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PHAR255 > C. Difficile > Flashcards

C. Difficile Flashcards

1
Q

What is CDAD?

A

clostridioides difficile associated diarrhea
- > 3 unformed stools/day for > 2 days with no other recognized cause
- AND detection of toxin A or B in the stool or toxin-producing C.difficile in the stool
-OR visualization of pseudomembranes via colonoscopy

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2
Q

When should we suspect CDAD?

A

patients with recent antibiotic use
-within the previous 3 months

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3
Q

What are the clinical manifestations of CDAD?

A

diarrhea (almost never grossly bloody)
-distinct odour
fever
abdominal pain
leukocytosis
may present wild mild diarrhea to life-threatening megacolon

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4
Q

Explain the pathogenesis of CDAD.

A
  1. exposure to antimicrobial agent establishes susceptibility to CDI through disruption of normal colonic microflora
  2. exposure to toxigenic C.diff
  3. virulent strain or high risk antibiotic or inadequate immune response
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5
Q

How is C.diff acquired?

A

exogenously
-most commonly in hospitals or nursing homes
note: carried in the stool, can be asymptomatic, high rates of colonization in neonates and children

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6
Q

Describe C.diff itself.

A

gram positive
spore forming
anaerobic bacillus
causes toxin mediated disease (toxin A and B)

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7
Q

Which antibiotics cause CDI?

A

ALL antibiotics have been associated with CDI, including those used to treat it

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8
Q

Which antibiotics are the highest risk for CDI?

A

clindamycin
fluoroquinolones
cephalosporins (esp 3rd/4th gen)
ampicillin
carbapenems

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9
Q

Which antibiotics are the lowest risk for CDI?

A

penicillin
macrolides
tetracyclines
TMP/SMX
aminoglycosides

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10
Q

How long is the risk of CDI present for after completion of antibiotic therapy?

A

until 3 months past therapy

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11
Q

What are the risk factors for CDI?

A

older age
greater severity of underlying illness
gastrointestinal surgery
enteral tube feeding
use of rectal electronic thermometers
antacid therapy: PPI > H2RA
hospitalization - linked to # of days

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12
Q

What are the important features of CDI?

A

recurrences are common
recurrence can be relapse (same strain) or new infection (new strain)
NAP1/BI/027: produce greater amounts of toxin

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13
Q

What are some general management strategies for CDI?

A

stop the offending antibiotic (if possible)
fluid and electrolyte replacement therapy
avoid drugs which inhibit peristalsis
-diphenoxylate/atropine and loperamide

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14
Q

How is CDI categorized?

A

mild-moderate vs severe and complicated vs uncomplicated
severe: leukocytes > 15,000 cell/uL and/or SCr > 1.5 baseline
severe-complicated: shock, hypotension, ileus or megacolon

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15
Q

What is first line therapy for initial mild-moderate CDI?

A

vancomycin 125mg po QID x 10-14d

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16
Q

What are alternative therapies for initial mild-moderate CDI?

A

fidaxomicin 200mg po BID x 10d
metronidazole 500mg po TID x 10-14d if mild diarrhea and $$$ is a problem

17
Q

What is the treatment for initial severe uncomplicated CDI?

A

vancomycin 125mg po QID x 10-14d
OR
fidaxomicin 200mg po BID x 10d

18
Q

What is the treatment for initial severe complicated CDI?

A

vancomycin 125-500mg po QID x 10-14d or via NG tube in conjunction with metronidazole 500mg IV q8h
-vancomycin retention enema sometimes added if ileus
alt: fidaxomicin 500mg po BID x 10d with IV metronidazole if severe allergy to po vancomycin

19
Q

What is the treatment for a first recurrence of CDI?

A

same as initial episode
-vancomycin or fidaxomicin, same doses

20
Q

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

A

vancomycin prolonged taper and/or pulsed regimen
fecal microbiota transplantation
monoclonal antibody that binds toxin
-actoxumab (toxin A)
-bezlotoxumab (toxin B)
surgery

21
Q

How long do paeds show asymptomatic colonization of C.diff for?

A

until 2 years

22
Q

What are the principles of treatment of CDI for pediatrics?

A

same principles of treatment:
-stop antibiotic
-supportive care: fluids, nutrition, antipyretics
-specific tx for pathogen if no improvement after d/c antibiotics

23
Q

What are the complications of CDI in pediatrics?

A

complications are infrequent
-associated with comorbid immunosuppression and GI dx

24
Q

What are monitoring parameters for CDI?

A

resolution of diarrhea
resolution of fever, abdominal pain, other sx
electrolytes, WBC
check for antimotility agents
adherence with therapy (esp complex tapers)
AE of drugs

25
Q

What is critical with CDI?

A

prevention of spread
-handwashing with soap and water
-isolation/separate room and equipment
-gloves and gown
-adequate room cleaning

26
Q

How can we prevent CDI?

A

good hygienic practices
deprescribe unnecessary PPIs
avoid unnecessary antibiotic use overall
narrow spectrum prescribing
dont treat asymptomatic C.diff
avoid anti-motility agents

27
Q

What is the role of probiotics in CDI?

A

data is not robust, it is unlikely to cause harm but uncertain of any benefit

PHAR255 (24 decks)

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