Clostridioides difficile infection

2 toxins associated with c.diff

TcdA
TcdB

risk factors

antibiotic or healthcare exposure
proximity to person with C.diff
age > 65
use of PPI, H2RA, chemo, immunosuppression
GI surgery
antibiotic exposure: FQ, clindamyicin, ¾ cephalosporins, carbapenems

when to test for c.diff

3+ profuse, watery/mucoid green, foul-smelling stools in 24 hours

what tests can you run

nucleic acid amplification test (NAAT) alone
antigen test (GDH) + toxin A/B test
NAAT + toxin A/B test

classification of c.diff

non-severe: WBC <15,000 and SCr < 1.5
severe: WBC > 15,000 or SCr > 1.5
fulminant: severe + hypotension or shock, ileus, toxic megacolon

c.diff antibiotic treatment

oral vancomycin
fidaxomicin
IV or oral metronidazole

drug with the lowest recurrence rates

fodaxomicin

stepwise to initial episode non-severe

fidaxomicin → vancomycin → mtronidazole

stepwise to initial episode severe

fidaxomicin → vancomycin

stepwise for recurrence episode

use other drug not used before (may chose the option of vancomycin tapered and pulsed regimen)

stepwise to fulimant treatment

vancomycin + metronidazole

risk factors for CDI recurrence

Age > 65
severe CDI on presentation
immunocompromised

adiminstration of fecal material from healthy person to restore a balanced gut microbiome to reduce recurrence

fecal microbiota transplant (FMT)

when is FMT indicated

if 3+ episodes of CDI or poor response to inital antibiotic therapy for CDI
required administration via endoscopy, colonoscopy, or rectal tube

fecal microbiota suppression
prevention of recurrence fo CDI for patients following antibiotic traemtn fro recurrent CDI via rectal tube

rebyota

when to initiate rebyota

24-72 hours after antibiotic treatment completion

bacterial spore suspension
resistance to c.diff colonization and restoration of the gut microbiome

vowst

when to initiate vowst

2-4 days after treatment completion

MAb trageting C.diff toxin B to neutralize its effects
prevention of recurrence

bezlotoxumab

when to initaite bezlotoxumab

1 dose during the course fo CDI treatment