Clostridium difficile infection resident survival guide: Difference between revisions

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{{familytree | F01 | | F02 | | F03 | F01='''Mild or moderate initial episode''' <br> <div style="float: left; text-align: left; height: 14em; width: 20em; padding:1em;">❑ [[Diarrhea]] plus any additional signs or symptoms not meeting severe or complicated criteria </div>| F02= '''Severe initial episode''' <br><div style="float: left; text-align: left; height: 14em; width: 20em; padding:1em;">❑[[Serum albumin]] <3g/dl <br>'''Plus''': <br>Any '''ONE''' of the following:<br>
{{familytree | F01 | | F02 | | F03 | F01='''Mild or moderate initial episode''' <br> <div style="float: left; text-align: left; height: 14em; width: 20em; padding:1em;">❑ [[Diarrhea]]<br> ❑ Absence of peritoneal signs and symptoms </div>| F02= '''Severe initial episode''' <br><div style="float: left; text-align: left; height: 14em; width: 20em; padding:1em;">❑ [[Serum albumin]] <3g/dl <br>'''Plus''': <br>Any '''ONE''' of the following:<br>
❑ WBC ≥15,000 cells/mm3 <br>
❑ WBC ≥15,000 cells/mm3 <br>
❑ Abdominal tenderness </div>| F03= '''Complicated severe initial episode''' <br><div style="float: left; text-align: left; height: 17em; width: 20em; padding:1em;">❑ Admission to the intensive care unit for CDI <br> ❑ [[Hypotension]] with or without required use of vasopressors <br> ❑ [[Fever]] ≥38.5 °C  <br> ❑ [[Ileus]] or significant abdominal distention <br> ❑ Mental status changes  <br> ❑ Serum [[lactate]] levels >2.2 mmol/l  <br> ❑ [[WBC]] ≥35,000 cells/mm3 or <2,000 cells/mm3  <br> ❑ End organ failure ([[mechanical ventilation]], [[renal failure]], etc.) </div> }}
❑ Abdominal tenderness </div>| F03= '''Complicated severe initial episode''' <br><div style="float: left; text-align: left; height: 17em; width: 20em; padding:1em;">❑ Admission to the intensive care unit for CDI <br> ❑ [[Hypotension]] with or without required use of vasopressors <br> ❑ [[Fever]] ≥38.5 °C  <br> ❑ [[Ileus]] or significant abdominal distention <br> ❑ Mental status changes  <br> ❑ Serum [[lactate]] levels >2.2 mmol/l  <br> ❑ [[WBC]] ≥35,000 cells/mm3 or <2,000 cells/mm3  <br> ❑ End organ failure ([[mechanical ventilation]], [[renal failure]], etc.) </div> }}

Revision as of 20:37, 8 January 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mugilan Poongkunran M.B.B.S [2], Rim Halaby, M.D. [3]

Synonyms and keywords: CDI

Definition

Clostridium difficile infection (CDI) is defined as the acute onset of diarrhea (≥ 3 unformed stools in ≤24 hours) with either documented toxigenic Clostridium difficile (C. difficile) or its toxin, or colonoscopic or histopathological findings of pseudomembranous colitis in the absence of any other documented cause of diarrhea.[1]

  • Health-care facility onset health-care facility associated (HO-HCFA): Onset of symptoms within 3 days of admission to a health-care facility
  • Community onset health-care facility associated (CO-HCFA): Onset of symptoms within 4 weeks of discharge from a health-care facility
  • Community onset (CA): Onset of symptoms outside health-care facility or <3 days after admission to a health-care facility and has not been discharged from health-care facility in the previous 12 weeks
  • Indeterminate or unknown: Onset of symptoms after being discharged from a health-care facility 4-12 weeks previously[2]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Clostridium difficile infection itself may present or complicate as a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

Management

 
 
 
 
Characterize the symptoms:
Diarrhea (Onset, duration, pattern, bloody, mucous or watery)
❑ Mental status change
Fever
Abdominal pain
Abdominal distention
Nausea
Vomiting
Loss of appetite
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

1. Assess volume status:
❑ General condition
❑ Thirst
Pulse
Blood pressure
❑ Eyes
❑ Mucosa


2. General examination:

❑ Extremities (edema)
❑ Abdomen (distension or tenderness)
❑ Anorectal (Bleeding)
❑ CVS
❑ RS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order tests:

CBC
ESR
Serum electrolytes
❑ Total serum protein and albumin
Stool analysis
Urinalysis
BUN
Creatinine

