Medicolegal Issues

C difficile Infection Misdiagnosed

A woman’s postsurgical fever was diagnosed as urinary tract infection. But it wasn’t.

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A 42-year-old woman underwent a hysterectomy performed by the defendant gynecologist at a New York City medical center. During the patient’s postsurgical hospitalization, she had a persistent fever, and it was noted that her leukocyte count had doubled. The gynecologist made a diagnosis of urinary tract infection (UTI) and prescribed ciprofloxacin. The woman was discharged four days after her surgery.

Four days later, she returned to the gynecologist’s office complaining of severe abdominal pain and vomiting. The gynecologist prescribed antacids and advised her to continue taking ciprofloxacin.

Three days after the office visit, the patient was hospitalized and diagnosed with Clostridium difficile colitis, which had caused colon perforation and subsequent peritonitis. The patient’s condition required a partial resection of the colon and creation of a colostomy, which was reversed six months later. The patient now has abdominal scarring and has developed an incisional hernia.

The plaintiff claimed that her 
C difficile infection developed shortly after her hysterectomy and that the defendant should have diagnosed and treated it, thus avoiding the resulting damage to her colon. The plaintiff claimed that she was given prophylactic antibiotics prior to surgery and that the defendant should have considered that the antibiotics and/or the procedure placed her at risk for C difficile colitis. The plaintiff also contended that ciprofloxacin should not have been prescribed and that its use likely worsened her infection.

The defendant claimed that the plaintiff’s symptoms did not suggest a C difficile infection and that no testing was warranted. The defendant acknowledged that ciprofloxacin may have allowed the proliferation of the plaintiff’s infection but that it was not negligent for him to prescribe the drug. Finally, the defendant claimed that the plaintiff’s infection was not preventable and could not have been diagnosed earlier.

According to a published account, a $776,000 verdict was returned.

Complications arising from the use of antibiotics are well known but occur with relative infrequency. Although clindamycin is known for causing pseudomembranous colitis, virtually any antibiotic may be implicated.

It is possible for pseudomembranous colitis to occur after a single dose, and symptoms can develop several weeks after antibiotics have been stopped. Other lesser-known risk factors for this condition include use of proton pump inhibitors or antineoplastic agents; any condition that slows gut motility; age older than 65; use of enteral tube feeding; chronic debilitation; and critical illness.

In this case, the patient presented with abdominal pain and vomiting (not unusual symptoms following general surgery), but apparently without diarrhea; this complicates the early diagnostic picture for colitis. The symptoms were unfortunate for the patient, but it would have been a difficult diagnosis for the clinician to make.

The jury was likely impressed by testimony describing the patient’s colonic perforation and would have been shocked by the need to perform a colostomy (even though it was reversed six months later). Some jurors automatically equate an unfortunate result with malpractice and will quickly reach that conclusion when presented with a compelling story—skipping the issue of whether the clinician actually made a mistake.

It is the defense attorney’s job to make sure that jurors selected for malpractice cases will actually decide that malpractice exists before concluding negligence and awarding damages. I used to ask potential jurors if they agreed with this statement: “In this day and age, if a patient has a bad outcome, someone probably made a mistake.” A surprising number of potential jurors would answer “Yes,” indicating a predisposition to hold clinicians accountable for a bad outcome, even clinicians who performed well and acted in conformity with the standard of care.

Sometimes all we, as clinicians, can do is show patients the concern and attention they deserve, do our best, and make sure an adequate professional liability policy is in place. —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

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