How do you manage C. Difficile Infections?

How do you manage C. Difficile Infections?

Diagnosis

Q. When do you suspect a Clostridium Difficile Infection (CDI)?

  • Symptoms of unexplained and new onset ≥3 unformed stools in 24 hours plus high clinical suspicion.
    • ex. Recent use of certain antibiotics increases risk for CDIs.

Q. What is the best diagnostic test/method for C Difficile?

  • Stool toxin + NAAT; GDH + toxin

Q. Any role in repeat testing?

  • No repeat testing needed (Strong recommendation)
  • Colonization is common in patients with multiple episodes, and can cause false positive

Prevention

Q. What measures are needed for infection prevention and control?

  • Contact precaution (use of hand gloves, washing hands with soap and water), at least 48 hours after diarrhea has resolved (strong recommendation)

Q. Role of PPI (proton pump inhibitors) restriction in controlling CDI rates?

  • Insufficient data/evidence for discontinuation of PPI’s as a measure for preventing C. Difficile infection

Q. Role of antibiotic stewardship in controlling CDI rates?

  • Restriction of fluoroquinolone, clindamycin, and cephalosporin should be considered (strong recommendation)

Treatment

Per the latest 2018 IDSA recommendations:

1. Discontinue inciting antibiotics as soon as possible.

2. Initial episode: either oral Vancomycin 125 mg QID or Fidaxomicin 200mg BID for 10 days (Strong recommendation)

3. Fulminant CDI: defined as hypotension or shock, ileus or mega-colon

  • Oral vancomycin 500mg QID or 500mg in 100ml NS via rectum every 6 hours as enema plus IV metronidazole 500mg every morning 8 hours
    • Oral vancomycin is preferred however, if ileus is present, rectal vancomycin can be used.
  • Summary: Oral or rectal Vancomycin + Metronidazole

4. Recurrent CDI:

  • 1st recurrence: 10 days x fidaxomicin or tapered oral vancomycin dose. (Note: Further inquire treatment regimen during first episode)
  • >1 recurrence: oral vancomycin tapered dosing or standard course of vancomycin followed by 400 mg TID for 20 days of rifaximin or fidaxomicin regimem
    • Tapered dose for first recurrence: First dose 125 mg Q6h x 10-14 days; 125 mg Q12h x 7 days; 125mg Q24h x 7 days; and 125 mg Q48-72 h x 2-8 weeks
  • Multiple recurrent episodes: Fecal microbiota transplantation. (strong recommendation)

Finally, obtaining an ID consult is recommended after the 1st episode of detection for guidance. (weak recommendation)


In summary…

VANC: Vancomycin, FDX: Fidaxomicin FMT: Fecal transplant
Chart by @prateekjuneja1

References:

Clinical Infectious Diseases, Volume 66, Issue 7, 1 April 2018, Pages e1–e48, https://doi.org/10.1093/cid/cix1085

Guyatt GH , Oxman AD, Kunz Ret al. ; GRADE Working Group. Going from evidence to recommendations. BMJ 2008; 336:1049–51.

Lessa FC , Mu Y, Bamberg WMet al. Burden of Clostridium difficile infection in the United States. N Engl J Med 2015; 372:825–34.

Chitnis AS , Holzbauer SM, Belflower RMet al. Epidemiology of community-associated Clostridium difficile infection, 2009 through 2011. JAMA Intern Med 2013; 173:1359–6

Post reviewed and edited by @udaygulati

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