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PHRM 835 > Clostridioides difficile Infection > Flashcards

Clostridioides difficile Infection Flashcards

1
Q

Clostridioides difficile is what pathogen

A

Gram-Positive, spore-forming Anaerobic bacillus

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2
Q

Clostridioides difficile produces?

A

toxins that mediate Diarrhea and Colitis

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3
Q

Clostridioides difficile is transmitted via

A

the fecal-oral route

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4
Q

Pathogenesis of Clostridioides difficile

A
  1. Broad-spectrum antibiotic therapy leads to disruption of normal, colonic flora 2. Disruption of colonic flora allows for C. difficile colonization and proliferation 3. C. difficile proliferation results in the release of Toxins A, B, and Binary Toxin CDT 4. Toxins A, B, and Binary Toxin CDT can damage to the colonic mucosa
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5
Q

What major offenders that often contribute to the pathogenesis of C. difficile Colitis?

A

Clindamycin, Cephalosporins, and Fluoroquinolones

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6
Q

Signs and Symptoms of C. difficile Colitis

A

-Fever -Abdominal Pain -Leukocytosis -Watery and Perfuse Diarrhea (Key Symptom)

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7
Q

Complications of C. difficile Colitis

A

C. difficile Colitis may progress to life-threatening, Toxic Megacolon

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8
Q

Risk Factors for C. difficile Infections

A

-Antibiotic Use (Clindamycin, Cephalosporins & Fluoroquinolones -Elderly Patients -Chemotherapy -Increased Duration of Hospitalization -GI Surgery -Nasogastric Tube -Alteration of Gut pH (due to PPIs) -Laxative Use -Immunosuppression

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9
Q

Diagnosing C. difficile Colitis

A

Key Symptom – 3 or more unformed stools in the last 24 hours

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10
Q

Diagnostic Tests for C. difficile Colitis

A

-Stool Culture -Stool Enzyme Immunoassay -Nucleic Acid Amplification Test (NAAT) / Polymerase Chain Reaction (PCR)

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11
Q

Stool Culture

A

most sensitive, but NOT practical due to delayed results (i.e., requires surveillance)

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12
Q

Stool Enzyme Immunoassay (EIA)

A

rapid and easy, but less sensitive than a Stool Culture, and Toxins may be detectable after cure

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13
Q

Nucleic Acid Amplification Test (NAAT) / Polymerase Chain Reaction (PCR)

A

rapid, sensitive, and specific, but expensive

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14
Q

Notes about Diagnostic Tests

A

-Do NOT test Asymptomatic patients!!! -Test for Cure is NOT recommended!!!

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15
Q

TriCore uses a 2-Step EIA to enhance Sensitivity and Specificity for:

A

-Toxins A and B produced by C. difficile bacteria -Glutamate Dehydrogenase (GDH)

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16
Q
A

If the results are different (left image), run a Nucleic Acid Amplification Test

(NAAT) / Polymerase Chain Reaction (PCR) test

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17
Q
A

BOTH are Negative, do NOT treat

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18
Q
A

BOTH are Positive, so TREAT

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19
Q
A
20
Q

There are 3 different types of Severity of C. difficile Infections:

A
  • Non-Severe
  • Severe
  • Fulminant
21
Q

Non–Severe

A
  • WBC < 15,0000 / mm3
  • SCr < 1.5 mg / dL
22
Q

Severe

A
  • WBC > 15,000 / mm3
  • SCr > 1.5 mg / dL
23
Q

Fulminant

A

Hypotension or shock

24
Q

Management of C. difficile Infections

A
  • Discontinue offending agent if possible
  • Fluid and Electrolyte Replacement
  • Avoid Anti-Motility Agents
  • Infection Control
25
Q

Infection Control

A
  • Hand washing is critical!
  • Contact precautions for patients
  • Use Chlorine–containing Cleaners or other Sporicidal Agents
26
Q

