Clostridium Difficile

Question 1

Which antibiotics have lower risk of upsetting local flora and causing C. Diff

Answer 1

Tetracyline
Doxycyline
Azithromycin

Question 2

Which antibiotics have increased risk of causing C. Diff

Answer 2

Fluoroquinolones
Carbapenems
3rd and 4th generation cephalosporins
Clindamycin

Question 3

Prophylactic Vancomycin in patients with previous C diff?

Answer 3

There is a risk of vancomycin resistant enterococcus (VRE) - but in practice this isnt a major problem

So prophylactic oral vancomycin for patients at risk of C Diff is ok

Question 4

Does alcohol sanitizer kill c diff spores

Answer 4

No.

We need to use constant barrier precautions
Hand wash (not alcohol) with chlorhexidine soap is required to kill C.Diff spores.

Also - clothes are fomytes

SHould we just be using hospital laundered scrubs which are washed at high temps to sterilize.

Clean the ultrasounds with chlorhexidine soap.

Question 5

What is the range of C diff severity

Answer 5

Mild diarrhoea

to

Septic shock

Toxic megacolon

Death

Question 6

When should we test for C Diff in the ICU

Answer 6

All patients with acute diarrhoea

But also must consider in Sepsis with no other source obvious and high leukocytosis (WCC 30 - 50)

Question 7

C

Answer 7

C. Diff Ag (PCR
- Still positive if C. Diff resolved for months

C.Diff Toxin
- Treatment causes negative toxin assay

Vital to use clinical evaluation and laboratory for diagnosis and treatment

Question 8

Which patients require colonoscopy before started treatment

Answer 8

Stable and diagnostic dilemma

Question 9

Should abdominal X rays be done

Answer 9

Serial AXR bedside to monitor for Toxic megacolon

CT Abdo - look for perf/ascites/other intrabdominal catastrophes

Question 10

Is anti-diarrheal medication indicated

Answer 10

No. Its contraindicated.
Avoid anticholinergics
Avoid anything that slows colon transit
Continue diarrhoea –> these patients do best –> continuous clearing of colon.
Severe C.Diff keep them NPO

Question 11

What agents are used for C.Diff treatment.
How long

Answer 11

Oral Vancomycin 125 mg 6 hourly for 10 - 14 days

Add metronidazole IV for severe disease –> goes into biliary tree and excreted into small bowel and then gets to the colon.

(No role for oral metronidazole)

Question 12

When should a colectomy be considered for source control

Answer 12

A patient deteriorating, failed medical therapy before severe MOF.

Get surgeons involved early so that they are on board and present in the process (denial-acceptance phase).

Question 13

What other antimicrobial can be used in refractory cases

Answer 13

Tigecycline - broad spectrum antibiotic which is effective against C.Diff.

Question 14

Alternative therapies for C. Diff

Answer 14

? Bezlotoximab - binds C Diff toxin

Question 15

Role for microbiotica - Gut flora transplantation

Answer 15

Not in acutely ill ICU patients