EXAM 4 C. Diff Flashcards
C. Diff basics
Gram (+), spore-forming
Transmitted person-to-person via fecal-oral route through ingestion of spores
Included in normal flora, but colonization higher in hospitalized patients
C. Diff risk factors
ABX exposure
healthcare exposure
Age > 65yo, proximity to C.diff infection
acid suppressing agents
chemotherapy
immunosuppression
GI surgery
C. Diff ABX exposure highest risk
highest risk : clindamycin and fluoroquinolones
3rd/4th gen cephalosporins
carbapenems
C. diff pathogenesis
disruption of colon flora
introduction of C. diff to colon
multiplication of C. diff and production of toxin
colon and rectal mucosa becomes edematous with raised plaques
Signs/symptoms of C. Diff
Profuse, watery, foul smelling diarrhea
Abdominal pain
antitbiotic associated diarrhea
Mild-mod diarrhea
Normal colon
Negative toxin assay
No treatment indicated
lab testing for C. diff
When to test: 3 or more profuse, watery or mucoid green, foul smelling stools in 24 hours
repeat testing within 7 days of same episode not recommended
non-severe C. diff
WBC < 15,000
SCr < 1.5
Severe C. diff
WBC > 15,000
SCr > 1.5
fulminant C. diff
Hypotension or shock ileus
Toxic megacolon –> medical emergency
C. diff treatment options
oral vancomycin
fidaxomicin
metronidazole (IV/PO)
oral vancomycin considerations
Broad spectrum and Standard of care
poor oral absorption –> so advantage bc it gets to site of infection
fidaxomicin considerations
Narrower spectrum than PO vanc
poor oral absorption
higher rates of sustained treatment response and lower recurrence rates
cost considerations: biggest barrier for use
metronidazole considerations
No longer recommended for first line
Reserved for fulminant
good oral absorption
less efficacious and higher risk of recurrence
what agents should C. diff patients avoid?
avoid peristaltic agents like loperamide –> bc it keeps toxin in body
C. diff treatment - Initial episode non-severe
fidaxomicin (first choice from top to bottom)
vancomycin
metronidazole
C. diff treatment - Initial episode severe
fidaxomicin
vancomycin
C. diff treatment - First CDI recurrence
fidaxomicin or vancomycin if not used in initial episode
Fidaxomicin extended dosing or vancomycin tapered
C. diff treatment - Second and subsequent CDI reccurence
Select different option from first CDI recurrence
C Diff treatment - Fulminant CDI
Vancomycin plus metronidazole
If ileus present consider vancomycin rectal
Risk factors for CDI recurrence
Age > 65 yo
Severe CDI on presentation
Immunocompromised host
reccurent prevention of C diff drugs
Fecal microbiota transplant (FMT)
Rebyota (fecal microbiota)
Vowst (fecal microbiota)
Bezlotoxumab (zinplava)
Fecal microbiota transplant (FMT)
Administration of fecal material from healthy pt to restore gut balance
Indication: 3 or more episodes of CDI or poor response to ABX for CDI
Can be used for reccurence or treatment
Rebyota (fecal microbiota)
Fecal microbiota suspension
Indication: prevention of recurrence of CDI following ABX for recurrent CDI
150 mL via rectal tube 24-72 hrs after treatment completion
Vowst (fecal microbiota)
Bacterial spore suspension – modulate bile acid to resist C. diff
Indication: prevention of recurrence of CDI following ABX for recurrent CDI
Oral option that needs bowel prep
Bezlotoxumab (zinplava)
Monoclonal antibody targets C. diff toxin
Indication: prevention of recurrence of CDI for pts high risk for recurrent CDI
Caution in patients with CHF
Probiotic use in C. diff
Controversial
Insufficient data and many ABX can kill probiotics
