ausência de exposição a antibióticos; com frequência, existe um factor de predisposição, p. ex., cirurgia intestinal recente, uremia, isquemia intestinal, quimioterapia, transplante de medula óssea. O patogénio responsável é o "Clostridium difficile", um membro da flora normal cujo sobrecrescimento se produz na presença de certos antibióticos ou na ausência da flora bacteriana normal devido a outros factores. Existem testes disponíveis de cultura e toxinas para identificar o C. Difficile, mas o(s) teste(s) microbiológico(s) positivo(s) na ausência de sinais clínicos não corrobora(m) um diagnóstico definitivo de colite pseudomembranosa. Muitas notificações de diarreia associadas ao tratamento com antibiótico podem não ter diagnósticos definitivos ou testes específicos para a colite pseudomembranosa. A diarreia sem complicações e induzida por antibióticos costuma acalmar espontaneamente dentro das duas semanas que se seguem à interrupção do tratamento com antibiótico. Para sintomas persistentes ou colite de Frank, pode ser necessário um tratamento agressivo para restabelecer o equilíbrio da flora intestinal dentro do tubo digestivo.
Definition (MDRJPN) 偽膜性大腸炎は大腸を侵す重度の壊死性の疾患であり、抗生物質療法の合併症として起こる。時には抗生物質への曝露がなくても発症することがある：疾病素因が存在することが多い（例、最近の腸の外科手術、尿毒症、腸管虚血、化学療法、または骨髄移植）。原因となる病原体は、ある種の抗生物質の存在下、あるいは、他の要因によって正常な細菌叢の不在下において過剰増殖する正常細菌叢のメンバーである「Clostridium difficile（クロストリジウム-ディフィシレ）」である。C. difficileの特定には培養および毒性検査が有用であるが、臨床所見がない場合の細菌陽性結果は偽膜性大腸炎の確定診断を裏付けるものではない。抗生物質療法に関連する下痢の多数の報告からは、偽膜性大腸炎の確定診断や特異的検査は行えないと考えられる。合併症のない抗生物質誘発性の下痢は、通常では抗生物質の中止後2週間以内に自然に消失する。持続する症状や大腸炎の場合には、腸管腔内の細菌叢バランスを回復するための積極的治療が必要である。
Concepts Classification (T185)
English Pseudomembranous colitis (SMQ)
Dutch Pseudomembraneuze colitis (SMQ)
French Colite pseudomembraneuse (SMQ)
German Pseudomembranoese Kolitis (SMQ)
Italian Colite pseudomembranosa (SMQ)
Portuguese Colite pseudomembranosa (SMQ)
Spanish Colitis pseudomembranosa (SMQ)
Czech Pseudomembránová kolitida (SMQ)
Japanese 偽膜性大腸炎（ＳＭＱ）
Hungarian Pseudomembranosus colitis (SMQ)
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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