Clostridium difficile: Difference between revisions
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==Treatment== | ==Treatment== | ||
===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> | |||
===Mild=== | |||
*Either discontinue offending antibiotics(if possible) or give [[Metronidazole]] 500mg PO q6hr x10-14d | |||
===Moderate=== | |||
{{Moderate Cdiff Antibiotics}} | |||
===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 | |||
*Hypotension with or without required use of vasopressors | |||
*Ileus or significant abdominal distention | |||
***WBC | *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:''' | |||
{{Severe Cdiff Antibiotics}} | |||
*Emergency colectomy should be considered if: | *Emergency colectomy should be considered if: | ||
**WBC >20K | **WBC >20K | ||
Revision as of 17:06, 5 February 2015
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
Asymptomatic
- No diagnostic testing or treatment required[1]
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 three 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[4]
Disposition
- Admit:
- Severe diarrhea
- Oupt abx failure
- Systemic response (fever, leukocytosis, severe abdominal pain)
Source
Tintinalli
- ↑ 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