Clostridium difficile: Difference between revisions
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##Otherwise consider other (more common) causes | ##Otherwise consider other (more common) causes | ||
#Antimicrobial resistance is not clinically problematic, first recurrence treated with the same agent used to treat the initial episode | #Antimicrobial resistance is not clinically problematic, first recurrence treated with the same agent used to treat the initial episode | ||
===[[Antibiotic Sensitivities]]<ref>Sanford Guide to Antimicrobial Therapy 2014</ref>=== | |||
{| class="wikitable" | |||
| align="center" style="background:#f0f0f0;"|'''Category''' | |||
| align="center" style="background:#f0f0f0;"|'''Antibiotic''' | |||
| align="center" style="background:#f0f0f0;"|'''Sensitivity''' | |||
|- | |||
| [[Penicillins]]||[[Penicillin G]]||X2 | |||
|- | |||
| ||[[Penicillin V]]||X1 | |||
|- | |||
| Anti-Staphylocccal [[Penicillins]]||[[Methicillin]]||X1 | |||
|- | |||
| ||[[Nafcillin]]/[[Oxacillin]]||X1 | |||
|- | |||
| ||[[Cloxacillin]]/[[Diclox.]]||X1 | |||
|- | |||
| Amino-[[Penicillins]]||[[AMP]]/[[Amox]]||X1 | |||
|- | |||
| ||[[Amox-Clav]]||X1 | |||
|- | |||
| ||[[AMP-Sulb]]||X2 | |||
|- | |||
| Anti-Pseudomonal [[Penicillins]]||[[Ticarcillin]]||X1 | |||
|- | |||
| ||[[Ticar-Clav]]||X1 | |||
|- | |||
| ||[[Pip-Tazo]]||X1 | |||
|- | |||
| ||[[Piperacillin]]||X2 | |||
|- | |||
| [[Carbapenems]]||[[Doripenem]]||X2 | |||
|- | |||
| ||[[Ertapenem]]||X2 | |||
|- | |||
| ||[[Imipenem]]||X2 | |||
|- | |||
| ||[[Meropenem]]||X2 | |||
|- | |||
| ||[[Aztreonam]]||R | |||
|- | |||
| [[Fluroquinolones]]||[[Ciprofloxacin]]||R | |||
|- | |||
| ||[[Ofloxacin]]||X1 | |||
|- | |||
| ||[[Pefloxacin]]||X1 | |||
|- | |||
| ||[[Levofloxacin]]||R | |||
|- | |||
| ||[[Moxifloxacin]]||R | |||
|- | |||
| ||[[Gemifloxacin]]||X1 | |||
|- | |||
| ||[[Gatifloxacin]]||R | |||
|- | |||
| 1st G [[Cephalo]]||[[Cefazolin]]||X1 | |||
|- | |||
| 2nd G. [[Cephalo]]||[[Cefotetan]]||X1 | |||
|- | |||
| ||[[Cefoxitin]]||R | |||
|- | |||
| ||[[Cefuroxime]]||X1 | |||
|- | |||
| 3rd/4th G. [[Cephalo]]||[[Cefotaxime]]||R | |||
|- | |||
| ||[[Cefizoxime]]||R | |||
|- | |||
| ||[[CefTRIAXone]]||X1 | |||
|- | |||
| ||[[Ceftaroline]]||X1 | |||
|- | |||
| ||[[CefTAZidime]]||X1 | |||
|- | |||
| ||[[Cefepime]]||R | |||
|- | |||
| Oral 1st G. [[Cephalo]]||[[Cefadroxil]]||X1 | |||
|- | |||
| ||[[Cephalexin]]||X1 | |||
|- | |||
| Oral 2nd G. [[Cephalo]]||[[Cefaclor]]/[[Loracarbef]]||X1 | |||
|- | |||
| ||[[Cefproxil]]||X1 | |||
|- | |||
| ||[[Cefuroxime axetil]]||X1 | |||
|- | |||
| Oral 3rd G. [[Cephalo]]||[[Cefixime]]||X1 | |||
|- | |||
| ||[[Ceftibuten]]||X1 | |||
|- | |||
| ||[[Cefpodox]]/[[Cefdinir]]/[[Cefditoren]]||X1 | |||
|- | |||
| [[Aminoglycosides]]||[[Gentamicin]]||R | |||
|- | |||
| ||[[Tobramycin]]||R | |||
|- | |||
| ||[[Amikacin]]||R | |||
|- | |||
| ||[[Chloramphenicol]]||I | |||
|- | |||
| ||[[Clindamycin]]||X1 | |||
|- | |||
| [[Macrolides]]||[[Erythromycin]]||X1 | |||
|- | |||
| ||[[Azithromycin]]||X1 | |||
|- | |||
| ||[[Clarithromycin]]||X1 | |||
|- | |||
| Ketolide||[[Telithromycin]]||X1 | |||
|- | |||
| Tetracyclines||[[Doxycycline]]||X1 | |||
|- | |||
| ||[[Minocycline]]||X1 | |||
|- | |||
| Glycylcycline||[[Tigecycline]]||X1 | |||
|- | |||
| ||[[Daptomycin]]||X1 | |||
|- | |||
