Clostridium difficile: Difference between revisions
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''This page is for <u>adult</u> patients; for pediatric patients see [[clostridium difficile (peds)]].'' | |||
==Background== | ==Background== | ||
*Most common cause of infectious diarrhea in hospitalized | [[File:Pseudomembranous colitis 1.jpg|thumb|Pseudomembranous colitis with yellow pseudomembranes seen on the wall of the sigmoid colon.]] | ||
*[[Clostridium]] is a genus of [[gram-positive bacteria]] | |||
*Most common cause of infectious diarrhea in hospitalized patients | |||
*Use contact isolation if suspect | *Use contact isolation if suspect | ||
*Risk factors for | *Alcohol-based hand sanitizers do not reduce spores, but good hand washing does<ref>Leffler DA and Lamont JT. Clostridium difficile Infection. N Engl J Med. 2015; 372:1539-1548.</ref> | ||
===Risk factors for Pseudomembranous Colitis=== | |||
*Recent antibiotic use (any) | |||
** | *GI surgery | ||
** | *Severe underlying medical illness | ||
*Chemo | |||
*Elderly | |||
==Clinical Features== | |||
''Varies according to severity and intrinsic host factors (immunosuppression, etc.).'' | |||
*Profuse watery [[diarrhea]] | |||
**Usually develops after 7-10 days of antibiotics use or within 2 weeks of discontinuation | |||
*History of risk factor(s) (see Background) | |||
*May report diffuse [[abdominal pain]]/cramping | |||
*At the extreme, may present with [[sepsis]] secondary to intestinal perforation or [[toxic megacolon]] | |||
==Differential Diagnosis== | |||
{{Diarrhea DDX}} | |||
==Evaluation== | |||
[[File:MPX1834 synpic40781.png|thumb|Pseudomembranous colitis from ''C. difficile'' on abdominal CT demonstratin diffuse colonic wall thickening and a shaggy endoluminal contour.]] | |||
[[File:PMC5137169 gr1.png|thumb|Pseudomembranous colitis with (A) Accordion sign in transverse colon (thin arrows). (B) Colonic wall thickness, target sign (thick arrow), peritoneal fluid (thin arrow) and pericolonic fat stranding (arrowhead).]] | |||
===Workup=== | |||
*Consider testing patients with unexplained and new-onset ≥3 unformed stools within 24 hours<ref name="ISDA C. Diff 2017">Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) McDonald CL, et al. Clinical Infectious Diseases, Volume 66, Issue 7, 1 April 2018, Pages e1–e48, https://doi.org/10.1093/cid/cix1085</ref> | |||
*Institutions should have an agreed protocol using a stool toxin test as part of a multistep algorithm (e.g. glutamate dehydrogenase [GDH] plus toxin; GDH plus toxin, arbitrated by nucleic acid amplification test [NAAT]) | |||
**or NAAT plus toxin) rather than a NAAT alone for all specimens received in the clinical laboratory when there are no preagreed institutional criteria for patient stool submission (Figure 2) (weak recommendation, low quality of evidence). | |||
*C. diff toxin assay | *C. diff toxin assay | ||
**Sn 63-94%, Sp 75-100% | **Sn 63-94%, Sp 75-100% | ||
*Culture | *Culture | ||
** | **Positive culture only means C. diff present, not necessarily that it is causing disease | ||
===Testing Algorithm=== | |||
''For patients with suspected Clostridium difficile associated diarrhea (CDAD)'' | |||
*'''Low''' suspicion | |||
**Send stool for C. diff toxin assay | |||
***Positive → treat (no further testing indicated) | |||
***Negative → do not treat (no further testing indicated) | |||
*'''High''' suspicion | |||
**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 | |||
===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) | |||
===Severe Criteria<ref name="IDSA">IDSA Guidelines [http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/cdiff2010a.pdf PDF]</ref><ref>ACG Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections http://gi.org/guideline/diagnosis-and-management-of-c-difficile-associated-diarrhea-and-colitis/</ref><ref>McDonald LC, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases. 2018;66:e1.</ref>=== | |||
*Leukocytosis with a white blood cell count of ≥15000 cells/mL | |||
*Serum creatinine level >1.5 mg/dL | |||
*Serum [[lactate]] levels >2.2 mmol/l | |||
*[[Mental status changes]] | |||
*[[leukocytosis|WBC]] ≥35,000 cells/mm3 or <2,000 cells/mm3 | |||
*Patient requiring ICU admission | |||
*End organ failure ([[mechanical ventilation]], [[renal failure]], etc.) | |||
===Severe Fulminant Criteria<ref>McDonald LC, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases. 2018;66:e1.</ref>=== | |||
*[[Hypotension]] with or without required use of vasopressors | |||
*[[Ileus]] or significant abdominal distention | |||
*Megacolon | |||
=== | ==Management== | ||
===Asymptomatic=== | |||
*No diagnostic testing or treatment required<ref>Bagdasarian, N, et al. Diagnosis and Treatment of Clostridium difficile in Adults. JAMA. 2015; 313(4):398-408.</ref> | |||
*Consider discontinuing offending antibiotics | |||
===Non-Severe=== | |||
