Clostridium difficile infection resident survival guide

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

Definition

Clostridium difficile infection (CDI) is defined as the acute onset of diarrhea with documented toxigenic Clostridium difficile (C. difficile) or its toxin and no other documented cause for diarrhea. C. difficile, a Gram-positive, spore-forming bacterium is spread by the fecal-oral route. It is non-invasive and produces toxins A and B that cause disease, ranging from asymptomatic carriage, to mild diarrhea, to colitis, or pseudomembranous colitis. The risk factors are exposure to antibiotics, exposure to the organism, others comorbid conditions, gastrointestinal tract surgery, and medications that reduce gastric acid.

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

• Proton-pump inhibitors (PPIs)
• Fluoroquinolones
• Clindamycin
• Penicillins
• Cephalosporins
• Histamine 2 receptor antagonists

Management

Aduts with CDI

Characterize the symptom: ❑ Diarrhea (Onset, duration, pattern, bloody or watery) ❑ Mental status change ❑ Fever ❑ Abdominal pain ❑ Nausea ❑ Vomiting ❑ Loss of appetite ❑ Weight loss Examine the patient: 1. Assess volume status: ❑ General condition ❑ Thirst ❑ Pulse ❑ Blood pressure ❑ Eyes ❑ Mucosa 2. Other system examination: ❑ Extremities (Edema) ❑ Abdomen (Distension or tenderness) ❑ Anorectal (Bleeding) ❑ CVS ❑ RS Order tests: 1. Assess volume status: ❑ CBC ❑ ESR ❑ Serum electrolytes ❑ Total serum protein and albumin ❑ Stool analysis ❑ Urinalysis ❑ BUN ❑ Creatinine ❑ Serum glucose

Strong clinical suspicion of CDI: ❑ 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

Yes

No

❑ Isolate the patient ❑ Discontinue non-C.Difficle treatment antibiotics ❑ Intravenous fluids OR Oral rehydration therapy based upon hydration status ❑ Appropriate attention to infection prevention and control ❑ Emperical antibiotic (Metronidazole OR vancomycin based on clinical severity) ❑ Hand hygiene and barrier precautions ❑ Single-use disposable equipment should be used

❑ Intravenous fluids OR Oral rehydration therapy based upon hydration status ❑ Review further inciting antibiotic and other drug history and risk factors for CDI

Hospital approval/affordable for Nucleic acid amplification tests (NAATs) for C. difficile toxin

Yes

No

Fecal glutamate dehydrogenase (GDH) screening tests for C. difficile

Positive

Negative

Enzyme immunoassay (EIA) for toxins A + B

Evalute for other acute diarrhea causes

Negative

Positive

Fecal nucleic acid amplification tests: ❑ Polymerase chain reaction (PCR): Most preferred ❑ Isothermal amplification tests

Negative

Positive

Evalute for other acute diarrhea causes

No strong clinical suspicion of CDI

Strong clinical suspicion of CDI

Rx for CDI

❑ Isolate the patient ❑ Discontinue non-C.Difficle treatment antibiotics ❑ Stop all anti-peristaltic agents ❑ Intravenous fluids OR Oral rehydration therapy based upon hydration status ❑ Appropriate attention to infection prevention and control ❑ Hand hygiene and barrier precautions ❑ Single-use disposable equipment should be used

Assessment of severity

Any of the following: ❑ Admission to 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.)

❑Serum albumin <3g/dl Plus: Any ONE of the following: ❑ WBC ≥15,000 cells/mm3 ❑ Abdominal tenderness

Diarrhea plus any additional signs or symptoms not meeting severe or complicated criteria

Severe and complicated

Severe

Mild-moderate

Significant abdominal distention

No significant abdominal distention

Oral vancomycin 125 mg QID X 10 days

Oral metronidazole 500 mg TID X 10 days

Oral vancomycin 125 mg QID Plus ❑ Intravenous metronidazole 500 mg TID ❑ CT

Any ONE of the following: ❑ Failure to respond to metronidazole therapy within 5–7 days ❑ Intolerant/allergic to metronidazole ❑ Pregnant/breastfeeding women

S01= Oral vancomycin 500 mg QID Plus ❑ Vancomycin per rectum (500 mg in a volume of 500 ml QID) Plus ❑ Intravenous metronidazole 500 mg TID

CT showing colon wall thickening, ascites, “megacolon”, ileus, or perforation

CT normal

❑ Oral vancomycin 125 mg QID X 10 days OR ❑ Oral fidaxomicin 200 mg BD X 10 days)

Surgical consultation and operative management in required cases

Patient improving, complete the antibiotic course

Do's

• Only stools from patients with diarrhea should be tested for C. difficile.. Very occasionally, a patient with ileus and complicated disease will have a formed stool, in which case the laboratory should be made aware of this special clinical situation. Rectal swabs can be used for PCR and thus may be useful in timely diagnosis of patients with ileus.

Don't s

• Repeat testing should be discouraged. Repeat testing increases the likelihood of false positives and if requested, the physician should confer with the laboratory to explain the clinical rationale.
• Testing for cure should not be done.
• Empiric therapy for CDI should not be discontinued or withheld in patients with a high pre-test suspicion for CDI.

References

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