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Pseudomembranous colitis, sometimes called antibiotic-associated colitis or C. difficile colitis, is an inflammatory condition of the colon that occurs in some people who have received antibiotics.

The inflammation in pseudomembranous colitis is almost always associated with an overgrowth of the bacterium Clostridium difficile (C. difficile), although in rare cases, other organisms can be involved.

Pseudomembranous colitis occurs more often in adults than in children, and it's rare in infants because of protective antibodies received from their mothers. The condition can cause you to experience painful, alarming symptoms and can even become life-threatening. However, treatment for most cases of pseudomembranous colitis is successful.

The most common and the initial sign of pseudomembranous colitis is watery, and sometimes bloody, diarrhea.

Symptoms of pseudomembranous colitis include:

• Diarrhea
• Abdominal cramps and pain
• Fever, which may be higher than 101 F (38.3 C)
• Urge to have a bowel movement (fecal urgency)
• Pus or mucus in your stool
• Nausea
• Dehydration

Symptoms of pseudomembranous colitis can begin within one to two days after you begin receiving an antibiotic, or they may not occur until several weeks after you discontinue the antibiotic.

When to see a doctor
Contact your doctor if you're taking or have recently taken antibiotics and you develop any of the signs or symptoms associated with pseudomembranous colitis, including constant diarrhea, abdominal pain, and blood or pus in your stool.

Antibiotics can lead to pseudomembranous colitis by disturbing the normal bacterial balance within your colon, which facilitates the colonization and growth of C. difficile or other bacteria. Potent toxins are released when these bacteria become numerous, causing inflammation of your colon.

The most commonly used antibiotics associated with pseudomembranous colitis are fluoroquinolones, penicillins, lincosamides such as clindamycin, and cephalosporins. However, virtually any antibiotic can cause pseudomembranous colitis. Pseudomembranous colitis has also been associated with antibiotics that you may receive before an operation to prevent surgery-related infections.

Although antibiotics are by far the drugs most often associated with the development of pseudomembranous colitis, other so-called antimicrobial medications (such as antiviral or antifungal drugs) may be responsible. In addition, in people with cancer, chemotherapy may sometimes disrupt the bacteria within their intestines and trigger the development of pseudomembranous colitis.

Antibiotic use is the key risk factor for pseudomembranous colitis. However, other risk factors include:

• Age older than 65 years
• Weakened immune system
• Diseases of the colon, such as inflammatory bowel disease and colorectal cancer
• Intestinal surgery
• Cancer chemotherapy with medications, such as 5-fluorouracil and cisplatin

Pseudomembranous colitis is more common in certain people in hospitals and nursing homes, often when they're receiving drugs or undergoing surgery in which antibiotics are part of the treatment regimen.

By the time your doctor detects pseudomembranous colitis, you may already be seriously ill. If the condition isn't successfully treated at the time of diagnosis, a number of complications can develop, including:

• Abnormally low levels of potassium in your blood (hypokalemia), due to the loss of potassium during excessive diarrhea
• Dehydration leading to abnormally low blood pressure (hypotension), related to significant loss of fluids and electrolytes due to diarrhea
• Kidney failure, due to severe dehydration resulting from diarrhea
• Abnormally low levels of protein in your blood (proteinemia) from a leaky colon wall
• A hole in your bowel (perforated colon), which can lead to an infection of your abdominal cavity
• Toxic megacolon, a rare but serious distension of the colon, leaving it incapable of expelling gas and stool, which could cause your colon to rupture

Most people respond well to treatment, but pseudomembranous colitis can be fatal without effective treatment. The risk of death is highest in older adults.

You're likely to start by first seeing your family doctor or a general practitioner. However, in some cases when you call to set up an appointment, you may be referred immediately to a digestive disorders specialist called a gastroenterologist or to an emergency department if your symptoms are severe.

It's a good idea to come well prepared to your appointment so that you can make the most of your time with your doctor. Here's some information to help you get ready and an overview of what to expect.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance. For example, your doctor may ask you to restrict your diet or stop taking certain medications to prepare for tests that are commonly used to diagnose pseudomembranous colitis.
• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of your key medical information, including the names of all medications that you're currently taking or that you've taken in the last month or so. Your doctor will also want to know about other conditions for which you've recently been treated, including any procedures or hospitalizations.
• Take a family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.

