Med-Surg: Chapter 21: Clostridioides Difficile (C. diff)

Question 1

What was the cause of emergence of C. Diff?

Answer 1

increased use of antibiotics and the increased incidence of S. aureus infections

Question 2

C. Diff is the most common cause of what?

Answer 2

antibiotic-associated diarrhea

Question 3

Risk Factors for C. Diff

Answer 3

• recent antibiotic use (antimicrobials like clindamycin, cephalosporins, and fluoroquinolones)
• greater than 64 years old
• NGT or feeding tubes
• prolonged hospitalizations
• Chemotherapy
• Gastrointestinal surgery
• Acid-suppressing medications
• Comorbid conditions

Question 4

Why is the use of antimicrobial agents a risk factor for C. diff?

Answer 4

antimicrobials suppress the normal bowel flora and create an environment for C. diff to flourish
-the greater number of antimicrobials, greater number of doses, and greater number of duration increases the risk of a C. diff infection

Question 5

Why is the use of acid-suppressing medications a risk factor for C. diff?

Answer 5

these medications prevent the protective effect of stomach acid, which usually kills C. diff bacteria

Question 6

Pathophysiology of C. Diff

Answer 6

a spore-forming, gram-positive anaerobic bacillus

• the spores are resistant to many types of disinfectants, heat, and dryness
• can live for months on surfaces, in skin folds, and on hands on healthcare workers
• mostly found in healthcare settings

Question 7

How is C. Diff transmitted?

Answer 7

through the oral-fecal route

• occurs when a pathogen from feces is introduced into the oral cavity of a host
• hands of healthcare providers is the primary source
• direct person-to-person contact; contact-isolation precautions

Question 8

Clinical Manifestations

Answer 8

• test positive for C. diff toxins in their stool
• mild to moderate diarrhea
• can be asymptomatic

Question 9

Complications

Answer 9

• volume depletion (hypovolemia)
• low blood pressure (hypotension)
• renal insufficiency
• electrolyte imbalances (hypo/hyperkalemia, hypo/hypernatremia)
• hypoalbuminemia (low serum albumin levels)
• peritonitis (inflammation of peritoneum)
• paralytic ileus (intestinal obstruction)
• toxic megacolon (rapid dilation of large intestines)
• fulminant pseudomembranous colitis
• sepsis
• death
• skin breakdown

Question 10

What contributes to the skin breakdown caused by C. diff?

Answer 10

excessive moisture, alkaline pH, colonization with microorganisms, and friction

Question 11

How to maintain skin integrity

Answer 11

• perineal cleansing
• creams and ointments serve as a moisture barrier; apply after cleaning
• fecal management systems

Question 12

Complications of C. Diff are commonly seen in who?

Answer 12

• a WBC of 15.0 10^3/mm3 or higher

- catastrophic complications: with a WBC count of 50.0 10^3/mm3

Question 13

Patients who are severely ill may require what?

Answer 13

-subtotal colectomy (part of colon removed) with preservation of the rectum
or
-colectomy (removal of entire colon) for treatments for severe C. diff infections that progress to fulminant pseudomembranous colitis, paralytic ileus, toxic megacolon, or sepsis

Question 14

Medications given for C. Diff

Answer 14

• Metronidazole (Flagyl)
• Vancomycin (Vancocin)
• Probiotics

Question 15

Medications for C. Diff: Vancomycin

Answer 15

antibiotic

• oral
• first line treatment of an initial episode of severe C. diff (causes prompt symptom resolution)
• effective b/c it is not absorbed in the intestines and kills the bacteria at the site of infection in the colon
• administered IV or orally
• trough levels drawn and monitored weekly to avoid toxic doses and maintain therapeutic levels
• if trough levels high, can cause nephrotoxicity and ototoxicity
• weekly BUN and serum creatinine to assess kidney function b/c of nephrotoxicity

Question 16

Medications for C. Diff: Metronidazole

Answer 16

broad spectrum antimicrobial (anti-protozoal)
-IV is used when oral vancomycin is not appropriate for the treatment of C. diff b/c of coexisting ileus or toxic megacolon
-can cause GI discomfort
-can cause Darkening of urine
-can cause neurotoxicity, CNS effects
-can cause pseudomembranous colitis (fever, diarrhea, abdominal pain, bloody stool)
>contraindicated in active CNS disorders, blood dyscrasias, and during lactation
>do not use in first trimester
>avoid alcohol
>use other forms of contraception

Question 17

Medications for C. diff: Probiotics

Answer 17

live bacteria and yeasts

• reduce the incidence of simple antibiotic-associated diarrhea
• used to treat recurrent C. diff
• used supplementally

Question 18

What is done before treatment for C. diff can begin?

Answer 18

the suspected causative antibiotic must be stopped

• C. diff infection will resolve within 2 to 3 days of discontinuing the antibiotic to which the patient was previously exposed
• use of anti-peristaltic agents should be avoided b/c they may delay clearance of toxins from the colon and exacerbate toxin induced colonic injury or precipitate ileus (intestinal obstruction that results in failure of intestinal contents to pass through) and toxic megacolon (life-threatening complication of inflammatory bowel disease that causes rapid dilation of the large intestines, which results in septic shock)