Serum glucose
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Test the liquid stool for C. difficile:

❑ Nucleic acid amplification tests (NAAT) for C. difficile toxin genes such as PCR (Standard), OR
❑ Two or three steps glutamate dehydrogenase (GDH) screening with subsequent toxin A and B enzyme immunoassay

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Discontinue any inciting antibiotics
Stop anti-motility drugs
Take infection control precaution:
♦ Place the patient in a private room or in a room with another patient when CDI is suspected or confirmed
♦ Use and hygiene and barrier precautions
♦ Use single use disposable equipement
♦ Disinfect environmental surfaces
Assess the severity of the patient's condition to tailor the management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild or moderate initial episode
Diarrhea
❑ Absence of peritoneal signs and symptoms
 
Severe initial episode
Serum albumin <3g/dl
Plus:
Any ONE of the following:

❑ WBC ≥15,000 cells/mm3

❑ Abdominal tenderness
 
Complicated severe initial episode
❑ Admission to the intensive care unit for CDI
Hypotension with or without required use of vasopressors
Fever ≥38.5 °C
Ileus or significant abdominal distention
❑ Mental status changes
❑ Serum lactate levels >2.2 mmol/l
WBC ≥35,000 cells/mm3 or <2,000 cells/mm3
❑ End organ failure (mechanical ventilation, renal failure, etc.)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Deliver supportive care
♦ IV fluid resuscitation
♦ Electrolyte replacement
♦ VTE prophylaxis
❑ Order a CT scan
❑ Obtain a surgical consult
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer antibiotics:
Metronidazole 500 mg 3 times/day, orally, for 10 days
 
Administer antibiotics:
Vancomycin 125 mg 4 times/day for 10 days
 
Absence of abdominal distention:
Administer antibiotics:
Vancomycin 125 mg 4 times/day, orally or by NG tube, PLUS
❑♦ Metronidazole 500 mg 3 times/day
❑ Continue oral or enteral feeding
 
Presence of significant abdominal distention:
Administer antibiotics:
Vancomycin 500 mg 4 times/day, orally or by NG tube, PLUS
Vancomycin 500 mg in a volume of 500 mL, per rectum, 4 times/day, PLUS
♦ IV Metronidazole 500 mg 3 times/day
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
First recurrence?
❑ Repeat the treatment of the initial episode
❑ Use vancomycin if severe
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Second recurrence?
❑ Administer vancomycin in a tapered and/or pulsed way
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Third recurrence?
❑ Consider fecal microbiota transplant (FMT)
 
 
 
 


The algoithm is based on the 2013 American Journal of Gastroenterology guidelines.[2]

Do's

  • Only unformed stools from patients with diarrhea should be tested for C. difficile. Inform the laboratory when a patient with ileus and complicated disease has a formed stool.
  • Rectal swabs can be used for PCR and thus may be useful in timely diagnosis of patients with ileus.[1][8]
  • Add vancomycin therapy delivered via enema to treatments in patients in whom oral antibiotics cannot reach a segment of the colon, such as with Hartman’s pouch, ileostomy, or colon diversion.
  • Test for C. difficile among pregnant or periparturient women with diarrhea because of the increased rate of maternal and fetal mortality.[9]

Management of CDI in IBD Patients

  • Test for C. difficile among all patients with IBD who develop diarrhea following recent hospitalization or antibiotic use or in the setting of previously quiescent disease or with a disease flare.
  • Test for C. difficile among all patients with an IBD flare.
  • Consider the simultaneous treatment for IBD flare and empiric therapy against CDI among IBD patients who have severe colitis.[2]

Don't s

  • Don't screen for clostridium difficle among patients without diarrhea.
  • Don't repeat testing for negative tests.
  • Dont use anti-peristaltic agents to control diarrhea for confirmed or suspected CDI patients, as they may obscure symptoms and precipitate complicated disease.[10]
  • Repeat testing should be discouraged as it increases the likelihood of false positives and if requested, the physician should confer with the laboratory to explain the clinical rationale.[11][12]
  • Empiric therapy for CDI should not be discontinued or withheld in patients with a high pre-test suspicion for CDI.
  • Dont treat asymptomatic C.Difficle carriers as treating such patients may increase the shedding of spores and growth of new resistant strains.[13]
  • Don't test for cure following an episode of clostridium difficile diarrhea.
  • The evidence for the use of probiotics, Lactobacillus casei, Lactobacillus bulgaricus, and Streptococcus thermophilus to decrease the incidence of antibiotic-associated diarrhea is insufficient.[14][2]

