Role of the Pharmacist (C. diff + TDM)

Question 1

Common symptoms of C.diff infection?

Answer 1

1. diarrhoea
2. distinctive smell
3. raised CRP/WCC
4. pyrexia
5. toxic confusional state in the elderly

(can masquerade as sepsis - in which case you would administer broad spectrum antibiotics - would make C.diff worse)

Question 2

Complication of severe c.diff?

Answer 2

pseudomembranous colitis
(damaged pseudomembranous on the colon)

Question 3

Clinical signs of pseudomembranous colitis?

Answer 3

1. abdominal distention
2. high WCC
3. diarrhoea

Question 4

immediate management strategy for c.diff infection?

Answer 4

• take stool sample
• patient isolation
• daily monitoring w stool chart
• stop the offending antibiotics
• review drugs that may cause diahroea

Question 5

Why is it so important to avoid loperamide in hospital c.diff patients?

Answer 5

loperamide is an diarrhoea drug.
MOA: reduces gut motility
this would lead to the c.diff toxin potentially being in contact with the gut for longer (worsen condition)

Question 6

What treatment would you give for C.diff infection?

Answer 6

*oral administration is more effective!

1: PO Vancomycin
- vancomycin doesn’t pass through gut, oral absorption, high efficacy in severely ill

2. if patient nil by mouth: IV Metronidazole

Question 7

Which antibiotics are most likely to cause C.diff infection?

Answer 7

4Cs

1. Clindamycin
2. Cephalosporin
3. Co-amoxiclav (broad-spectrum penicillin)
4. Ciprofloxacin (quinolone)

broader spectrum antibiotics are more likely to cause C.diff infections.

Question 8

Which antibiotics are lower risk for C.diff?

Answer 8

narrow spectrum antibiotics
ones that don’t travel across the gut
- glycopeptides (Vancomycin)
- aminoglycosides (Gentamicin)

Question 9

What factors increase the risk of developing C.diff?

Answer 9

1. Over 7 day antibiotic course
2. older age
3. NG-tube (by-passes the protective aspects of the stomach)
4. PPIs (acid suppression)

Question 10

What is meant by a narrow therapeutic index?

Answer 10

the concentration between min concentration for efficacy is close to concentration for toxicity

Question 11

What is a post-antibiotic effect?

Answer 11

bacterial growth continues to be inhibited even after levels fall below minimum inhibitory conc (MIC)

Question 12

How are aminoglycosides dosed now?

Answer 12

aminoglycosides are now administered as one daily dose
decreased nephrotoxicity
increased efficacy

Question 13

In what circumstances, would you dose aminoglycosides as multiple times per day?

Answer 13

in pregnancy, endocarditis, ascites

important to confirm low trough result before dosing is continued in patients with known or likely renal impairment.