| Glyco/Lipoclycopeptides||[[Vancomycin]]||'''S''' | |||
|- | |||
| ||[[Teicoplanin]]||'''S''' | |||
|- | |||
| ||[[Telavancin]]||'''S''' | |||
|- | |||
| ||[[Fusidic Acid]]||X1 | |||
|- | |||
| ||[[Trimethoprim]]||X1 | |||
|- | |||
| ||[[TMP-SMX]]||X1 | |||
|- | |||
| Urinary Agents||[[Nitrofurantoin]]||X1 | |||
|- | |||
| ||[[Fosfomycin]]||X1 | |||
|- | |||
| Other||[[Rifampin]]||X1 | |||
|- | |||
| ||[[Metronidazole]]||'''S''' | |||
|- | |||
| ||[[Quinupristin dalfoppristin]]||I | |||
|- | |||
| ||[[Linezolid]]||I | |||
|- | |||
| ||[[Colistimethate]]||X1 | |||
|} | |||
==Disposition== | ==Disposition== |
Revision as of 03:02, 24 June 2014
Background
- Most common cause of infectious diarrhea in hospitalized pts
- Use contact isolation if suspect
- Risk factors for pseudomembranous colitis:
- Recent abx use (any)
- GI surgery
- Severe underlying medical illness
- Chemo
- Elderly
Diagnosis
History
- Diarrhea that develops during abx use or w/in 2wk of discontinuation
- Recent discharge from hospital
- Profuse watery diarrhea
Exam
- Abdominal pain
- Fever
- Leukocytosis
- +Fecal leukocytes (distinguishes from benign forms of abx-induced diarrhea)
Labs
- C. diff toxin assay
- Sn 63-94%, Sp 75-100%
- Culture
- Positve culture only means C. diff present, not necessarily that it is causing disease
Harbor Testing Algorithm
- Patient with suspected Clostridium difficile associated diarrhea (CDAD)
- Low suspicion for CDAD
- Send stool for C. diff toxin assay
- Positive --> treat (no further testing indicated)
- Negative --> do not treat (no further testing indicated)
- Send stool for C. diff toxin assay
- High suspicion for CDAD
- Send stool for C. diff toxin assay AND treat empirically
- Positive --> treat (no further testing indicated)
- Negative --> Consider discussion with ID (false negative tests may occur); eval for other causes of diarrhea
- Send stool for C. diff toxin assay AND treat empirically
- Low suspicion for CDAD
- Repeat testing
- Never a need for repeat testing within 7 days of a previous test
- NO NEED to repeat positive tests as symptoms resolve as a “test of cure”
- NO NEED to repeat test soon after initial negative test (more likely to be a false positive test than a true positive test)
Treatment
- Mild
- Either d/c offending abx (if possible) or give metronidazole 500mg PO q6hr x10-14d
- Moderate
- Metronidazole 500mg PO or IV q6hr x10-14d
- Severe
- Criteria
- Age >60yr
- Temp >38.4 (101)
- Serum albumin <2.5
- WBC >15K
- Pt requires ICU admission
- Pseudomembranous colitis on endoscopy
- Tx
- Vancomycin 125-250mg PO q6hr x10d (IV form is not effective)
- Add metronidazole 500mg IV q6hr if ileus or pt cannot tolerate PO
- Criteria
- Emergency colectomy should be considered if:
- WBC >20K
- Lactate >5
- Age >75
- Immunosuppression
- Toxic megacolon
- Colonic perforation
- Multi-organ system failure
Recurrent Infection
- Occurs <=4 weeks after the completion of therapy
- Otherwise consider other (more common) causes
- Antimicrobial resistance is not clinically problematic, first recurrence treated with the same agent used to treat the initial episode
Antibiotic Sensitivities[1]
Disposition
- Admit:
- Severe diarrhea
- Oupt abx failure
- Systemic response (fever, leukocytosis, severe abdominal pain)
Source
Tintinalli
See Also
- ↑ Sanford Guide to Antimicrobial Therapy 2014