IC17 clostridium difficile Flashcards
Which group of patients are at high risk of getting C diff infection? How does C diff spread / source of infection? What medication can help to reduce C. diff infection?
C. difficile:
- Toxin B is more clinically important
- Spread via fecal-oral route (found in rooms with patients with CDI, hands of HCP, medical equipment)
- Common amongst elderly, hospitalized patients and long term care facilities
- Doxycycline/tigecycline can reduce C. difficile growth, reduce toxin production and have minimal effect on normal flora
What are some prevention methods for C difficile infection?
Critical role of antimicrobial stewardship in reducing CDI incidence
Infection control and Prevention:
- Good hand hygiene, wear gowns
- Sanitize rooms and medical equipment (use sporicidal agents)
- Place CDI-infected patients in private rooms, if not prioritize stool incontinence patients, or group all CDI-infected patients in 1 room
- Reduce duration, dose, frequency and number of antibiotics if possible
- Discontinue any antibiotics where patients have completed the full course
- Discontinue PPIs if not indicated for
- Take probiotics to help restore the normal microbiota
What is needed for diagnosis of C. diff infection?
Diagnostics based on
- clinical presentation (>= 3 loose stools in 24 hours)
OR Radiographic test (megacolon)
AND - Positive Stool test for C. Difficile or its toxin
OR Colonoscopy or histopathologic evidence of pseudomonas colitis / yellow plagues
What are the risk factors of C. diff infection?
- GI surgery (disrupts normal microbiota)
- Elderly > 65 y/o
- Multiple / severe comorbidities
- Immunosuppressed
- History of CDI
- Tube feeding
- Prior hospitalization
- Duration of hospitalization
- Long term care facilities
- Lack of hand hygiene and sanitation
- Use of antibiotics associated with CDI-diarrhea
a. E.g. clindamycin, 3rd/4th gen cephalosporins, amoxicillin, ampicillin, fluoroquinolones - Use of PPI
What are the subjective evidences of C. difficile infection?
- *Watery diarrhea (3 or more loose stools within 24 hours)
Mild
- diarrhea, abdominal cramps
Moderate (have systemic symptoms)
- fever, malaise, nausea, diarrhea, abdominal cramps, distension, leukocytosis (high WBC), hypovolemia
Severe
- WBC > 15x10^9/L, SCR > 133umol/L, diarrhea, fever, diffused abdominal cramps and distension
Fulminant
- Hypotensive, ileus (colon not moving), megacolon
When do you test for presence of C. difficile infection?
TEST only if symptomatic (diarrhea)
What are the objective evidences of C. difficile infection?
TEST only if symptomatic (diarrhea)
Not on laxatives 48 hours before test
- *Stool test (diagnostic tests)
- Nucleic acid amplification test (NAAT) –> test for genes that produces toxin A or B (but does not tell u whether genes are activated or bacteria is producing toxins)
- Polymerase Chain Reaction (PCR) –> test for genes that produces toxin A or B
- Enzyme immunoassay toxin A or B –> test toxin A or B
- Glutamate dehydrogenase immunoassay –> test C. diff
If use GDH immunoassay, need to do EIA (2 test)
Usually if patient symptomatic, test using NAAT or PCR (1 test)
- Radiographic test –> to show megacolon
- Colonoscopy or histography –> to see if have pseudomembranous yellow plagues
- General lab test e.g. WBC, procalcitonin, CRP (to tell us severity)
What are the criteria for non-severe, severe and fulminant C. difficile infection?
Non-severe:
WBC < 15x10^9/L
AND
SCr < 133umol/L
Severe:
WBC > 15x10^9/L
OR
SCr > 133umol/L
Fulminant:
Hypotensive, ileus or megacolon
What are the antibiotics that can be given for non-severe C. difficile?
Non-severe:
Criteria:
WBC < 15x10^9/L
AND
SCr < 133umol/L
- PO Metronidazole 400mg TDS
- PO Vancomycin 125mg QDS
(PO Fidaxomicin 200mg BD – not available in Sg)
Metronidazole is for patients with low risk of morbidity
1. Comorbidities
2. Elderly and frail
3. Hypotensive
4. Severe diarrhea
5. Other severe symptoms
Vancomycin is for more serious patients with high risk for morbidity
Duration: 10 days, unless delayed response then 14 days
What are the antibiotics that can be given for severe C. Difficile?
Severe:
Criteria:
WBC > 15x10^9/L
OR
SCr > 133umol/L
Antibiotics:
1. PO Vancomycin 125mg QDS
(PO Fidaxomicin 200mg BD – not available in Sg)
Duration: 10 days, unless delayed response then 14 days
What are the antibiotics that can be given for fulminant C. Difficile?
Fulminant
Criteria:
Hypotensive, ileus or megacolon
Antibiotics:
1. IV Metronidazole 500mg TDS
AND
2. PO Vancomycin 500mg QDS
+/-
3. PR Vancomycin 500mg QDS
Always give ORAL vancomycin for C. difficile since don’t want drug to be absorbed but stay at the colon
Max out the dose for fulminant
Duration: 10 days, unless delayed response then 14 days
What is the duration of treatment for all types of C. difficile infection?
Duration: 10 days, unless delayed response then 14 days
What are the risk factors for 1st recurrence of C. Difficile infection?
- On other antibiotics during or after initial CDI treatment
- Defective humoral response to CDI
- Old age
- Severe underlying disease
- On PPI
What are the treatment options for 1st recurrence of C. difficile infection?
If PO Vancomycin was given in initial episode of CDI:
- PO Vancomycin tapered/pulsed dose
- 125mg QDS x 10-14days
–> 125mg BD x 7 days
–> 125mg OD x 7 days
–> 125mg every 2-3 days x 2-8 weeks
(PO Fidaxomicin 200mg BD x 10 days
OR
PO fidaxomicin 200mg BD x 5days then 5mg EOD x 20days)
If metronidazole was given in the initial episode of CDI
- PO Vancomycin 125mg QDS (10 days)
How to monitor response for C. difficile infection?
Step 4: Monitor Response
- Resolve within 10 days
- Should not go beyond 10-14 days of duration
- Do NOT do stool test to confirm cure
