C.Diff,Biome-SS QL

Question 1

What is C. difficile?

Answer 1

Anaerobic gram-positive
 spore-forming bacillus.
NAP1/B1/027
SPORES Survive
Opportunistic. Suppressed in biome of diversity

Question 2

How is C Diff spread? What is the challenge with its control?

Answer 2

Fecal oral route. The challenge is that it **creates spores, and these spores can survive outside of the colon for months, and are resistant to standard disinfection.

Question 3

What is the leading cause of nosocomial diarrhea in the US?

Answer 3

C DIFF!

Question 4

There is a particular strain of C Diff that has caused epidemics in our country. What strain is this and why is it so dangerous?

Answer 4

NAP1/BI/027 strain. This strain has a mutation in the gene that makes the toxin —> MORE toxin!

Question 5

An infection with C Diff requires 2 factors. What are these 2 factors?

Answer 5

1. Alteration of the normal microbiome —> vulnerable colon (usually d/t antibiotics). 2. Exposure to the organism (usually in a health care facility).

Question 6

What antibiotics in particular are associated with C Diff infection?

Answer 6

ALL OF THEM.

Question 7

After C Diff gets inside a vulnerable person, how/where does it act?

Answer 7

Once ingested, they germinate in the small bowel —> multiply in the colon and cause inflammation.

Question 8

What is the biome “cloud?”

Answer 8

The organisms that a human emits in the space surrounding them. Humans emit 10^6 particles per hour.

Question 9

Is it healthier to have a more or less diverse colonic biome?

Answer 9

MORE diverse!

Question 10

Does the gut microbiota change over time or remain stable?

Answer 10

stable from age 3-5 years on. living in close quarters will increase a biome diversity.

Question 11

What are the different clinical manifestations of the colonization of C Diff?

Answer 11

1. Asymptomatic colonization (60-65%)
2. Diarrhea, mild to severe
3. Fulminant colitis/toxic megacolon (2-3%)
4. Recurrent infection (20-30%)

Question 12

How is C Diff diagnosed?

Answer 12

Toxin A&B EIA Enzyme Immunoassay through stool sample.
*Testing for the toxin produced by C Diff.

Can also do C Diff PCR to rule out C Diff. But a positive result only shows that the patient was exposed, not if they are currently infected.

Question 13

How can we prevent C Diff infections?

Answer 13

1. Antibiotic stewardship!!!! And recommend probiotics when prescribing
2. Isolation of ill patients.
3. Hand hygiene —> WASH hands with soap and water.
4. Discontinue unnecessary PPIs (ruins defense mechanism of the body).

Question 14

What is the treatment of C Diff?

Answer 14

1. Stop offending antibiotics if possible.
2. Vancomycin 125mg QID x10-14 days if severe disease or metronidazole intolerant. OR if complicated, PO vanco + IV metronidazole

Question 15

What are the possible mechanisms of C Diff recurrence?

Answer 15

1. Persistent spores
2. Impaired host immune response
3. Decreased biome diversity
4. Reinfection from environment.

Question 16

How should you treat a patient’s first recurrence of C Diff?

Answer 16

Re-treat with vancomycin x10-14 days.

Question 17

How should you treat a patient’s 2nd recurrent C Diff?

Answer 17

Vancomycin pulse therapy: Vancomycin Q2D x4 days, then skin 2 days, continue for 4 more, skip 3 days, continue for 4 more, skip 4 days, continue for 4 more, then skip 5 days and continue for 4 more.

Question 18

How should you treat a patient’s 3rd recurrent C Diff?

Answer 18

Fecal Microbiota Transplant: administration of feces from a human donor to another.

Question 19

What are the different routes of administration of FMT? Do certain routes work better than others?

Answer 19

1. Nasogastric or nasoduodenal tube 2. Retention enemas 3. Colonoscopy 4. Encapsulation NO! All routes are equally as effective.

Question 20

Is there any risk that goes along with a fecal transplant?

Answer 20

YES! - Risk of infection - Risks related to administration, i.e. perforation, sedation-related complications, aspiration pneumonia or regurgitation of feces after nasoduodenal tube.

Question 21

Is there any other pharmacologic treatment for recurrent C Diff infections that is not antibiotics?

Answer 21

Zinplava: monoclonal antibody against the toxin C Diff. **VERY expensive and only drops recurrence rate from 27-17%. Just came on to the market.