Clostridioides difficile

Clostridioides difficile

Most frequent infectious cause of healthcare-associated diarrhea in hospitalized patients (North America and Europe)

true

T/F: Exposure to any antimicrobial is the single most important risk factor for CDI.

Toxin A

Enterotoxin strain of C. diff

Toxin B

Cytotoxin strain of C. diff

BI/NAP1/027

Which strain of C.diff is associated with severe CDI, has higher rates of relapse, produces toxin A and B (produces 16x more toxin A and 23x more toxin B), and is fluoroquinolone-resistant?

fluoroquinolone

BI/NAP1/027 is _____-resistant

1. Antibiotic use

2. Advanced age: ≥65

3. Immunocompromised: cancer, HIV

4. GI surgery or manipulation of the GI tract: tube feeding

5. Gastric-acid suppression medications (long-term PPI use)

6. Hospitalization/healthcare exposure

Risk factors for C. diff

- Fluroquinolones

- Clindamycin

- Penicillins and combinations (broad spectrum): Zosyn, Unasyn, Augmentin

- Cephalosporins: generations 2-4

- Carbapenems

Antibiotics that are frequently associated with C. diff

- Macrolides

- Penicillins (narrow spectrum)

- Cephalosporins: 1st gen

- SMX-TMP

- Sulfonamides

Antibiotics that are occasionally associated with C. diff

- Aminoglycosides

- Tetracyclines

- Tigecycline

- Chloramphenicol

- Metronidazole

- Vancomycin

Antibiotics that are rarely associated with C. diff.

Diarrhea

Abdominal discomfort

Fever

Colitis

Fulminant disease

Clinical presentation of C. diff

Malaise

Abdominal pain

Nausea

Anorexia

Watery diarrhea

Low-grade fever

Evidence of colitis

Severe abdominal pain

Perfuse diarrhea

High fever

Evidence of fulminant disease

1. Unexplained and new-onset ≥3 unformed stools in 24 hours

2. Stool culture for C. diff

3. Detection of toxin A or B

4. WBC count: marked leukocytosis

5. Endoscopic exam

Diagnosis of C. diff

Colonization:

- NO clinical symptoms present

- Positive C. diff test and/or its toxin

(more common)

Infection:

- Clinical symptoms present

- Positive C. diff test and/or its toxin

How to differentiate between C. diff colonization and C. diff infection?

WBC ≤ 15,000 cells/ml

SCr < 1.5 mg/dL

Which WBC count and SCr level indicate non-severe C.diff?

WBC > 15,000 cells/ml

SCr ≥ 1.5 mg/dL

Which WBC count and SCr level indicate severe C.diff?

Macrolides

Fidaxomicin (Dificid) should NOT be used in patients with an allergy to _____.

Preferred: Fidaxomicin (Dificid) 200 mg BID x 10 days

Alternative 1: Vancomycin (Firvanq) 125 mg PO QID x 10 days

Alternative 2 (if the 2 above are unavailable): Metronidazole (Flagyl) 500 mg PO TID x 10-14 days

Treatment recommendation for initial episode, non-severe C. diff

- WBC ≤ 15,000 AND SCr < 1.5

Preferred: Fidaxomicin 200 mg BID x 10 days

Alternative 1: Vancomycin 125 mg PO QID x 10 days

Treatment recommendation for initial episode, severe C. diff.

- WBC > 15,000 AND SCr ≥ 1.5

Vancomycin 500 mg PO/NGT QID PLUS Metronidazole 500 mg IV Q8H

*If ileus, consider adding rectal instillation of: Vancomycin 500 mg in 100 ml of NS Q6H

Treatment recommendation for initial episode, fulminant

- Hypotension or shock, ileus, megacolon

1. Preferred: Fidaxomicin 200 mg PO BID x 10 days OR Fidaxomicin 200 mg PO BID x 5 days, followed by once every other day x20 days

2. Alternative: Vancomycin tapered and pulsed

- Vanco 120 mg PO QID x10-14 days, then BID x 7 days, then daily x 7 days, then every 2-3 days x2-8 weeks

Treatment of the first recurrence of C. diff (within 90 days)

Vancomycin 125 mg PO QID x 10 days

Could also use Dificid

For the treatment of the first recurrence of C. diff, what is the treatment if Metronidazole was used for the first episode?

Bezlotoxumab (Zinplava) 10 mg/kg IV once during administration of standard treatment regimen

Adjunctive treatment for recurrence of C. diff.

1. Fidaxomicin 200 mg PO BID x 10 days OR 200 mg PO BID x 5 days followed by once every other day x20 days

2. Vancomycin tapered or pulsed OR Vancomycin 125 mg PO QID x 10 days, THEN Rifaximin 400 mg PO TID x 20 days

3. Fecal microbiota transplantation (FMT): used if patient has C. diff >2 times (total of 3 episodes)

Treatment of the second or subsequent recurrence of C. diff

Bezlotoxumab (Zinplava)

- single dose of 10 mg/kg IV over 60 min

A human monoclonal antibody that binds to C. diff Toxin B and neutralizes its effect

- NOT effective if given without the standard treatment of C. diff

- Precaution in CHF patients (exacerbates HF)

- AEs: nausea, pyrexia, headache

Fecal Microbiota Transplantation (FMT)

Investigational treatment for recurrent CDI (RCDI) and failure of appropriate treatment

- administered via nasoduodenal tube or enema

- FDA alert for enteropathogenic E. coli (EPEC) and Shiga-toxin-producing E. coli (STEC)

glove use

The only CDI prevention recommendation with the highest strength of recommendation and quality of evidence; decreases the risk of transmission

true

T/F: For hand hygiene, soap and water are preferred over alcohol-based hand hygiene products.