Fidaxomicin first line per 2018 IDSA guidelines <ref>Stuart Johnson, Valéry Lavergne, Andrew M Skinner, Anne J Gonzales-Luna, Kevin W Garey, Ciaran P Kelly, Mark H Wilcox, Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults, Clinical Infectious Diseases, Volume 73, Issue 5, 1 September 2021, Pages e1029–e1044, https://doi.org/10.1093/cid/ciab549</ref> | |||
{{Non-Severe Cdiff Antibiotics}} | |||
== | ===Severe=== | ||
{{Severe Cdiff Antibiotics}} | |||
===Severe Fulminant=== | |||
''See criteria above (Evaluation section)'' | |||
*[[Vancomycin]] 500 mg PO or NG four times daily for 10 days | |||
*Considered rectal instillation of [[Vancomycin]] | |||
*[[Metronidazole]] 500 mg IV every 8 hours, particularly if ileus is present. | |||
*Consider emergency colectomy if: | |||
* | |||
* | |||
* | |||
* | |||
**WBC >20K | **WBC >20K | ||
**[[Lactate]] >5 | **[[Lactate]] >5 | ||
**Age >75 | **Age >75 | ||
**Immunosuppression | **Immunosuppression | ||
**Toxic megacolon | **[[Toxic megacolon]] | ||
**Colonic perforation | **Colonic perforation | ||
**Multi-organ system failure | **Multi-organ system failure | ||
===Recurrent Infection=== | ===Recurrent Infection=== | ||
''Relapse occurs in 10-25% of patients'' | |||
*Occurs <=4 weeks after the completion of therapy | |||
**Otherwise consider other (more common) causes | |||
*1st recurrence: Fidaxomicin first line therapy | |||
*2nd recurrence: tapered [[vancomycin]] with pulse doses | |||
*3rd recurrence: PO [[vancomycin]] 10-14 days followed immediately by [[rifaximin]] "chaser" 400mg TID x20 days <ref>Melville NA. Rifaximin 'Chaser' Reduces C difficile Recurrent Diarrhea. June 07, 2011. http://www.medscape.com/viewarticle/744157</ref> | |||
*Other options: | |||
**[[IVIG]] | |||
**Fecal transplant | |||
**[[Fidaxomicin]] 200mg BID x10 days noninferior to PO [[vancomycin]], and reduces recurrences at 4 weeks after treatment (~15% vs 25%) <ref>Louie TJ et al. Fidaxomicin versus [[Vancomycin]] for Clostridium difficile Infection. N Engl J Med 2011; 364:422-431.</ref> | |||
==Disposition== | |||
*Admit: | |||
**Severe diarrhea | |||
**Outpatient antibiotic failure | |||
**Systemic response (fever, leukocytosis, severe abdominal pain) | |||
==[[Antibiotic Sensitivities]]<ref>Sanford Guide to Antimicrobial Therapy 2014</ref>== | |||
{| class="wikitable" | {| class="wikitable" | ||
| align="center" style="background:#f0f0f0;"|'''Category''' | | align="center" style="background:#f0f0f0;"|'''Category''' | ||
Line 213: | Line 257: | ||
| ||[[Colistimethate]]||X1 | | ||[[Colistimethate]]||X1 | ||
|} | |} | ||
==See Also== | ==See Also== | ||
*[[Diarrhea]] | *[[Diarrhea]] | ||
*[[Clostridium]] | *[[Clostridium]] | ||
==References== | |||
<references/> | |||
[[Category:ID]] | [[Category:ID]] | ||
[[Category:GI]] |
Latest revision as of 04:45, 7 January 2023
This page is for adult patients; for pediatric patients see clostridium difficile (peds).
Background
- Clostridium is a genus of gram-positive bacteria
- Most common cause of infectious diarrhea in hospitalized patients
- Use contact isolation if suspect
- Alcohol-based hand sanitizers do not reduce spores, but good hand washing does[1]
Risk factors for Pseudomembranous Colitis
- Recent antibiotic use (any)
- GI surgery
- Severe underlying medical illness
- Chemo
- Elderly
Clinical Features
Varies according to severity and intrinsic host factors (immunosuppression, etc.).
- Profuse watery diarrhea
- Usually develops after 7-10 days of antibiotics use or within 2 weeks of discontinuation
- History of risk factor(s) (see Background)
- May report diffuse abdominal pain/cramping
- At the extreme, may present with sepsis secondary to intestinal perforation or toxic megacolon
Differential Diagnosis
Acute diarrhea
Infectious
- Viral (e.g. rotavirus)
- Bacterial
- Campylobacter
- Shigella
- Salmonella (non-typhi)
- Escherichia coli
- E. coli 0157:H7
- Yersinia enterocolitica
- Vibrio cholerae
- Clostridium difficile
- Parasitic
- Toxin
Noninfectious
- GI Bleed
- Appendicitis
- Mesenteric Ischemia
- Diverticulitis
- Adrenal Crisis
- Thyroid Storm
- Toxicologic exposures
- Antibiotic or drug-associated
Watery Diarrhea
- Enterotoxigenic E. coli (most common cause of watery diarrhea)[2]
- Norovirus (often has prominent vomiting)
- Campylobacter
- Non-typhoidal Salmonella
- Enteroaggregative E. coli (EAEC)
- Enterotoxigenic Bacteroides fragilis
Traveler's Diarrhea
Evaluation
Workup
- Consider testing patients with unexplained and new-onset ≥3 unformed stools within 24 hours[3]
- Institutions should have an agreed protocol using a stool toxin test as part of a multistep algorithm (e.g. glutamate dehydrogenase [GDH] plus toxin; GDH plus toxin, arbitrated by nucleic acid amplification test [NAAT])
- or NAAT plus toxin) rather than a NAAT alone for all specimens received in the clinical laboratory when there are no preagreed institutional criteria for patient stool submission (Figure 2) (weak recommendation, low quality of evidence).
