Clostridium difficile
Background
- Most common cause of infectious diarrhea in hospitalized pts
- Use contact isolation if suspect
- Alcohol-based hand sanitizers does not reduce spore, but good hand washing does[1]
- Risk factors for pseudomembranous colitis:
- Recent abx use (any)
- GI surgery
- Severe underlying medical illness
- Chemo
- Elderly
- 60-70% of infants are asymptomatic carriers of c diff[2]
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
Asymptomatic
- No diagnostic testing or treatment required[3]
Mild
- Either discontinue offending antibiotics(if possible) or give Metronidazole 500mg PO q6hr x10-14d
Moderate
- 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
- Serum lactate levels >2.2 mmol/l
- Hypotension with or without required use of vasopressors
- Ileus or significant abdominal distention
- 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.)
Treatment:
- Vancomycin 125 mg PO four times daily for 10 days
- Fidaxomicin 200 mg PO two times daily for 10 days
- 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[6]
Disposition
- Admit:
- Severe diarrhea
- Oupt abx failure
- Systemic response (fever, leukocytosis, severe abdominal pain)
References
- ↑ Leffler DA and Lamont JT. Clostridium difficile Infection. N Engl J Med. 2015; 372:1539-1548.
- ↑ Jangi S and Lamon JT. Asymptomatic colonization by Clostridium difficile: implications for disease in later life. J Pediatr Gastroenterol Nutr. 2010; 51(1):2-7.
- ↑ Bagdasarian, N, et al. Diagnosis and Treatment of Clostridium difficile in Adults. JAMA. 2015; 313(4):398-408.
- ↑ 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/
- ↑ Sanford Guide to Antimicrobial Therapy 2014