Clostridioides Difficle Infection (CDI)

What is the microbiology of C.diff

Gram +

Rod

Spore-forming

Anaerobic

What are the 2 states of C.diff

Vegetative (growth)

Spore (non-growth)

Clinical presentation of Mild-Mod C.diff

Diarrhea

± abdominal cramps

Mild abdominal tenderness

Mild leukocytosis (<15,000 cells)

Clinical presentation of Mod-Severe C.diff

Profuse diarrhea

Abdominal cramping

Significant abdominal pain and distension

Systemic symptoms

Peudomembranous colitis present (thick/swollen colon walls)

Profound leukocytosis (> 15,000 cells)

What Abx classes are frequently associated with C.diff

Clindamycin

Penicillins (broad spectrum)

Cephalosporins (broad spectrum)

Fluoroquinolones

C.diff testing options

Stool culture

Enzyme immunoassays (EIA) for GDH antigen

EIA for Toxins A & B

Nucleic acid amplification (NAAT) test

What following test should be given if patient is positive for GDH antigen

EIA for toxins A & B

T/F: Negative toxin DNA NAAT test has a low predictive value and is commonly retested

False

What is the next step of action if a patient tested Positive for toxin DNA NAAT test and toxin antigen test

Stay on enteric isolation for their duration of stay

What test is recommended after a Positive toxin DNA NAAT test

EIA for toxins A & B

Criteria for Non-severe CDI

WBC < 15,000 cells/mL

AND

1.5 mg/dL

Criteria for Severe CDI

WBC >/= 15,000 cells/mL

OR

SCr > 1.5 mg/dL

Criteria for Fulminant CDI

Hypotension or Shock

Ileus (obstruction, hardened stool)

Megacolon

What are the first line therapies for initial episode for severe or non-severe infection

Fidaxomicin

Vancomycin

Metronidazole (if non-severe)

What is the dosing of Fidaxomicin (FDX) for initial episode for severe or non-severe infection

200mg BID PO for 10 days

What is the dosing of Vancomycin for initial episode for severe or non-severe infection

125mg QID PO for 10 days

What is the dosing of Metronidazole for initial episode for severe or non-severe infection

500mg TID PO for 14 days

What is the first line therapies and dosing for Initial episode, Fulminant for hypotension/shock

Vancomycin 500mg QID PO/Nasogastric tube

What additional therapy can be given if a patient has Fulminant, initial CDI and has an ileus

Vancomycin rectal instillation

Plus

Metronidazole 500mg IV TID

Infection control measures to prevent CDI spread

Contact precautions

PPE

Isolate patient to private room

Hand washing (not just sanitizer)

Continue precaution 48 hours after ___ diarrhea

Medications to avoid in CDI

Antiperistaltics

• Loperamide (Imodium)

• Diphenoxylate / Atropine (Lomotil)

• Opioid agonists (morphine, fentanyl, etc)

Non-CDI targeted Abx

T/F: A repeat C.diff toxin test should be performed once patients are stable

False

For the first recurrence of CDI, what are the preferred therapies

Fidaxomicin 200 mg BID for 10 days

OR

200mg BID for 5 days, then once EOD for 20 days

For the first recurrence of CDI, what are the alternative therapies

Vancomycin PO tapered and pulsed regimen

OR

125mg QID PO for 10 days (IF Metronidazole was used for first episode)

What treatment plan is used for multiple recurrent infections where appropriate Abx were used for at least 3 CDI episodes

Induction course of Vancomycin

AND

Fecal Microbiota Transplantation (FMT) via enema/colonoscope/nasoduodenal tube/oral capsules

What is the dosing for FMT rectal enema, Rebytota, for rCDI

150 mL once, given 24-72 hours after completion of Abx

What are possible symptoms from taking Rebyota

Stomach pain

Diarrhea

Bloating

Swollen belly

What is the dosing for FMT oral capsules, Vowst, for rCDI

4 caps SID for 3 days, given 2-4 days after completing Abx