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PHAR 255 > C. Diff > Flashcards

C. Diff Flashcards

1
Q

What is Clostridioides difficile associated diarrhea? (3 criteria, well, more like 2 + 1)

A
  1. Diarrhea - ≥ 3 unformed stools per 24h for ≥ 2 days with no other recognized cause
    - Diarrhea will not occur in the presence of ileus
  2. AND detection of toxin A or B in the stool or toxin-producing C. difficile in the stool
  3. OR visualization of pseudomembranes in the colon via colonscopy
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2
Q

When should C. diff associated diarrhea be suspected?

A

In patients with recent antibiotic use - within the previous 3 months

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3
Q

How does C. diff manifest clinically? (5)

A
  1. Diarrhea - almost never grossly bloody
    - Distinct odor
  2. Fever - 28% of cases
  3. Abdominal pain - 22%
  4. Leukocytosis - 50%
  5. May present with mild diarrhea to life-threatening toxic megacolon
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4
Q

What is the pathogenesis of C. diff? (3)

A

Step 1 - exposure to antimicrobial agents establishes susceptibility to CDI through disruption of normal colonic microbiota
Step 2 - exposure to toxigenic C. diff
Step 3 - virulent strain or high risk antibiotic or inadequate host immune response

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5
Q

C. diff is acquired ___________ - most often in ________ or _______ ______

A

exogenously; hospital; nursing homes

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6
Q

What is the morphology of C. diff? (4)

A
  1. Gram positive
  2. Spore forming
  3. Anaerobic bacillus
  4. Causes toxin mediated disease - two toxins - A and B (diagnosis is confirmed by the presence of these toxins)
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7
Q

All antibiotics have been associated with CDI, including those used to treat it. Which ones have the highest risk though? (5)

A
  1. Clindamycin
  2. Fluoroquinolones
  3. Cephalosporins (esp. 3rd and 4th generation)
  4. Ampicillin
  5. Carbapenems
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8
Q

All antibiotics have been associated with CDI, including those used to treat it. Which ones have the lowest risk though? (5)

A
  1. Penicillin
  2. Macrolides
  3. Tetracycline
  4. TMP/SMX
  5. Aminoglycosides
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9
Q

Risk of CDI continues until _ months past antibiotic therapy

A

3

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10
Q

What are the risk factors for CDI? (7)

A
  1. Older age
  2. Greater severity of underlying disease
  3. Gastrointestinal surgery
  4. Use of rectal electronic thermometers
  5. Enteral tube feeding
  6. Antacid therapy - PPIs > H2RAs
  7. Hospitalization - linked to # of days
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11
Q

What are 3 important features to note about CDI recurrences?

A
  1. Recurrences are common - 15-30% for first recurrence
  2. Recurrences may be relapse (same strain) or new infection (new strain)
  3. Different strains produce greater amounts of toxin
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12
Q

How is CDI managed? (4)

A
  1. Stop the offending antibiotic - if possible
  2. Fluid and electrolyte replacement therapy
  3. Avoid drugs which inhibit peristalsis such as diphenoxylate/atropine and loperamide
  4. Categorize as mild to moderate vs. severe AND uncomplicated vs. complicated
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13
Q

Severe CDI is defined as?
What does severe-complicated also include?

A

Severe - Leukocytes ≥ 15,000 cell/ul and/or SCr ≥ 1.5x baseline
Severe-complicated - hypotension, shock, ileus or megacolon

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14
Q

What is the first-line medication for mild to moderate initial episode of CDI? What is the dosing and for how long?

A

Vancomycin 125mg PO QID for 10-14 days

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15
Q

What are the 2 alternative medications for mild to moderate initial episode of CDI? What is the dosing and for how long?

A
  1. Fidamoxicin 200mg PO BID for 10 days
  2. Metronidazole 500mg PO TID for 10-14 days can be used in patients with mild diarrhea when the costs of vancomycin or fidaxomicin may be prohibitive for their use
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16
Q

What are the 2 drug treatment options for severe-uncomplicated initial episode of CDI? What is the dosing and for how long?