Treatment of Initial C. difficile Infection Non-Severe

A
  • Vancomycin, 125 mg PO, QID for 10 days
  • Fidaxomicin, 200 mg PO, BID for 10 days
  • Metronidazole, 500 mg PO, TID for 10 days
27
Q

Treatment of Initial C. difficile Infection Severe

A
  • Vancomycin, 125 mg PO, QID for 10 days
  • Fidaxomicin, 200 mg PO, BID for 10 days
28
Q

Treatment of Initial C. difficile Infection Fuminant

A
  • Vancomycin, 500 mg PO QID PLUS
  • Metronidazole, 500 mg IV, q8h
29
Q

Treatment of Recurrent C. difficile 1st Recurrence If Vancomycin was used for Initial Episode

A

Fidaxomicin, 200 mg PO, BID for 10 days

30
Q

Treatment of Recurrent C. difficile 1st Recurrence If Fidaxomicin (or Vancomycin) was used for Initial Episode

A
  • Vancomycin, tapered and pulsed, 125 mg QID, for 10 – 14 days, then Vancomycin, 125 mg PO, BID for 7 days, and then Vancomycin, 125 mg PO, every 2 – 3 days for 2 – 8 weeks
31
Q

Treatment of Recurrent C. difficile 1st Recurrence If Metronidazole was used for Initial Episode

A

Vancomycin, 125 mg PO, QID for 10 days

32
Q

Treatment of Recurrent C. difficile 2nd or more recurrence

A
  • Vancomycin, tapered and pulsed (See above)
  • Vancomycin, 125 mg PO, QID for 10 days, followed by Rifamixin, 400 mg PO, TID for 20 days
  • Fidaxomicin, 200 mg PO, BID for 10 days
  • Fecal Microbiota Transplantation (FMT)
33
Q

Fecal Microbiota Transplantation (FMT) can be considered if

A

a patient has 3 or more occurences

34
Q

Other C. difficile Infection Treatment Options

A
  • Fecal Microbiota Transplantation (FMT)
  • Bezlotoxumab, 10 mg / kg IV, for 1 dose
35
Q

Fecal Microbiota Transplantation (FMT)

A

donated human stool; used for Recurrent C. difficile infections

36
Q

Bezlotoxumab, 10 mg / kg IV, for 1 dose

A
  • Human monoclonal antibody that binds to CD TcdB (Clostridium difficile Toxin B)
  • Used in combination with another active agent
  • Decreases recurrence rates, but shows no difference in initial cure rates
37
Q

Other Considerations in C. difficile Infection Treatment

A
  • Probiotics
  • Cholestyramine
38
Q

Probiotics are not currently recommended to prevent Clostridium difficile infections due to:

A
  • Lack of standardization of Probiotics
  • Risk of Bacteremia in Immunosuppressed patients
39
Q

Cholestyramine NOT recommended since it binds to

A

Vancomycin

40
Q

AP is a 70-year-old female who is admitted with an elevated WBC and abdominal pain. She has had 5 loose stools in the last 24 hours. She has a history of recurrent Urinary Tract Infections (UTIs). She has recently completed 2 weeks of therapy with Ciprofloxacin for Pyelonephritis.

Labs

Tmax – 38.8 °C

WBC 31 x 103 cells / mm3

SCr 2.1 mg / dl (Baseline 1.7)

PCR positive for C. difficile,

Albumin 3.2 g / dL

What are her risk factors for C. difficile infection?

A

ntibiotic (Ciprofloxacin) use AND Age (older than 65)

41
Q

AP is a 70-year-old female who is admitted with an elevated WBC and abdominal pain. She has had 5 loose stools in the last 24 hours. She has a history of recurrent Urinary Tract Infections (UTIs). She has recently completed 2 weeks of therapy with Ciprofloxacin for Pyelonephritis.

Labs

Tmax – 38.8 °C

WBC 31 x 103 cells / mm3

SCr 2.1 mg / dl (Baseline 1.7)

PCR positive for C. difficile,

Albumin 3.2 g / dL

How would you classify her infection by level of severity?