Prepare a list of questions to ask your doctor, ordered from most important to least important, in case your time with your doctor is limited. Some basic questions to ask your doctor about pseudomembranous colitis include:

• What is likely causing my symptoms?
• Are there any other possible causes for my condition?
• What kinds of tests do I need?
• Is my condition likely temporary or chronic?
• What is the best course of action?
• I have these other health conditions. How can I best manage them together?
• Are there any restrictions that I need to follow?
• Is there anything I can do to prevent a recurrence of this condition?
• If my symptoms do recur, what treatment options will be available?
• Should I see a specialist? What will that cost, and will my insurance cover seeing a specialist?
• Is there a generic alternative to the medicine you're prescribing me?
• Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• In the last several weeks, have you taken antibiotics, had a surgical procedure or been hospitalized?
• Is anyone at home sick with diarrhea, or has anyone at home been hospitalized in the last several weeks?
• Have you ever been diagnosed with diarrhea related to C. dificile or antibiotics?
• When did you first begin experiencing signs and symptoms?
• Have your symptoms stayed the same or gotten worse?
• Are you having abdominal pain?
• Do you have diarrhea? Is there blood or pus in your stools?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Are you being treated for any other medical conditions?

What you can do in the meantime
While you're waiting for your appointment, drink plenty of fluids and stick to bland foods. Ask your doctor if you should switch to a liquid diet before your appointment.

A number of medical conditions — Crohn's disease, ulcerative colitis, bacterial infections and parasitic infections — can cause diarrhea and other signs and symptoms similar to those of pseudomembranous colitis. Because of this, you'll need tests to definitively diagnose pseudomembranous colitis and rule out other disorders.

Your doctor will likely order one or both of the following tests to help make a diagnosis of pseudomembranous colitis:

• Stool sample. A laboratory evaluation conducted on one or more stool samples can detect the toxin released by C. difficile. False-negative results are possible with this test. Doctors sometimes repeat this test if it doesn't show the presence of C. difficile when there are strong reasons to suspect the disorder.
• Colon examination. In a colonoscopy or sigmoidoscopy, your doctor uses a tube with a miniature camera at its tip. The tube is advanced through your rectum and into your colon, allowing your doctor to examine the interior of your colon for signs of pseudomembranous colitis. If you have pseudomembranous colitis, the exam may show raised, yellow plaques or lesions within your colon, as well as swelling.

Your doctor may obtain an abdominal radiograph (X-ray) if you have severe symptoms to look for complications such as toxic megacolon or colon rupture. A computerized tomography (CT) scan to get detailed images of your colon also may be performed. The CT scan can show a thickening of the wall of your colon, which may suggest pseudomembranous colitis.

He or she may also order blood tests, because an abnormally high white blood cell count (leukocytosis) may indicate pseudomembranous colitis.

Once the diagnosis of pseudomembranous colitis is made, your doctor will stop the antibiotic that was associated with development of the disorder. Sometimes, this may be enough to resolve your condition, or at least ease signs, such as diarrhea.

If you have severe symptoms and your doctor suspects pseudomembranous colitis, you may be started on treatment before stool tests confirm the diagnosis. Once you begin treatment for pseudomembranous colitis, signs and symptoms may begin to improve within a few days, and they often resolve completely within two weeks.

To treat more-severe cases of pseudomembranous colitis, your doctor will choose from among a number of medications, particularly antibiotics other than the one associated with your illness.

Most common medications
The antibiotic metronidazole (Flagyl) is the first drug of choice for treating disorders associated with C. difficile bacteria. However, recent research suggests that the antibiotic vancomycin (Vancocin) may produce a faster response and may be associated with a lower risk of recurrence. If your condition is severe, your doctor may prescribe vancomycin first because of its rapid response rate. However, vancomycin only works when it's given as a pill. If you are very ill and not eating, your doctor may prescribe intravenous metronidazole.