A
  1. Vancomycin 125mg PO QID for 10-14 days or
  2. Fidamoxicin 200mg PO BID for 10 days
17
Q

What is the first-line drug treatment for severe-complicated initial episode of CDI? What is the dosing and for how long? (2)

A
  1. Vancomycin 125-500mg PO QID for 10-14 days or via NG tube in conjunction with metronidazole 500mg IV Q8H
  2. Vancomycin retention enema sometimes added if ileus
18
Q

What is the alternative drug treatment for severe-complicated initial episode of CDI? What is the dosing and for how long?

A

Fidamoxicin 200mg PO BID for 10 days with IV metronidazole if severe allergy to PO vancomycin

19
Q

What is the drug treatment option for a first recurrence of CDI?

A

Same as initial episode (vancomycin or fidaxomicin - same doses)

20
Q

What is the main drug treatment option for second or subsequent recurrences of CDI?

A

Vancomycin as a prolonged taper and/or pulsed regimen
- E.g., 125mg QID x 14 days; 125mg TID x 7 days; 125mg BID x 7 days; 125mg once daily x 7 days; 125mg every 2 or 3 days for 2-8 weeks

21
Q

What are 3 alternative treatment options for second or subsequent recurrences of CDI?

A
  1. Fecal microbiota transplantation (FMT)
  2. Monoclonal antibody that binds to toxin
    - Toxin A = actoxumab
    - Toxin B = bezlotoxumab
  3. Surgery
22
Q

True or False? In terms of diagnosis, treatment, and complications - CDI in pediatrics is the same as adults

A

True

23
Q

What are the 2 drug treatment options for mild to moderate initial episode of CDI in pediatrics? Should know the dosing and for how long.
(Same applies to first recurrence, mild to moderate)

A

One of:
1. Metronidazole 30mg/kg/day PO QID for 10 days (max 500mg/dose)
2. Vancomycin 40mg/kg/day PO QID for 10 days (max 125mg/dose)

24
Q

What is the drug treatment option for severe-uncomplicated initial episode of CDI in pediatrics? Should know the dosing and for how long.
(Same applies to first recurrence, severe, uncomplicated)

A

Vancomycin 40mg/kg/day PO QID for 10 days (max 125mg/dose)

25
Q

What is the drug treatment option for severe-complicated initial episode of CDI in pediatrics? Should know the dosing and for how long

A

Vancomycin 40mg/kg/day PO QID (max 125mg/dose) via NG tube for 10-14 days. Consider addition of IV metronidazole 30mg/kg/day QID (max 500mg/dose) for 10 days

26
Q

What is the drug treatment option for second or subsequent recurrences of CDI in pediatrics?
What is the other potential option?

A
  1. Vancomycin as a prolonged taper and/or pulsed regimen
  2. Consider fecal microbiota transplantation for recurrence following a vancomycin taper
27
Q

What are the monitoring parameters for any patient with CDI? (6)

A
  1. Resolution of diarrhea
  2. Resolution of fever; abdominal pain, other symptoms
  3. Check for antimotility agents
  4. WBC, electrolytes
  5. Adherence with therapy - esp. complex tapering regimen
  6. Adverse effects of drugs - depending on which agent is being used
28
Q

Prevention of C. diff spread is critical. What should be done to minimize spread? (4)

A
  1. Handwashing with soap and water rather than alcohol gel
  2. Gloves and gowns
  3. Isolation/separate room and equipment
  4. Adequate room cleaning
29
Q

Probiotics to prevent CDI. Yay or nay?

A

It’s worth a shot - so yay I guess

30
Q

How can we prevent CDI in the first place? (6)

A
  1. Practicing good hygienic practices
  2. Deprescribing unnecessary PPIs
  3. Avoid anti-motility agents if possible - value in Traveller’s diarrhea but not here
    - Concerns of toxic megacolon and recurrence
  4. Avoid unnecessary antibiotic use overall
  5. Don’t treat asymptomatic C. diff
  6. Support narrow spectrum prescribing for other infections

PHAR 255 (14 decks)

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