A

Severe since her WBC > 15 x 103 cells / mm3 and SCr is greater than 1.5 mg / dL. Meeting just one of these criteria makes a C. difficile infection Severe

42
Q

AP is a 70-year-old female who is admitted with an elevated WBC and abdominal pain. She has had 5 loose stools in the last 24 hours. She has a history of recurrent Urinary Tract Infections (UTIs). She has recently completed 2 weeks of therapy with Ciprofloxacin for Pyelonephritis.

Labs

Tmax – 38.8 °C

WBC 31 x 103 cells / mm3

SCr 2.1 mg / dl (Baseline 1.7)

PCR positive for C. difficile,

Albumin 3.2 g / dL

Which treatment regimen would you recommend (including drug, dose, route, frequency / interval, and duration)?

A
  • Vancomycin, 125 mg PO, QID for 10 days OR
  • Fidaxomicin, 200 mg PO, BID for 10 days
43
Q

AP is a 70-year-old female who is admitted with an elevated WBC and abdominal pain. She has had 5 loose stools in the last 24 hours. She has a history of recurrent Urinary Tract Infections (UTIs). She has recently completed 2 weeks of therapy with Ciprofloxacin for Pyelonephritis.

Labs

Tmax – 38.8 °C

WBC 31 x 103 cells / mm3

SCr 2.1 mg / dl (Baseline 1.7)

PCR positive for C. difficile,

Albumin 3.2 g / dL

On Day 2 of therapy, the patient is hemodynamically stable, but is still having a fever. Her WBC is 18 x 103 cells / mm3. What do you recommend for AP?

A

Continue current regimen until finished (for 8 more days)

44
Q

AP is a 70-year-old female who is admitted with an elevated WBC and abdominal pain. She has had 5 loose stools in the last 24 hours. She has a history of recurrent Urinary Tract Infections (UTIs). She has recently completed 2 weeks of therapy with Ciprofloxacin for Pyelonephritis.

Labs

Tmax – 38.8 °C

WBC 31 x 103 cells / mm3

SCr 2.1 mg / dl (Baseline 1.7)

PCR positive for C. difficile,

Albumin 3.2 g / dL

On Day 10 of therapy, the patient’s diarrhea has resolved. Her WBC is 9.4x 103 cells / mm3. She has been afebrile for 4 days. A repeat C. DIFF COMPLETE was obtained on Day 9, and the result returns positive today (Day 1). What do you recommend. Explain

A. Repeat treatment with same regimen used for initial infection

B. Give Vancomycin tapered regimen

C. Give Fidaxomicin 200 mg PO, BID for 10 days

D. Administer Fecal Microbiota Transplantation (FMT)

E. No therapy is indicated

A

E. – No therapy is indicated; Test for cure is NOT recommended.

Typically following treatment of a C. difficile infection, follow-up tests are NOT performed

45
Q

AP is a 70-year-old female who is admitted with an elevated WBC and abdominal pain. She has had 5 loose stools in the last 24 hours. She has a history of recurrent Urinary Tract Infections (UTIs). She has recently completed 2 weeks of therapy with Ciprofloxacin for Pyelonephritis.

Labs

Tmax – 38.8 °C

WBC 31 x 103 cells / mm3

SCr 2.1 mg / dl (Baseline 1.7)

PCR positive for C. difficile,

Albumin 3.2 g / dL

\AP completes treatment for C. difficile and has resolution of symptoms. 18 days after completion of therapy, she develops diarrhea with 8 – 10 loose stools in 24 hours.

Tmax 38.0 °C
WBC 12 x 103 cells / mm3
SCr 1.9 mg / dL (baseline 1.7)
C. DIFF COMPLETE EIA test is positive for C. difficile Albumin 3.2 g / dL.

What do you recommend?

A

witch to Fidaxomicin if started on Vancomycin (or Switch to Vancomycin if started on Fidaxomicin)

PHRM 835 (5 decks)

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