Clostridioides difficle Infections

Question 1

What are the risk factors of CDI?

Answer 1

> 65y
Multiple or severe comorbidities
Hx of CDI
GI surgery
Tube feeding
Prior hospitalisation (last 1y)
Nursing home, LTC facilities
Abx use
Gastric suppressive thera

Question 2

What is the pathophysiology of CDI?

Answer 2

Spores transmitted by fecal-oral route
Colonisation of intestinal tract w C. difficile
Facilitated by abx use which disrupts the barrier fn of normal colonic flora
Toxins lead to inflamm & diarrhoea
Ig against toxins can be protective (asymptomatic carrier)

Question 3

What are the signs and symptoms of CDI?

Answer 3

> = 3 watery stools in 24h

Question 4

What are the stages of CDI?

Answer 4

Mild
Moderate
Severe
Fulminant

Question 5

What is the criteria for mild CDI?

Answer 5

Watery stools
Abdo cramping

Question 6

What is the criteria for moderate CDI?

Answer 6

Fever, malaise
Watery stools
Abdo cramping, distension
Hypovolemia
WBC < 15 x 10^9 /L
SCr < 133micromol/L (1.5 mg/dL)

Question 7

What is the criteria for severe CDI?

Answer 7

Fever
Watery stools
Abdo cramping, distension
WBC >= 15 x 10^9 /L
SCr >= 133 micromol/L (1.5 mg/dL)

Question 8

What is the criteria for fulminant CDI?

Answer 8

Hypotension, shock
Watery stools
Ileus
Megacolon

Question 9

What are the treatment categories for CDI?

Answer 9

Non-severe
Severe
Fulminant

Question 10

What is the recommended regimen for non-severe CDI?

Answer 10

PO Vancomycin 125 mg QDS
PO Fidaxomycin 200 mg BD

Alt:
PO Metronidazole 400 mg TDS

Question 11

What is the recommended regimen for severe CDI?

Answer 11

PO Vancomycin 125 mg QID
PO Fidaxomycin 200 mg BD

Question 12

What is the recommendation for fulminant CDI?

Answer 12

IV Metronidazole 500 mg Q8H AND
PO Vancomycin 500 mg QID
+/- PR Vancomycin 500 mg QDS

Question 13

What are the diagnostic criteria for CDI?

Answer 13

Radiographic evi of ileus or toxic megacolon or Presence of diarrhoea (3 unformed stools in 24h) AND

C.difficile stool test +ve OR
Colonoscopic or histopathologic evi of pseudomembranous colitis (CDI)

Question 14

What are the prevention strategies against CDI?

Answer 14

Reduce unnecessary prescription of abx
Isolate pts w CDI
If unable to isolate, cohort them and prioritise isolation for those with incontinence
Compliance to hand hygiene
Environmental cleaning (sporicidal agents)

Question 15

What are the adjunctive therapy for CDI?

Answer 15

Deprescribing PPI
Probiotics

Question 16

What is the recommended regimen for first occurrence of CDI?

Answer 16

If initial therapy was vancomycin
PO Vancomycin 125 mg QID x10-14d –> PO Vancomycin 125 mg BD x 7d –> PO Vancomycin 125 mg once daily x 7d –> PO Vancomycin 125 mg Q2-3d x 2-8 weeks OR
PO fidaxomycin 200 mg BD x10d OR
PO fidaxomycin 200 mg BD x5d –> PO fidaxomycin 200 mg EOD x20d

If initial therapy was metronidazole
PO Vancomycin 200 mg QID x10d

Question 17

What is the recommended regimen for subsequent recurrences of CDI?

Answer 17

PO Vancomycin 125 mg QID x10-14d –> PO Vancomycin 125 mg BD x 7d –> PO Vancomycin 125 mg once daily x 7d –> PO Vancomycin 125 mg Q2-3d x 2-8 weeks

OR
PO Vancomycin 125 mg QID x10d –> rifaximin 400 mg TDS x 20d
PO fidaxomycin 200 mg BD x5d –>PO fidaxomycin 200 mg EOD x20d
Fecal microbiota transplant