If you're a pregnant woman in your first trimester, don't take metronidazole because of the risk of birth defects. It's also a poor choice if you're breast-feeding because the drug's effect on babies is unknown. Doctors also generally avoid prescribing this medication in children younger than 10 years old. In certain cases, doctors may give a combination of vancomycin and metronidazole.

Rifaximin (Xifaxan) is another antibiotic that doctors sometimes use to manage pseudomembranous colitis.

The antibiotics used to treat pseudomembranous colitis are usually given by mouth. However, depending on the severity of the inflammation and the medication, you may be treated with these drugs intravenously, via an enema, or through a tube inserted through your nose and threaded into your stomach (nasogastric tube).

Recurrent inflammation
Even in people who are treated successfully, pseudomembranous colitis may recur in up to 20 percent of cases within weeks to months after treatment has been completed. You may need a second or third round of drug therapy to resolve your condition.

If your infection comes back, your doctor may treat you again with metronidazole. If it comes back still again, you may receive a prolonged course of vancomycin to get rid of the infection.

Your doctor may also give you a yeast called Saccharomyces boulardii (Florastor) or another probiotic to help restore your colon's normal bacteria. Probiotics are dietary supplements or foods that contain beneficial bacteria normally found in your intestinal tract. Small studies have suggested that probiotics may shorten the duration of diarrhea related to antibiotic use and may prevent a relapse of C. difficile infection, but more research is needed.

Why antibiotics as a treatment?
Antibiotics cause pseudomembranous colitis because they kill the normal bacteria in your colon and allow toxic C. difficile to grow. Although it may seem strange to use antibiotics to treat a disorder caused by antibiotics, treatment with antibiotics eradicates the C. difficile and allows the normal bacteria to grow back, restoring the balance of bacteria in your colon to what it was before any antibiotics were given.

Dealing with dehydration
If you become dehydrated due to diarrhea, your doctor will prescribe electrolyte solutions to replace lost fluids. At times, these rehydration solutions will be administered intravenously.

Don't take anti-diarrheal medications — such as loperamide (Imodium) or the combination drug diphenoxylate and atropine (Lomotil) — without your doctor's knowledge. These drugs could worsen the signs and symptoms of pseudomembranous colitis.

When surgery is an option
If antibiotic treatment doesn't reduce colonic inflammation and ease your symptoms, and your condition worsens, your doctor may recommend intestinal surgery. This is rare, however; surgery is needed in less than 4 percent of people with pseudomembranous colitis.

Surgery becomes an option in people who have progressive organ failure, rupture of the colon and inflammation of the lining of the abdominal wall (peritonitis). Surgery typically involves removal (resection) of the diseased section of the bowel (subtotal colectomy).

To support your doctor's treatment for pseudomembranous colitis, several self-help measures may benefit you:

• Drink fluids. Drink water and other clear fluids, such as apple juice, tea and bouillon. Fluids with added sodium and potassium (electrolytes) also may be beneficial. Stay away from carbonated beverages, orange juice and other citrus drinks, alcohol, and caffeinated drinks, all of which can make your signs and symptoms worse.
• Eat several meals of small portion sizes throughout the day. This is better than eating two or three larger meals because the smaller meals tend to promote more-normal bowel movements.
• Eat foods that can help ease diarrhea. These include rice, bananas, plain baked potatoes and toast.
• Avoid high-fat, fried or spicy foods. These can worsen your symptoms.

Antibiotics are used only when your doctor believes they're necessary; make sure you take them exactly as prescribed. Particularly if you've already had an episode of pseudomembranous colitis, be sure to discuss this disease history with your doctor before taking antibiotics again.

Some research suggests that the use of probiotics can prevent pseudomembranous colitis when used before, during and after treatment with antibiotics. The most commonly used probiotic in these circumstances is Saccharomyces boulardii (Florastor), which is more widely used in Europe than in the United States. Avoid this supplement if you have yeast allergies. While these probiotics are available over-the-counter, your doctor may prescribe them, especially if you have had recurrent infection.

You may still be positive for C. difficile for several weeks after you have responded to treatment and are feeling well. Although repeat treatment isn't usually needed in this case, you and your family should take strict precautions to avoid spreading the infection. Wash your hands frequently, sanitize your linens using hot water and bleach, and avoid sharing personal items such as razors, towels and clothing.