The Role of Staphylococcus aureus in Clostridium difficile Toxin­–Negative Nosocomial and Antibiotic-Associated Diarrhea

Anna Belman, MD; Jay Patel, BA; Mel Ona, MD; David Tompkins, MD; George T. Martin, MD

Previous studies have implicated Staphylococcal enterocolitis as a significant etiologic agent of nosocomial and antibiotic-associated diarrhea (AAD) as early as the 1950s.1 Since then, the role of Staphylococcus aureus has been overshadowed by the emergence of Clostridium difficile as the most common cause of AAD, accounting for up to 33% of cases.2 Several publications have re-examined the role of S. aureus in C. difficile toxin–negative acute colitides.2-4 Our research goal was to investigate the magnitude of this role in our community hospital setting.

Stool samples from patients being tested for C. difficile toxin were also cultured for S. aureus on blood agar plates for 24 hours. The decision to obtain assays for C. difficile was based on a clinical suspicion of nosocomial diarrhea secondary to antibiotics. Patient charts were retrospectively reviewed to gather pertinent data.

Sixty-eight patients were studied. Although the incidence of C. difficile toxin positivity in this sample was 13%, there were no cases of acute colitis associated with S. aureus.

Staphylococcal enterocolitis remains a rare, yet dangerous, cause of C. difficile toxin–negative nosocomial diarrhea and AAD.1 In our community hospital setting, we found no cases of S. aureus colitis in a sample population of 68 patients. However, this finding does not preclude its being an etiologic agent in AAD in selected subsets of patients, such as children or patients who are severely immunocompromised, such as those on chemotherapy, organ transplantation patients, or patients with HIV/AIDS.

Anna Belman, MD

Jay Patel, BA
Mel Ona, MD
David Tompkins, MD
George T. Martin, MD

Dr. Belman and Dr. Ona are Internal Medicine Residents at Lutheran Medical Center in Brooklyn, New York. Mr. Patel is a medical student at St. George’s University School of Medicine in Grenada, West Indies. Dr. Tompkins is Vice Chairman of the Department of Internal Medicine and Dr. Martin is Chairman of the Department of Internal Medicine, both at Lutheran Medical Center in Brooklyn, New York.

Address correspondence to: Dr. George T. Martin, Chairman, Department of
Internal Medicine, Lutheran Medical Center, 150 55th St., Brooklyn, NY 11220; E-mail:

1. Altemeier W, Hummel RP, Hill EO. Staphylococcal enterocolitis following antibiotic therapy. Ann Surg. 1963;157:847-858.

2. Asha NJ, Tompkins D, Wilcox MH. Comparative analysis of prevalence, risk factors, and molecular epidemiology of antibiotic-associated diarrhea due to Clostridium difficileClostridium perfringens, and Staphylococcus aureus. J Clin Microbiol. 2006;44:2785-2791.

3. Thakkar S, Agrawal R. A case of Staphylococcus aureus enterocolitis: a rare entity. Gastroenterol Hepatol (N Y). 2010;6:115-117.

4. Boyce JM, Havill NL. Nosocomial antibiotic-associated diarrhea associated with enterotoxin-producing strains of methicillin-resistant Staphylococcus aureus. Am J Gastroenterol. 2005;100:1828-1834.

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