Clostridium difficile: Difference between revisions
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''This page is for <u>adult</u> patients; for pediatric patients see [[clostridium difficile (peds)]].'' | |||
==Background== | ==Background== | ||
*[[Clostridium]] is a genus of [[ | [[File:Pseudomembranous colitis 1.jpg|thumb|Pseudomembranous colitis with yellow pseudomembranes seen on the wall of the sigmoid colon.]] | ||
*[[Clostridium]] is a genus of [[gram-positive bacteria]] | |||
*Most common cause of infectious diarrhea in hospitalized patients | *Most common cause of infectious diarrhea in hospitalized patients | ||
*Use contact isolation if suspect | *Use contact isolation if suspect | ||
*Alcohol-based hand sanitizers | *Alcohol-based hand sanitizers do not reduce spores, but good hand washing does<ref>Leffler DA and Lamont JT. Clostridium difficile Infection. N Engl J Med. 2015; 372:1539-1548.</ref> | ||
===Risk factors | ===Risk factors for Pseudomembranous Colitis=== | ||
*Recent antibiotic use (any) | *Recent antibiotic use (any) | ||
*GI surgery | *GI surgery | ||
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==Clinical Features== | ==Clinical Features== | ||
''Varies according to severity and intrinsic host factors (immunosuppression, etc.).'' | |||
*[[ | *Profuse watery [[diarrhea]] | ||
*Usually | **Usually develops after 7-10 days of antibiotics use or within 2 weeks of discontinuation | ||
* | *History of risk factor(s) (see Background) | ||
*May report diffuse [[abdominal pain]]/cramping | |||
*At the extreme, may present with [[sepsis]] secondary to intestinal perforation or [[toxic megacolon]] | |||
*[[ | |||
*[[ | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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==Evaluation== | ==Evaluation== | ||
=== | [[File:MPX1834 synpic40781.png|thumb|Pseudomembranous colitis from ''C. difficile'' on abdominal CT demonstratin diffuse colonic wall thickening and a shaggy endoluminal contour.]] | ||
[[File:PMC5137169 gr1.png|thumb|Pseudomembranous colitis with (A) Accordion sign in transverse colon (thin arrows). (B) Colonic wall thickness, target sign (thick arrow), peritoneal fluid (thin arrow) and pericolonic fat stranding (arrowhead).]] | |||
===Workup=== | |||
*Consider testing patients with unexplained and new-onset ≥3 unformed stools within 24 hours<ref name="ISDA C. Diff 2017">Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) McDonald CL, et al. Clinical Infectious Diseases, Volume 66, Issue 7, 1 April 2018, Pages e1–e48, https://doi.org/10.1093/cid/cix1085</ref> | |||
*Institutions should have an agreed protocol using a stool toxin test as part of a multistep algorithm (e.g. glutamate dehydrogenase [GDH] plus toxin; GDH plus toxin, arbitrated by nucleic acid amplification test [NAAT]) | |||
**or NAAT plus toxin) rather than a NAAT alone for all specimens received in the clinical laboratory when there are no preagreed institutional criteria for patient stool submission (Figure 2) (weak recommendation, low quality of evidence). | |||
*C. diff toxin assay | *C. diff toxin assay | ||
**Sn 63-94%, Sp 75-100% | **Sn 63-94%, Sp 75-100% | ||
*Culture | *Culture | ||
**Positive culture only means C. diff present, not necessarily that it is causing disease | **Positive culture only means C. diff present, not necessarily that it is causing disease | ||
===Testing Algorithm=== | ===Testing Algorithm=== | ||
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*NO NEED to repeat positive tests as symptoms resolve as a “test of cure” | *NO NEED to repeat positive tests as symptoms resolve as a “test of cure” | ||
*NO NEED to repeat test soon after initial negative test (more likely to be a false positive test than a true positive test) | *NO NEED to repeat test soon after initial negative test (more likely to be a false positive test than a true positive test) | ||
===Severe Criteria<ref name="IDSA">IDSA Guidelines [http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/cdiff2010a.pdf PDF]</ref><ref>ACG Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections http://gi.org/guideline/diagnosis-and-management-of-c-difficile-associated-diarrhea-and-colitis/</ref><ref>McDonald LC, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases. 2018;66:e1.</ref>=== | |||
*Leukocytosis with a white blood cell count of ≥15000 cells/mL | |||
*Serum creatinine level >1.5 mg/dL | |||
*Serum [[lactate]] levels >2.2 mmol/l | |||
*[[Mental status changes]] | |||
*[[leukocytosis|WBC]] ≥35,000 cells/mm3 or <2,000 cells/mm3 | |||
*Patient requiring ICU admission | |||
*End organ failure ([[mechanical ventilation]], [[renal failure]], etc.) | |||
===Severe Fulminant Criteria<ref>McDonald LC, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases. 2018;66:e1.</ref>=== | |||
*[[Hypotension]] with or without required use of vasopressors | |||
*[[Ileus]] or significant abdominal distention | |||
*Megacolon | |||
==Management== | ==Management== | ||
===Asymptomatic=== | ===Asymptomatic=== | ||
*No diagnostic testing or treatment required<ref>Bagdasarian, N, et al. Diagnosis and Treatment of Clostridium difficile in Adults. JAMA. 2015; 313(4):398-408.</ref> | *No diagnostic testing or treatment required<ref>Bagdasarian, N, et al. Diagnosis and Treatment of Clostridium difficile in Adults. JAMA. 2015; 313(4):398-408.</ref> | ||
