Clostridium difficile infection resident survival guide

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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 (≥ 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

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 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order tests 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
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 plus any additional signs or symptoms not meeting severe or complicated criteria
 
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)
 
 
 
 


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][7]
  • 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.[8]

Management of CDI in IBD Patients

  • Test for C. difficile in all patients with IBD who develop diarrhea in the setting of previously quiescent disease or with a disease flare.[9] Initiate empirical therapy directed against CDI in inflammatory bowel disease IBD patients with severe colitis.[10]

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.[11]
  • 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.[12][13]
  • 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.[14]
  • 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.[15]

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. Bartlett JG (2006). "Narrative review: the new epidemic of Clostridium difficile-associated enteric disease". Ann Intern Med. 145 (10): 758–64. PMID 17116920.
  3. 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.
  4. 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.
  5. 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
  6. 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.
  7. 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.
  8. 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.
  9. Jen MH, Saxena S, Bottle A, Aylin P, Pollok RC (2011). "Increased health burden associated with Clostridium difficile diarrhoea in patients with inflammatory bowel disease". Aliment Pharmacol Ther. 33 (12): 1322–31. doi:10.1111/j.1365-2036.2011.04661.x. PMID 21517920.
  10. Ben-Horin S, Margalit M, Bossuyt P, Maul J, Shapira Y, Bojic D; et al. (2009). "Combination immunomodulator and antibiotic treatment in patients with inflammatory bowel disease and clostridium difficile infection". Clin Gastroenterol Hepatol. 7 (9): 981–7. doi:10.1016/j.cgh.2009.05.031. PMID 19523534.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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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