Clostridium difficile

Question 1

After first episode, 20% of patients experience recurrence.

This is either due to reinfection from contaminated environment, or release of germinating spores in gut

What is criteria for recurrence?

Answer 1

CDI that occurs within 8 weeks of previous positive result

Question 2

Treatment for CDI

After how many days would you expect a clinical response?

Answer 2

3-5 days start to see clinical response

day 7 should be reasonable improvement, but not back to normal

may take weeks for stool consistency/ frequency to return to normal

Question 3

What are markers of severe CDI?

Answer 3

Temp >38.5
hypotension

WCC >15
Cr 1.5x baseline

ileus
colonic dilatation >6cm
pseudomembranous colitis

Question 4

Patient admitted with diarrhoea, recent courses of antibiotics, and on PPI.

CDI suspected

Should antibiotics be started?

Answer 4

vancomycin 125mg QDS until toxin result known

Question 5

CUH guidelines

What is first line treatment of CDI?
non-severe

Answer 5

Fidaxomicin 200mg BD for 10 days

Question 6

CUH guidelines

Patient on fidaxomicin first line treatment, for non-severe CDI

What to do if not improving?

Answer 6

Consider vancomicin/ metronidazole

refer gastro - faecal transplant

consider IVIG

Question 7

CUH guidelines

C. diff PCR positive
Toxin equivocal

How to proceed with result?

Answer 7

If no other cause of diarrhoea found e.g viral, laxatives, then treat with vancomycin

Question 8

CUH guidelines

What is first line treatment of CDI?
severe

Answer 8

vancomycin 500mg QDS oral plus
metronidazole 500mg TDS IV

refer to surgeons

Consider IVIG/ faecal transplant

once improving, stop metronidazole, and reduce dose of vancomycin to 250mg QDS. 14 days total

Question 9

CUH guidelines

What is treatment of first CDI recurrence?
second episode

Answer 9

vancomycin 125mg QDS 14 days

Question 10

CUH guidelines

What is treatment of second CDI recurrence?
third episode

Answer 10

refer gastro for faecal transplant

if not suitable for faecal transplant -
vancomycin 
250mg QDS 7 days
125mg QDS 7 days
125 BD 7 days
125 OD 7 days
125mg alternate days for 7 days
125mg every third day for 14 days then stop
(7 weeks total)

Question 11

What anti-parasitic drug has shown some benefit in treating CDI?

Answer 11

Nitazoxanide 500mg BD 7-10 days

this is unlicesnsed use currently