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infec y3s1 > IC17 C.difficile > Flashcards

IC17 C.difficile Flashcards

1
Q

bacteria type

A

Gram-positive, spore forming anaerobic bacillus

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2
Q

causes of infection

A
  • antibiotic-associated diarrhoea & colitis
  • Nosocomial diarrhoea → increases duration of hospitalisation & healthcare cost
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3
Q

transmission route

where can the bacteria be found

A

faecal-oral route

where it is found
* rooms of patients with CDI
* On hands of healthcare workers
* On medical instruments

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4
Q

pathogenesis

toxin; role of Ab

A
  • Colonisation of intestinal tract with C.difficile via faecal-oral route
    Facilitated by AB use → disrupts barrier function of normal colonic flora (imbalance of normal flora) ⇒ C.difficile can multiply & produce toxins
  • Toxigenic C.difficile releases toxin A & toxin B
    Toxin B ⇒ more clinically important; causes more severe disease
  • Toxins leads to inflammation & diarrhoea

Antibodies can be protective against toxins
* Asymptomatic carriers → higher serum levels of Ab compared to those who develop severe disease

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5
Q

risk factors

GA2T2 RICH2

A
  • Advanced age > 65 years ⇒ impaired immunity
  • Multiple or severe comorbidities
  • Immunosuppression
  • History of CDI ⇒ more vulnerable & susceptible
  • GI surgery ⇒ disruption of GI lining & microbiota
  • Tube feeding (enteral-feeding)
  • Prior hospitalisation (last 1 year); Duration of hospitalisation
  • Residence in nursing home or long‐term care facilities
  • Use of antibiotics
  • Use of gastric acid suppressive therapy ⇒ affects normal microbiota of GI
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6
Q

risk factors: AB

causative, protective, general guide

A

Greatest risks: clindamycin, 3rd/4th gen cephalosporins, Fluoroquinolones
* Highest risks while receiving AB, but still elevated even up to 12 weeks after stopping

Protective AB: doxycycline, tigecycline, metronidazole
* Active against C.difficile growth & inhibits toxin production
* Minimal effects on gut flora

Generally, increased risks with: (dose-dependent risk)
* Increased cumulative exposure of AB
* use for >2 weeks
* larger number of AB used

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7
Q

infection control & prevention

I HEA2P

A

Isolation
* Patients should have a private room with dedicated toilet → to decrease transmission to other patients
* If have limited number of private single rooms
Prioritise patients with stool incontinence for private rooms

Hand hygiene
* Wear gloves & gown
* Wash hands with soap and water > alcohol hand rub
To remove spores

Environmental cleaning With sporicidal agents

AMS
* Minimise frequency & duration of high-risk AB therapy
* Minimise number of AB agents prescribed

Acid suppression
* Unnecessary PPIs should be discontinued in general

Probiotics (Not routinely recommended)

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8
Q

range of clinical presentation

A
  1. asymptomatic
  2. mild symptoms
  3. moderate symptoms
  4. severe symptoms
  5. fulminant symptoms
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9
Q

clinical presentation: mild

A

Diarrhoea, abdominal cramps

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10
Q

clinical presentation: moderate

WBC

A

Fever, diarrhoea, nausea & malaise
Abdominal cramps & distension
Leukocytosis → elevated WBC count
Hypovolemia → decreased fluid volume due to dehydration

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11
Q

clinical presentation: severe

WBC & SCr

A

Fever, diarrhoea, diffuse abdominal cramps & distension
WBC ≥ 15 x 109 /L
Scr ≥ 133 μmol/L (1.5 mg/dL) → due to dehydration

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12
Q

clinical presentation: fulminant

A

hypotension/ shock

Ileus (inability of gut to move; no more peristalsis) & megacolon (inflammation of colon)
* Risks of perforation → bacteria can be released to other parts of the body

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13
Q

diagnostics

A
  1. Presence of diarrhoea (3 unformed stools in 24 hours) OR radiographic evidence of ileus/ toxic megacolon → symptoms
  2. Positive stool test result for C.difficile/ toxins OR colonoscopic/ histopathologic evidence of pseudomembranous colitis
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14
Q

stool test

requirements; stance on retesting

A
  • Only perform tests for symptomatic patients → stool test cannot distinguish between colonisation & infection
    Asymptomatic ⇒ likely just colonisation
  • To confirm patient did not receive laxative within prior 48 hours before sending test

Do not repeat testing <7 days Or when documenting care
* >60% with favourable clinical responses will still test positive

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15
Q

management of CDI
principles of treatment

who to treat, actions required (2)

A

Only patients with symptoms consistent with CDI ⇒ prescribe therapy

  • To discontinue any AB not specifically treating CDI
  • If additional AB therapy required
    Select narrowest agent possible
    Larger spectrum = more disrupted gut flora
    Avoid agents with strong association with CDI
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16
Q

management of CDI (initial)
duration of treatment

A

10 days
Extend to 14 days if symptoms not completely resolved

17
Q

management of CDI (initial)
definition of infection types

A

Non-severe
WBC <15 x 109 /L
AND
Scr <133 μmol/L (1.5 mg/dL)

Severe
WBC ≥ 15 x 109 /L
OR
Scr ≥ 133 μmol/L (1.5 mg/dL)

Fulminant
Hypotension OR ileus OR megacolon

18
Q

management of CDI (initial)
treament for infection types

A

Non-severe
* First line
PO fidaxomicin 200 mg BD
PO vancomycin 125 mg QDS
* Alternative
PO metronidazole 400 mg TDS

Severe
PO fidaxomicin 200 mg BD
PO vancomycin 125 mg QDS

Fulminant
IV metronidazole 500 mg q8h
* + PO vancomycin 500 mg QDS
* ± PR Vancomycin 500mg QDS
(per rectal)

19
Q

management of CDI (recurrence)
definition

A

Resolution of CDI symptoms → subsequent reappearance of symptoms after discontinuing treatment

20
Q

management of CDI (recurrence)
risk factors

A
  • Administration of other AB during/ after initial CDI treatment
  • Defective humoral immune response against C.difficile toxins
    Cannot produce Ab against C.difficile
  • Advanced age & underlying disease
  • Continued usage of PPIs
21
Q

management of CDI (recurrence)
treatment

fiaxomicin/ vancomycin initial

A
  • PO fidaxomicin 200 mg BD x 10 days
  • PO fidaxomicin 200 mg BD x 5 days, then 5 mg EOD x 20 days
  • PO vancomycin tapered/ pulsed:
    125 mg QDS x 10-14 days, then
    125 mg BD x 7 days, then
    125 mg OD x 7 days, then
    125 mg every 2-3 days x 2-8 weeks
22
Q

management of CDI (recurrence)
treatment

metronidazole initial

A

PO vancomycin 125 mg QDS x 10 days

23
Q

monitoring responses

if >14 days no response; managing poor response

A

Symptoms should resolve in 10 days
* If not can extend treatment for another 4 days (total 14 days)

Do not continue C.difficile treatment >10-14 days
* No evidence of reduced recurrence
* Also to allow for patient to continue other current ABs

Additional diagnostics/ escalation of pharmacologic treatment ⇒ if poor response

infec y3s1 (7 decks)

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