Clostridioides difficle Infection (CDI)

Objectives

1. Identify clinical signs and symptoms associated with Clostridioides difficile infection (CDI).

2. Differentiate between non-severe, severe, and fulminant CDI.

3. Design a pharmacotherapy plan (drug, dose, route, frequency and duration) for the management of non-severe, severe and fulminant CDI, including both initial and recurrent infections.

4. List infection control-related strategies aimed at preventing the spread of C. difficile in the healthcare setting

What is the clinical presentation of a patient with mild-moderate C. difficile infection?

• Diarrhea

• ± abdominal cramping

• Mild abdominal tenderness on physical exam

• No systemic symptoms

• No pseudomembranes present

• Mild leukocytosis (< 15,000 cells)

What is the clinical presentation of a patient with moderate-severe C. difficile infection

• Profuse diarrhea

• Abdominal cramping

• Significant abdominal pain and distension

• + Systemic symptoms

• Pseudomembranous colitis present

• Profound leukocytosis (> 15,000 cells)

When would you order tests for C. Diff?

1. If there’s > 3 new onset unexplained liquid/loose stools within the last 24 hours

2. No other explanation of diarrhea (laxatives, lactulose, tube feeds, oral contrast)

Compare and contrast

• Non-severe CDI

• Severe CDI

• Fulminant CDI

Initial Treatment of CDI in adults

Non-severe or Severe

• Preferred: FIdoaxomicin 200mg PO BID 10 days

• Alt: Vancomycin 125mg QID PO 10 days

• Alt for non-severe: Metronidazole 500mg PO TID 10-14 days

Fulminant

• Vancomycin 500mg QID PO or nasogastric tube. If ileus, consider adding rectal instillation of Vancomycin. Add IV metronidazole 500mg TID if ileus present

Fidaxomicin

• MOA

• Dosing

• Advantages

• Disadvantages

• Mechanism of action: Binds to bacterial DNA-dependent RNA polymerase; inhibits bacterial RNA synthesis

• Dosing: 200 mg PO twice daily

• 
  

What infection control measures should be used to prevent the spread of CDI to other patients?

• Contact precautions

• Move patient to private room

• Gown and gloves required upon entry into the patient room

• Use dedicated patient equipment

• Handwashing with soap and water after patient contact

• Continue precautions at least 24 hours after diarrhea has resolved

Should loperamide be used in our patient for the management of diarrhea? Why or why not?

Loperamide slows intestinal motility, allowing C.diff toxins to remain in the colon longer and increases risk of severe complications

What medications are avoided in CDI?

Antiperistaltics

• Loperamide (Imodium)

• Diphenoxylate/atropine (Lomotil)

• Opioid agonists (morphine, fentanyl, etc.)

Non-CDI targeted antibiotics

• Removal of inciting antibiotic whenever possible

• Limit re-exposure to antibiotics to prevent recurrent infections

T/F A repeat C. difficile toxin test should be performed once patients are stable as a “test of cure.”

False → limited clinical value

• Many patients remain positive after successful treatment

• can lead to unnecessary treatment if colonization detected rather than active infection

Treatment of Recurrent CDI in Adults

Preferred

• Fidaxomicin 200mg BID 10 days

• OR Fidaxomicin 200mg BID for 5 days, then once every other day for 20 days

ALT

• Vancomycin PO in a taper and pulsed regimen

• Vancomycin 125mg QID PO for 10 days → IF metronidazole was used for 1st episode

What is Fecal Microbiota Transplantation (FMT)?

• Transplantation of stool from healthy individuals

• Re-establish microbiota balance

• Use appropriate antibiotics for at least 3 CDI episodes before offering

Compare REBYOTA and VOWST

• Formulation

• Dosing

• Indication

• Timing

• Counseling points