Sandbox G

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Guillermo Rodriguez Nava, M.D. [2]

Overview

  1. If a patient has a strong pre-test probability for CDI, empiric therapy should be considered regardless of the laboratory testing result[1]. CDI accounts for about 20% of antibiotic-associated diarrhoea cases in the USA[2].The main risk factors for CDI are:
    1. Antibiotic exposure and the first three months after cessation of antibiotics[3]. Commonly clindamycin, penicillins, cephalosporins, fluoroquinolones,and multiple antibiotics[4].
    2. Exposure to Clostridium difficile: up to 25% of hospitalized patients and residents of lonf term facilities are colonized[2].
    3. Age >65[3]. Commonly clindamycin, penicillins, cephalosporins, fluoroquinolones,and multiple antibiotics[4].
    4. History of inflammatory bowel disease[3]. Commonly clindamycin, penicillins, cephalosporins, fluoroquinolones,and multiple antibiotics[4].
  2. Any antimicrobial agent should be discontinued[1].
  3. Current guidelines recommend to choose the treatment regimen based on the severity of the disease[5] [1][2][4]:
    1. Mild: diarrhea as the only symptom.
    2. Moderate: raised white cell count but <15,000 cells/mL and serum creatine <1.5 times baseline.
    3. Severe: leucocytosis >15,000 cells/mL OR serum creatinene level >1.5 times baseline or abdominal tenderness and serum albumin < 3 g/dL.
    4. Severe complicated: hypotension or shock, ileus, megacolon, leucocytosis >20,000 cells/mL OR leucopenia <2,000, lactate >2.2 mmol/L, delirium, fever ≥ 38.5 °C, organ failure.
  4. Duration: recommendations stablish a 10-14 days treatment. If clinical response in 5-7 days, complete 10 days[4].
  5. Do not use metronidazole beyond the first recurrence episode of CDI or for long-term therapy because of the risk of neurotoxicity[5].
  6. For mild-to-moderate patients who are intolerant/allergic to metronidazole and for pregnant/breastfeeding women, vancomycin should be used at standard dosing[1].
  7. The use of anti-peristaltic agents to control diarrhea from confirmed or suspected CDI should be limited or avoided[1].
  8. Supportive care should be delivered to all patients with severe or severe complicated CDI[1].
  9. CT scanning of the abdomen and pelvis is recommended in patients with severe complicated CDI[1].
  10. Surgical consult should be obtained in all patients with complicated CDI[1].
  11. If there is a third recurrence after a pulsed vancomycin regimen, fecal microbiota transplant should be considered[1].

Medical Therapy

▸ Click on the following categories to expand treatment regimens.[1][5][2][4][6]

Initial episode

  ▸  Mild to moderate

  ▸  Severe

  ▸  Severe complicated

Recurrence

  ▸  First recurrence

  ▸  Second recurrence

Mild to moderate
Recommended treatment
Metronidazole 500 mg orally q8h
If no improvement in 5-7 days
Vancomycin 125 mg orally q6h
Severe
Reommended treatment
Vancomycin 125 mg orally q6h
Severe complicated
Recommended treatment
Vancomycin 500 mg orally q6h
PLUS
Metronidazole 500 mg IV q8h
If ileus present, addVancomycin 500 mg in 100 mL NS per rectum q6h as retention enema.
First recurrence
Recommended treatment
Same as first episode but stratified by severity
Second recurrence
Recommended treatment
Vancomycin in tapered and pulsed doses
     125 mg 4 times daily for 14 days
     125 mg 2 times daily for 7 days
     125 mg once daily for 7 days
     125 mg once every 2 days for 8 days (4 doses)
     125 mg once every 3 days for 15 days (5 doses)


References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH; et al. (2013). "Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections". Am J Gastroenterol. 108 (4): 478–98, quiz 499. doi:10.1038/ajg.2013.4. PMID 23439232.
  2. 2.0 2.1 2.2 2.3 Planche, Tim (2013). "Clostridium difficile". Medicine. 41 (11): 654–657. doi:10.1016/j.mpmed.2013.08.003. ISSN 1357-3039.
  3. 3.0 3.1 3.2 Hensgens MP, Goorhuis A, Dekkers OM, Kuijper EJ (2012). "Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics". J Antimicrob Chemother. 67 (3): 742–8. doi:10.1093/jac/dkr508. PMID 22146873.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 Knight, Christopher L.; Surawicz, Christina M. (2013). "Clostridium difficile Infection". Medical Clinics of North America. 97 (4): 523–536. doi:10.1016/j.mcna.2013.02.003. ISSN 0025-7125.
  5. 5.0 5.1 5.2 Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC; et al. (2010). "Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA)". Infect Control Hosp Epidemiol. 31 (5): 431–55. doi:10.1086/651706. PMID 20307191.
  6. Kelly CP, LaMont JT (2008). "Clostridium difficile--more difficult than ever". N Engl J Med. 359 (18): 1932–40. doi:10.1056/NEJMra0707500. PMID 18971494.