C diff Flashcards
Risk factors
Antibiotic exposure
healthcare exposure
age > or equal to 65 yo
proximity to person with C diff
use of acid suppression agents
chemotherapy
immunosupression
GI surgery
Antibiotic exposure with highest risk to cause C diff
Fluoroquinolones
Clindamycin
3rd/4th generation cephalosporins
carbapenems
Signs and symptoms
Two primary symptoms
- profuse, watery, or mucoid green, foul smelling diarrhea
- abdominal pain
other signs and symptoms
fever
leukocytosis
hypoalbuminemia
acute kidney injury
When to test for C diff
3 or more profuse, watery, foul smelling stools in 24 hours
Testing methods for C diff diagnosis
Nucleic acid amplification test (NAAT) alone (in conjunction with signs/ symtoms)
2. Antigen test (GDH)+ Toxin A/B test
3. NAAT + Toxin A/B test
Severity based on WBC and SCr
Non-Severe:
WBC: < or equal to 15,000/mcl
SCr: <1.5 mg/dl
Severe:
WBC: >15,000/mcl
SCr: >1.5 mg/dl
Fulminant:
Hypotension or shock ileus
toxic megacolon
C diff infection treatment options
Oral vancomycin
Fidaxomicin
Metronidazole (IV or PO)
Vancomycin key information and patient focused consideration
Standard dose - 125mg PO Q6H
Fulminant CDI dosing - 500mg PO Q6H
Patient considerations
- liquid version can have a bitter taste, usually covered by insurance, liquid is more expensive
Fidaxomicin (Dificid) key information and patient focused consideration
standard dosing - 200mg PO Q12H
cost is pricy, might not be covered by insurance
Metronidazole key information and patient focused consideration
standard dosing - 500mg PO Q8H
Fulminant dosing - 500mg IV Q8H
less efficacious and higher risk for recurrence
C diff treatment for
initial episode non severe
based on Scr and WBC
DOC: fidaxomicin 200mg PO Q12H x 10 days
second options:
vancomycin 125mg PO Q6H x 10 days
metronidazole 500mg PO Q8H x 10 days
C diff treatment for
initial episode SEVERE
DOC Fidaxomicin 200mg Q12H x 10 days
Other option:
Vancomycin 125mg PO Q6H x 10 days
C diff treatment for first CDI recurrence
- If patient has recurrent you should change drug or dosing regimen (if patient was on any of these for their first episode switch to different option)
Fidaxomicin 200mg Q12H x 10 days
or
Vancomycin 125mg PO Q6H x 10 days
or
Fidaxomicin 200mg PO Q12H x 5 days, then 200mg PO every other day x 20 days
or
Vancomycin tapered and pulsed regimen
C diff treatment for second and subsequent CDI recurrence
Fidaxomicin 200mg Q12H x 10 days
or
Vancomycin 125mg PO Q6H x 10 days
or
Fidaxomicin 200mg PO Q12H x 5 days, then 200mg PO every other day x 20 days
or
Vancomycin tapered and pulsed regimen
again if patient was on any of the following previously do NOT use the same treatment switch to different
Fulminant CDI treatment options
Vancomycin 500mg PO Q6H
PLUS
Metronidazole 500mg IV Q8H
if ileus present, consider adding vancomycin 500mg via rectal instillation Q6H
duration of treatment is not well defined
Risk factors for CDI recurrence
Age > or equal to 65 years
severe CDI on presentation
immunocompromised host
Fecal microbiota transplant what is it and what are potential indications
this is administration of fecal material from healthy person to restore a balanced gut microbiome - (can be used as both treatment option and method to reduce recurrence)
Indications:
three or more episodes of CDI
poor response to initial antibiotic therapy for CDI
Rebyota (recal microbiota, live-jslm)
indication and dosing
PREVENTION of recurrence of CDI for patients following antibiotic treatment for recurrent CDI
dosing - 150ml administered via rectal tube 24-72 hours after treatment completion
Vowst (fecal microbiota, live-brpk) what is it, what are indications, and what is dosing
it will modulate bile acid concentrations and restore fatty acids, which results in resistance to C diff colonization and restoration of the gut microbiome
Indication:
PREVENTION of recurrence of CDI for patients following antibiotic treatment for recurrent CDI
Dosing - 4 capsules PO once daily x 3 days starting 2-4 days after treatment completion
Bezlotoxumab (Zinplava)
what is it, what are indications, what is dosing, patient consideration
monoclonal antibody targeting C diff toxin B to neutralize its effects
indication:
Prevention of recurrence of CDI for patients at high risk for CDI recurrence
Dosing - 10mg/kg IV x 1 dose during the course of CDI treatment
Patient consideration
CAUTION IN PATIENTS WITH CHF (THIS CAN INCREASE RISK OF CHF AND POSSIBLY MORTALITY)
JB is a 67-year-old male presenting to the hospital with a 3-day onset of profuse,
watery, foul-smelling diarrhea and abdominal pain. He reports having 7 stools in the
last 24 hours. He reports finishing a 7-day course of levofloxacin 5 days ago for
possible pneumonia.
Past medical history
▪HTN
▪GERD
▪T2DM
Home medications
▪Lisinopril 40 mg PO once daily
▪Pantoprazole 40 mg PO once daily
▪Metformin 1000 mg PO BID
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What risk factors does
JB have for CDI?
recent antibiotic use
age >65
use of anti-acid agent
CT of the abdomen and pelvis is performed
and shows colitis
▪C. difficile testing is sent and the GDH and
toxin tests are positive
▪Pertinent lab values
▪WBC 22,000 cells/mL
▪Hgb 13.1 g/dL
▪Plt 205,000/mm3
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▪Na 138 mmol/L
▪K 4.9 mmol/L
▪Cl 100 mmol/L
▪CO2 23 mmol/L
▪BUN 10 mg/dL
▪SCr 1.8 mg/dL
How would you classify
JB’s CDI?
WBC >15,000
SCr >1.5
Patient is classified as initial episode and severe
JB is admitted to the hospital for management of CDI
▪What is your treatment recommendation?
▪Fidaxomicin 200 mg PO Q12H x 10 days
▪Vancomycin 125 mg PO Q6H x 10 days
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Findaxomicin 200mg PO Q12H x 10 days
JB returns to the hospital 3 weeks later. Although he initially responded to
vancomycin, his symptoms returned 2 weeks after finishing treatment. He is
again experiencing profuse, watery, foul-smelling diarrhea and abdominal pain.
He reports having 5 stools in the last 24 hours.
▪C. difficile testing is sent and the GDH and toxin tests are positive.
▪Pertinent lab values
▪WBC 14,000 cells/mL
▪Hgb 13.5 g/dL
▪Plt 207,000/mm3
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▪Na 139 mmol/L
▪K 4.2 mmol/L
▪Cl 103 mmol/L
▪CO2 22 mmol/L
▪BUN 11 mg/dL
▪SCr 1.1 mg/dL
How would you classify
JB’s CDI?
What would be appropriate treatment options
First recurrence CDI, second episode non-severe
Make sure to change up treatment
- could do Fidaxomicin 200mg PO Q12H x 10 days
- could do vancomycin taper regimen
- could consider options to reduce recurrence – Rebyota ®, Vowst ®,
bezlotoxumab
