(Kiosk 1) Out of Bed: Optimized Rehabilitation in a Patient with Crohn’s Disease and a Second Episode of Clostridium difficile

Case Diagnosis: Clostridium difficile infection (CDI) in a 73-year-old male with severe Crohn’s Disease and new incomplete tetraplegia.

Case Description or Program Description: A patient with past medical history significant for severe Crohn’s Disease on infliximab was admitted for a new spinal cord injury classified as C5 AIS C. His acute care hospital course was complicated by ESBL+ bacteremia, sacral pressure injury with osteomyelitis, and CDI. Physiatry was consulted for rehabilitation of his neurologic injury.

Inpatient rehabilitation was complicated by a second episode of CDI, for which the patient was placed under isolation precautions and started on oral vancomycin. An anal pouch was placed for stool management. After three weeks of four times daily dosing, stool consistency failed to improve but vancomycin was tapered and isolation precautions were modified to permit out-of-bed therapy and outdoor socialization. Infliximab was temporarily held, and the patient underwent a successful colostomy seven weeks after the second CDI diagnosis. Standard offloading protocol remained in place throughout this episode.

Setting: Tertiary academic medical center

Assessment/Results: At four weeks postoperatively the patient had made strides in physical and occupational therapy, demonstrated increased independence, and was subjectively pleased with the freedom and improved quality of life that his colostomy offered.

Discussion (relevance): Advanced age, history of severe Crohn’s Disease with one recent episode of CDI, and lengthy hospitalization all increased this patient’s risk for infection. His baseline loose stool consistency made it difficult to assess medication response, and persistent diarrhea both complicated wound management and severely limited necessary therapy. The decision to lift isolation precautions and pursue colostomy were made with assistance from multiple specialists including infectious disease, gastroenterology, and general surgery.

Conclusions: The physiatrist is uniquely suited to manage complex rehabilitation requiring the consultation of multiple medical specialists, and pursuit of elective surgical intervention facilitated a faster return to therapy in this patient with a new spinal cord injury.