Lecture 8 - GI Infections 2 Flashcards
Toxin A vs B
Toxin A = make sick
Toxin B = virulence
C.Diff Risk factors
Meds = Abx, acid suppressing, chemo
Advanced age
Hospialization
Severe illness = immunocompromised, stem cell transplant
Enteral feeding
Obesity
GI surgery
Risk factors for recurrent C.diff
Age > 75
> 10 unformed stools/24hrs
SCr > 1.2mg/dL
C.diff has resistance to…
Clindamycin and fluoroquinolone, cause increases virulence
C.diff clinical presentation
Asymptomatic -> full blown diarrhea
Typical onset w/I 2-3 days of colonization
Foul-smelling, greenish, watery stools
Ab discomfort, cramping
Fever (103/104)
Nausea, anorexia
Inc WBC, SCr, Lactate
C.diff complications
Dehydration, electrolyte disturbance
Post-infectious IBS
Fulminant colitis = bunch of issues
Death
What agents to avoid C.diff?
Antiperistaltic agents
C.diff diagnosis
> 3 unformed stools in < 24hrs or radiographic evidence
- Liquid stool, positive test for toxigenic C.diff, imaging
Difference w/ community acquired = symptoms present n no prior inpatient stay 12weks before onset
C.diff diagnostic testing
- Clinical evidence of C.diff
- Send stool for GDH (antigen) and Toxin (A/B EIA)
Both positive = C.diff +
Both negative = C.diff -
If antigen + / toxin - then do NAAT PCR
if toxin positive = C.diff positive
C.diff prevention
surveillance/early detection
Hand hygiene contact precautions
environmental control
C.diff approach to therapy
D/c - acid suppression, constipation, diarrheal
Classify
Select txm
Non-severe C.diff
WBC < 15 and SCr < 1.5
Severe C.diff
WBC > 15 or SCr > 1.5
Fulminant is….
associated with hypotension or shock or ileum or megacolon
essentially icu
How to treat initial Fulminant
Vancomycin 500mg PO/via GT q6h
if ileum, + PR Vanco +/- metronidazole IV
Initial C.diff treatment if non-severe or severe?
Preferred: Fidaxomicin 200mg PO BID X 10 days
Alternative: Vancomycin 125mg PO q6H X 10 days
Can you use IV vanco for C.diff??
nah, use PO
What to use for non-severe C.diff if no fidaxomicin/vanco available?
Metronidazole 500mg PO TID X 10-14 days
cant use for severe
1st recurrence (2nd episode) C.diff treatment
- Fidaxomicin 200mg BID X 10days
- prolonged tapered and pulsed vanco regiment
- vanco 125mg Q6h X 10 days; opinion if metronidazole used for 1st episode
adjunctive: bezlotoxumab 10mg/kg IV x 1 w/ antibiotics. caution in pts with congestive HF
2nd recurrence (3+ episode)
- fidaxomicin 200mg PO BID X 10 days or fidaxomicin 200mg X5 days then every other 20days
- vanco tapered and pulsed
- vanco 125mg q6h x 10 days followed by rifaximin 400mg q8h x 20 days
- fecal microbiota transplantation
adjunctive: bezlotoxumab 10mg/kg IV x 1 w/ antibitoics. caution in pts w/ congestive HF
Prophylaxis for recurrent C.diff
insufficient evidence for/against
IF using: Vanco 125mg BID during abx txm then atleast 1 day following d/c of abx
Metronidazole/fidaxomicin are not recommended
vanco MOA
inhibit cell wall synthesis, bacteriostatic against C.diff
Fidaxomicin MOA
Macrolide, bind 50S ribosomal subunit leading to protein synthesis inhibition
Bactericidal
Metronidazole MOA
DNA disruption, inhibits nucleic acid synthesis thus damaging bacterial cells
** peripheral neuropathy inc with inc dose over time ***
who should not get probiotics
no immunocompromised
critically ill
impaired intestinal barrier
Fecal microbiota transplantation
move poop from one person to another
super effective
H.pylori risk factors
male gender
diet
food prep methods
stress
Med interactions for Endoscopic testing
Hold PPI for 2 weeks before
Abx can alter sensitivity, wait 4 weeks
OG H.pylori recommended treatment
Clarithromycin Triple therapy for 14 days
** if resistance < 15% and no macrolide exposure for any reason **
PPI/H2RA + Clarith 500 BID + Amoox 1g BID/ Metronidazole 500 TID if allergy (Prevpac)
Bismuth-based Quadruple therapy
10-14 days, often 14
** option if macrolide exposure or penicillin allergy **
PPI/H2RA + Bismuth subsal QID + Metronidazole 250 QID or 500 TID/QID + tetracycline 500mg QID
Prilosec + Pylera
Concomitant therapy
10-14 days
** option if clarithromycin resistance > 15% or repeated exposure **
PPI BID + Amox 1g BID + Metronidazole 500mg BID + Clarithromycin 500mg BID
Sequential therapy
PPI + Amox/ Levo if allergy + metronidazole (after amoxicillin) + clarithromycin (after amoxicillin)
Hybrid Therapy
PPI + amoxicillin + metronidazole (days 8-14) + clarithromycin (days 8-14)
levofloxacin Triple Therapy
PPI + amoxicillin + levofloxacin
Levofloxacin sequential therapy
PPI + amoxicillin + Levo (days 7+) + metronidazole (days 7+)
If PCN allergy + no macrolide exposure, what are options?
Bismuth-based quadruple
Calrithromycin triple w/ metronidazole
If PCN allergy + Macrolide exposure, what are options?
Bismuth based quadruple
No PCN allergy + Macrolide exposure, what are options?
Bismuth-based quadruple
Levo triple
Levo sequential
Concomitant, hybrid, LOAD
No PCN allergy + No macrolide exposure, what are options?
All of them
H.pylori Salvage treatment
confirm eradication in high risk groups
can use UBT, SAT or endoscopy test, have to wait 4weeks after abx to retest
refer to specialist if still positive to H.pylori
Salvage Treatment Regimens
Bismuth-based Quadruple therapy*
Levoflox triple therapy*
Concomitant therapy for 10-14 days
Rifabutin Triple therapy for 10 days
High dose Dual therapy for 14 days
Rifabutin Triple Therapy
PPI + amoxicillin + rifabutin
High dose dual therapy
PPI + Amox
Salvage therapy if started clarithromycin-triple
bismuth-based quad start
Salvage therapy if started bismuth-quad
levo triple start
Talicia
Rifabutin Based Therapy
Admin: 4 tabs q8hrs w/ food for 14 days
avoid use in creatine clearance < 30
combo of omeprazole, amoxicillin, rifabutin