References

  1. 1.0 1.1 Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC; et al. (2010). "Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA)". Infect Control Hosp Epidemiol. 31 (5): 431–55. doi:10.1086/651706. PMID 20307191.
  2. 2.0 2.1 2.2 2.3 Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH; et al. (2013). "Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections". Am J Gastroenterol. 108 (4): 478–98, quiz 499. doi:10.1038/ajg.2013.4. PMID 23439232.
  3. Bartlett JG (2006). "Narrative review: the new epidemic of Clostridium difficile-associated enteric disease". Ann Intern Med. 145 (10): 758–64. PMID 17116920.
  4. Johnson S, Samore MH, Farrow KA, Killgore GE, Tenover FC, Lyras D; et al. (1999). "Epidemics of diarrhea caused by a clindamycin-resistant strain of Clostridium difficile in four hospitals". N Engl J Med. 341 (22): 1645–51. doi:10.1056/NEJM199911253412203. PMID 10572152.
  5. Pépin J, Saheb N, Coulombe MA, Alary ME, Corriveau MP, Authier S; et al. (2005). "Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec". Clin Infect Dis. 41 (9): 1254–60. doi:10.1086/496986. PMID 16206099.
  6. Kwok CS, Arthur AK, Anibueze CI, Singh S, Cavallazzi R, Loke YK (2012). "Risk of Clostridium difficile infection with acid suppressing drugs and antibiotics: meta-analysis". Am J Gastroenterol. 107 (7): 1011–9. doi:10.1038/ajg.2012.108. PMID 22525304. Review in: Ann Intern Med. 2012 Aug 21;157(4):JC2-13 Review in: Evid Based Med. 2013 Oct;18(5):193-4
  7. Janarthanan S, Ditah I, Adler DG, Ehrinpreis MN (2012). "Clostridium difficile-associated diarrhea and proton pump inhibitor therapy: a meta-analysis". Am J Gastroenterol. 107 (7): 1001–10. doi:10.1038/ajg.2012.179. PMID 22710578.
  8. Kundrapu S, Sunkesula VC, Jury LA, Sethi AK, Donskey CJ (2012). "Utility of perirectal swab specimens for diagnosis of Clostridium difficile infection". Clin Infect Dis. 55 (11): 1527–30. doi:10.1093/cid/cis707. PMID 22911648.
  9. Centers for Disease Control and Prevention (CDC) (2005). "Severe Clostridium difficile-associated disease in populations previously at low risk--four states, 2005". MMWR Morb Mortal Wkly Rep. 54 (47): 1201–5. PMID 16319813.
  10. Koo HL, Koo DC, Musher DM, DuPont HL (2009). "Antimotility agents for the treatment of Clostridium difficile diarrhea and colitis". Clin Infect Dis. 48 (5): 598–605. doi:10.1086/596711. PMID 19191646.
  11. Deshpande A, Pasupuleti V, Pant C, Hall G, Jain A (2010). "Potential value of repeat stool testing for Clostridium difficile stool toxin using enzyme immunoassay?". Curr Med Res Opin. 26 (11): 2635–41. doi:10.1185/03007995.2010.522155. PMID 20923255.
  12. Luo RF, Banaei N (2010). "Is repeat PCR needed for diagnosis of Clostridium difficile infection?". J Clin Microbiol. 48 (10): 3738–41. doi:10.1128/JCM.00722-10. PMC 2953130. PMID 20686078.
  13. Johnson S, Homann SR, Bettin KM, Quick JN, Clabots CR, Peterson LR; et al. (1992). "Treatment of asymptomatic Clostridium difficile carriers (fecal excretors) with vancomycin or metronidazole. A randomized, placebo-controlled trial". Ann Intern Med. 117 (4): 297–302. PMID 1322075.
  14. Hickson M, D'Souza AL, Muthu N, Rogers TR, Want S, Rajkumar C; et al. (2007). "Use of probiotic Lactobacillus preparation to prevent diarrhoea associated with antibiotics: randomised double blind placebo controlled trial". BMJ. 335 (7610): 80. doi:10.1136/bmj.39231.599815.55. PMC 1914504. PMID 17604300. Review in: Evid Based Med. 2008 Apr;13(2):46 Review in: Evid Based Nurs. 2008 Apr;11(2):57


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