Clostridium Difficile Flashcards
ATLAS scoring for C diff severity
Age Treatment with concomitant abx Leukocytes Albumin SCr
Vancomycin taper schedule
QID x2 weeks TID x1 weeks BID x1 week Daily x1 week TIW x1 week
Evidence for probiotics in C. Diff prevention
Conflicting evidence exists on the role of probiotics for both primary and secondary preven- tion (greater lack of evidence in secondary prevention). A Cochrane review supports use for primary prevention if baseline CDI rates are greater than 5%.
Prevalence of C. Difficile in stool of asymptomatic adults in community vs adult inpatients
<2% vs 3-26%
Proportion of patients with a first diagnosis of CDI who will develop at least one recurrence
[39]. After a first diagnosis of CDI, 10%–30% of patients develop at least 1 recur- rent CDI episode, and the risk of recurrence increases with each successive recurrence
C diff testing approach when stool screening submission implemented
Use a NAAT alone or a multistep algorithm for testing (ie, GDH plus toxin; GDH plus toxin, arbitrated by NAAT; or NAAT plus toxin) rather than a toxin test alone when there are preagreed institutional criteria for patient stool submission (Figure2) (weak recommendation, low quality of evidence).
Repeat C diff testing considerations
Do not perform repeat testing (within 7 days) during the same episode of diarrhea and do not test stool from asymp- tomatic patients, except for epidemiological studies (strong recommendation, moderate quality of evidence).
Duration of contact precautions for C diff
- Continue contact precautions for at least 48 hours after diarrhea has resolved (weak recommendation, low quality of evidence).
Risk factors for Cdiff acquisition
The risk of CDI was associated with increasing cumulative dose, number of antibiotics, and days of antibiotic exposure. For example, compared to patients who received only 1 antibiotic, the adjusted hazard ratios (HRs) for those who received 2, 3 or 4, or ≥5 antibiotics were 2.5 (95% CI, 1.6–4.0), 3.3 (95% CI, 2.2–5.2), and 9.6 (95% CI, 6.1–15.1), respectively [288]. Therefore, it is critical to avoid unnecessary antibiotics and to minimize the duration of use to reduce the risk ofCDI.
Thus, there appears to be a clinical association between PPI use and CDI, but the true causal relationship is unclear. No RCTs or qua- si-experimental studies have studied the relationship between discontinuing or avoiding PPI use and risk of CDI.
Treatment of initial C diff episode
- Either vancomycin or fidaxomicin is recommended over metronidazole for an initial episode of CDI. The dosage is vancomycin 125 mg orally 4 times per day or fidaxomicin 200mg twice daily for 10days (strong recommendation, high quality of evidence) (Table 1).
Treatment of fulminant Cdiff episode
For fulminant CDI, vancomycin administered orally is the regimen of choice (strong recommendation, moderate qual- ity of evidence). If ileus is present, vancomycin can also be administered per rectum (weak recommendation, low quality of evidence). The vancomycin dosage is 500mg orally 4 times per day and 500mg in approximately 100mL normal saline per rectum every 6 hours as a retention enema. Intravenously administered metronidazole should be administered together with oral or rectal vancomycin, particularly if ileus is present (strong recommendation, moderate quality of evidence). The metronidazole dosage is 500mg intravenously every 8 hours.
In patients not responding to vancomycin and metronidazole, intravenously administered tigecycline (loading dose of 100mg followed by 50mg 2 times per day)
Definition of fulminant Cdiff
*Fulminant CDI, previously referred to as severe, complicated CDI, may be characterized by hypotension or shock, ileus, or megacolon.
Treatment of first recurrence (non-fulminant) of CDI
- Treat a first recurrence of CDI with oral vancomycin as a tapered and pulsed regimen rather than a second standard 10-day course of vancomycin (weak recommendation, low quality of evidence),or 2. Treat a first recurrence of CDI with a 10-day course of fidax- omicin rather than a standard 10-day course of vancomycin (weak recommendation, moderate quality of evidence),
Oral vancomycin should be used as a tapered and pulsed-dose reg- imen if a standard 10-day course of vancomycin was used for the initial episode. Various regimens have been used and are similar to this one: After the usual dosage of 125mg 4 times per day for 10–14days, vancomycin is administered at 125mg 2 times per day for a week, 125mg once per day for a week, and then 125mg every 2 or 3days for 2–8 weeks, in the hope that C.difficile vegetative forms will be kept in check while allow- ing restoration of the normal microbiota.
CDI prophylaxis in patients with prior episodes starting abx
To date there are no prospective, randomized studies of secondary prophylaxis of CDI to guide recommendations, but if the deci- sion is to institute CDI prevention agents, it may be prudent to administer low doses of vancomycin or fidaxomicin (eg, 125mg or 200mg, respectively, once daily) while systemic antibiotics are administered. Factors that might influence the decision to administer secondary prophylaxis include length of time from previous CDI treatment, and patient characteristics (number of previous CDI episodes, severity of previous episodes, and underlying frailty of the patient).
Treatment of second and greater recurrences
Antibiotic treatment options for patients with >1 recurrence of CDI include oral vancomycin therapy using a tapered and pulsed regimen (weak recommendation, low quality of evi- dence), a standard course of oral vancomycin followed by rifaximin (weak recommendation, low quality of evidence), or fidaxomicin (weak recommendation, low quality of evidence).