- C. diff toxin assay
- Sn 63-94%, Sp 75-100%
- Culture
- Positive culture only means C. diff present, not necessarily that it is causing disease
Testing Algorithm
For patients with suspected Clostridium difficile associated diarrhea (CDAD)
- Low suspicion
- 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
- 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
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)
Severe Criteria[4][5][6]
- Leukocytosis with a white blood cell count of ≥15000 cells/mL
- Serum creatinine level >1.5 mg/dL
- Serum lactate levels >2.2 mmol/l
- Mental status changes
- WBC ≥35,000 cells/mm3 or <2,000 cells/mm3
- Patient requiring ICU admission
- End organ failure (mechanical ventilation, renal failure, etc.)
Severe Fulminant Criteria[7]
- Hypotension with or without required use of vasopressors
- Ileus or significant abdominal distention
- Megacolon
Management
Asymptomatic
- No diagnostic testing or treatment required[8]
- Consider discontinuing offending antibiotics
Non-Severe
Fidaxomicin first line per 2018 IDSA guidelines [9]
- Vancomycin 125 mg PO four times daily for 10 days
- Fidaxomicin 200 mg PO two times daily for 10 days
- Metronidazole 500mg PO or IV four times daily for 10 days (third line therapy)
Severe
- Vancomycin 125 mg PO four times daily for 10 days
- Fidaxomicin 200 mg PO two times daily for 10 days
Severe Fulminant
See criteria above (Evaluation section)
- Vancomycin 500 mg PO or NG four times daily for 10 days
- Considered rectal instillation of Vancomycin
- Metronidazole 500 mg IV every 8 hours, particularly if ileus is present.
- Consider emergency colectomy if:
- WBC >20K
- Lactate >5
- Age >75
- Immunosuppression
- Toxic megacolon
- Colonic perforation
- Multi-organ system failure
Recurrent Infection
Relapse occurs in 10-25% of patients
- Occurs <=4 weeks after the completion of therapy
- Otherwise consider other (more common) causes
- 1st recurrence: Fidaxomicin first line therapy
- 2nd recurrence: tapered vancomycin with pulse doses
- 3rd recurrence: PO vancomycin 10-14 days followed immediately by rifaximin "chaser" 400mg TID x20 days [10]
- Other options:
- IVIG
- Fecal transplant
- Fidaxomicin 200mg BID x10 days noninferior to PO vancomycin, and reduces recurrences at 4 weeks after treatment (~15% vs 25%) [11]
Disposition
- Admit:
- Severe diarrhea
- Outpatient antibiotic failure
- Systemic response (fever, leukocytosis, severe abdominal pain)
Antibiotic Sensitivities[12]
See Also
References
- ↑ Leffler DA and Lamont JT. Clostridium difficile Infection. N Engl J Med. 2015; 372:1539-1548.
- ↑ Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
- ↑ Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) McDonald CL, et al. Clinical Infectious Diseases, Volume 66, Issue 7, 1 April 2018, Pages e1–e48, https://doi.org/10.1093/cid/cix1085
- ↑ IDSA Guidelines PDF
- ↑ ACG Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections http://gi.org/guideline/diagnosis-and-management-of-c-difficile-associated-diarrhea-and-colitis/
- ↑ McDonald LC, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases. 2018;66:e1.
- ↑ McDonald LC, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases. 2018;66:e1.
- ↑ Bagdasarian, N, et al. Diagnosis and Treatment of Clostridium difficile in Adults. JAMA. 2015; 313(4):398-408.
- ↑ Stuart Johnson, Valéry Lavergne, Andrew M Skinner, Anne J Gonzales-Luna, Kevin W Garey, Ciaran P Kelly, Mark H Wilcox, Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults, Clinical Infectious Diseases, Volume 73, Issue 5, 1 September 2021, Pages e1029–e1044, https://doi.org/10.1093/cid/ciab549
- ↑ Melville NA. Rifaximin 'Chaser' Reduces C difficile Recurrent Diarrhea. June 07, 2011. http://www.medscape.com/viewarticle/744157
- ↑ Louie TJ et al. Fidaxomicin versus Vancomycin for Clostridium difficile Infection. N Engl J Med 2011; 364:422-431.
- ↑ Sanford Guide to Antimicrobial Therapy 2014