Clostridium difficile - Revision history

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Zbuchwald: /* Recurrent Infection */

2023-01-07T04:45:59Z

Recurrent Infection

← Older revision		Revision as of 04:45, 7 January 2023
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	*Occurs <=4 weeks after the completion of therapy		*Occurs <=4 weeks after the completion of therapy
	**Otherwise consider other (more common) causes		**Otherwise consider other (more common) causes
	*1st recurrence: ~~same agent as used to treat initial episode (antimicrobial resistance is not clinically problematic)~~		*1st recurrence: Fidaxomicin first line therapy
	*2nd recurrence: tapered [[vancomycin]] with pulse doses		*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>		*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>

Zbuchwald: /* Non-Severe */

2023-01-07T04:44:06Z

Non-Severe

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	===Non-Severe===		===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}}		{{Non-Severe Cdiff Antibiotics}}

Rossdonaldson1: /* Management */

2020-11-05T16:39:29Z

Management

← Older revision		Revision as of 16:39, 5 November 2020
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	===Severe===		===Severe===
	{{Severe Cdiff Antibiotics}}		{{Severe Cdiff Antibiotics}}


	===Severe Fulminant===		===Severe Fulminant===

Neil.m.young: /* Severe Fulminant */

2020-05-04T17:23:49Z

Severe Fulminant

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	===Severe Fulminant===		===Severe Fulminant===
	''See criteria above (Evaluation section)''		''See criteria above (Evaluation section)''
	VAN, 500 mg 4 times per day by mouth or by nasogastric tube. If ileus, consider adding rectal instillation of VAN. Intravenously administered metronidazole (500 mg every 8 hours) should be administered together with oral or rectal VAN, particularly if ileus is present.
	*[[Vancomycin]] 500 mg PO or NG four times daily for 10 days		*[[Vancomycin]] 500 mg PO or NG four times daily for 10 days
	*Considered rectal instillation of [[Vancomycin]]		*Considered rectal instillation of [[Vancomycin]]

Neil.m.young: /* Management */

2020-05-04T17:22:36Z

Management

← Older revision		Revision as of 17:22, 4 May 2020
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	===Asymptomatic===		===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>		*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

	===~~Mild~~===		===Non-Severe===
	*Either discontinue offending antibiotics (if possible) or give [[metronidazole]] 500mg PO q6hr x10-~~14d~~		{{Non-Severe Cdiff Antibiotics}}

	===~~Moderate~~===		===Severe===
	{{~~Moderate~~ Cdiff Antibiotics}}		{{Severe Cdiff Antibiotics}}

	===Severe===
			===Severe Fulminant===
	''See criteria above (Evaluation section)''		''See criteria above (Evaluation section)''
	~~{{Severe Cdiff Antibiotics}}~~		VAN, 500 mg 4 times per day by mouth or by nasogastric tube. If ileus, consider adding rectal instillation of VAN. Intravenously administered metronidazole (500 mg every 8 hours) should be administered together with oral or rectal VAN, particularly if ileus is present.
			*[[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:		*Consider emergency colectomy if:
	**WBC >20K		**WBC >20K

Neil.m.young: /* Severe CriteriaIDSA Guidelines PDFACG Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections http://gi.org/guideline/diagnosis-and-management-of-c-difficile-associated-diarrhea-and-colitis/ */

2020-05-04T17:17:08Z

Severe CriteriaIDSA Guidelines PDFACG Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections http://gi.org/guideline/diagnosis-and-management-of-c-difficile-associated-diarrhea-and-colitis/

← Older revision		Revision as of 17:17, 4 May 2020
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	*NO NEED to repeat test soon after initial negative test (more likely to be a false positive test than a true positive test)		*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>===		===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		*Serum [[lactate]] levels >2.2 mmol/l
	*[[Hypotension]] with or without required use of vasopressors
	*[[Ileus]] or significant abdominal distention
	*[[Mental status changes]]		*[[Mental status changes]]
	*[[leukocytosis\|WBC]] ≥35,000 cells/mm3 or <2,000 cells/mm3		*[[leukocytosis\|WBC]] ≥35,000 cells/mm3 or <2,000 cells/mm3
	*Patient requiring ICU admission		*Patient requiring ICU admission
	*End organ failure ([[mechanical ventilation]], [[renal failure]], etc.)		*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==		==Management==

ClaireLewis at 19:58, 29 September 2019

2019-09-29T19:58:24Z

← Older revision		Revision as of 19:58, 29 September 2019
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	**Usually develops after 7-10 days of antibiotics use or within 2 weeks of discontinuation		**Usually develops after 7-10 days of antibiotics use or within 2 weeks of discontinuation
	*History of risk factor(s) (see Background)		*History of risk factor(s) (see Background)
	*May report ~~profuse~~ abdominal pain/cramping		*May report diffuse [[abdominal pain]]/cramping
	*At the extreme, may present with [[sepsis]] secondary to intestinal perforation or [[toxic megacolon]]		*At the extreme, may present with [[sepsis]] secondary to intestinal perforation or [[toxic megacolon]]

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	===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>===		===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>===
	*Serum lactate levels >2.2 mmol/l		*Serum [[lactate]] levels >2.2 mmol/l
	*[[Hypotension]] with or without required use of vasopressors		*[[Hypotension]] with or without required use of vasopressors
	*[[Ileus]] or significant abdominal distention		*[[Ileus]] or significant abdominal distention
	*Mental status changes		*[[Mental status changes]]
	*WBC ≥35,000 cells/mm3 or <2,000 cells/mm3		*[[leukocytosis\|WBC]] ≥35,000 cells/mm3 or <2,000 cells/mm3
	*Patient requiring ICU admission		*Patient requiring ICU admission
	*End organ failure (mechanical ventilation, renal failure, etc.)		*End organ failure ([[mechanical ventilation]], [[renal failure]], etc.)

	==Management==		==Management==

Rossdonaldson1: /* Evaluation */

2019-07-04T06:16:32Z

Evaluation

← Older revision		Revision as of 06:16, 4 July 2019
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	===Workup===		===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>		*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		**Positive culture only means C. diff present, not necessarily that it is causing disease


	===Testing Algorithm===		===Testing Algorithm===