*Consider discontinuing offending antibiotics | |||
* | |||
=== | ===Non-Severe=== | ||
{{ | {{Non-Severe Cdiff Antibiotics}} | ||
===Severe=== | ===Severe=== | ||
{{Severe Cdiff Antibiotics}} | {{Severe Cdiff Antibiotics}} | ||
* | |||
===Severe Fulminant=== | |||
''See criteria above (Evaluation section)'' | |||
*[[Vancomycin]] 500 mg PO or NG four times daily for 10 days | |||
*Considered rectal instillation of [[Vancomycin]] | |||
*[[Metronidazole]] 500 mg IV every 8 hours, particularly if ileus is present. | |||
*Consider emergency colectomy if: | |||
**WBC >20K | **WBC >20K | ||
**[[Lactate]] >5 | **[[Lactate]] >5 | ||
**Age >75 | **Age >75 | ||
**Immunosuppression | **Immunosuppression | ||
**Toxic megacolon | **[[Toxic megacolon]] | ||
**Colonic perforation | **Colonic perforation | ||
**Multi-organ system failure | **Multi-organ system failure | ||
===Recurrent Infection=== | ===Recurrent Infection=== | ||
''Relapse occurs in 10-25% of patients'' | |||
*Occurs <=4 weeks after the completion of therapy | *Occurs <=4 weeks after the completion of therapy | ||
**Otherwise consider other (more common) causes | **Otherwise consider other (more common) causes | ||
* | *1st recurrence: same agent as used to treat initial episode (antimicrobial resistance is not clinically problematic) | ||
*2nd recurrence | *2nd recurrence: tapered [[vancomycin]] with pulse doses | ||
*3rd recurrence | *3rd recurrence: PO [[vancomycin]] 10-14 days followed immediately by [[rifaximin]] "chaser" 400mg TID x20 days <ref>Melville NA. Rifaximin 'Chaser' Reduces C difficile Recurrent Diarrhea. June 07, 2011. http://www.medscape.com/viewarticle/744157</ref> | ||
*Other options: | *Other options: | ||
**[[IVIG]] | **[[IVIG]] | ||
**Fecal transplant | **Fecal transplant | ||
** | **[[Fidaxomicin]] 200mg BID x10 days noninferior to PO [[vancomycin]], and reduces recurrences at 4 weeks after treatment (~15% vs 25%) <ref>Louie TJ et al. Fidaxomicin versus [[Vancomycin]] for Clostridium difficile Infection. N Engl J Med 2011; 364:422-431.</ref> | ||
===[[Antibiotic Sensitivities]]<ref>Sanford Guide to Antimicrobial Therapy 2014</ref> | ==Disposition== | ||
*Admit: | |||
**Severe diarrhea | |||
**Outpatient antibiotic failure | |||
**Systemic response (fever, leukocytosis, severe abdominal pain) | |||
==[[Antibiotic Sensitivities]]<ref>Sanford Guide to Antimicrobial Therapy 2014</ref>== | |||
{| class="wikitable" | {| class="wikitable" | ||
| align="center" style="background:#f0f0f0;"|'''Category''' | | align="center" style="background:#f0f0f0;"|'''Category''' | ||
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| ||[[Colistimethate]]||X1 | | ||[[Colistimethate]]||X1 | ||
|} | |} | ||
==See Also== | ==See Also== |
Revision as of 17:23, 4 May 2020
This page is for adult patients; for pediatric patients see clostridium difficile (peds).
Background
- Clostridium is a genus of gram-positive bacteria
- Most common cause of infectious diarrhea in hospitalized patients
- Use contact isolation if suspect
- Alcohol-based hand sanitizers do not reduce spores, but good hand washing does[1]
Risk factors for Pseudomembranous Colitis
- Recent antibiotic use (any)
- GI surgery
- Severe underlying medical illness
- Chemo
- Elderly
Clinical Features
Varies according to severity and intrinsic host factors (immunosuppression, etc.).
- Profuse watery diarrhea
- Usually develops after 7-10 days of antibiotics use or within 2 weeks of discontinuation
- History of risk factor(s) (see Background)
- May report diffuse abdominal pain/cramping
- At the extreme, may present with sepsis secondary to intestinal perforation or toxic megacolon
Differential Diagnosis
Acute diarrhea
Infectious
- Viral (e.g. rotavirus)
- Bacterial
- Campylobacter
- Shigella
- Salmonella (non-typhi)
- Escherichia coli
- E. coli 0157:H7
- Yersinia enterocolitica
- Vibrio cholerae
- Clostridium difficile
- Parasitic
- Toxin
Noninfectious
- GI Bleed
- Appendicitis
- Mesenteric Ischemia
- Diverticulitis
- Adrenal Crisis
- Thyroid Storm
- Toxicologic exposures
- Antibiotic or drug-associated
Watery Diarrhea
- Enterotoxigenic E. coli (most common cause of watery diarrhea)[2]
- Norovirus (often has prominent vomiting)
- Campylobacter
- Non-typhoidal Salmonella
- Enteroaggregative E. coli (EAEC)
- Enterotoxigenic Bacteroides fragilis
Traveler's Diarrhea
Evaluation
Workup
- Consider testing patients with unexplained and new-onset ≥3 unformed stools within 24 hours[3]
- Institutions should have an agreed protocol using a stool toxin test as part of a multistep algorithm (e.g. glutamate dehydrogenase [GDH] plus toxin; GDH plus toxin, arbitrated by nucleic acid amplification test [NAAT])
- or NAAT plus toxin) rather than a NAAT alone for all specimens received in the clinical laboratory when there are no preagreed institutional criteria for patient stool submission (Figure 2) (weak recommendation, low quality of evidence).
- C. diff toxin assay
- Sn 63-94%, Sp 75-100%
- Culture
- Positive culture only means C. diff present, not necessarily that it is causing disease
Testing Algorithm
For patients with suspected Clostridium difficile associated diarrhea (CDAD)
- Low suspicion
- Send stool for C. diff toxin assay
- Positive → treat (no further testing indicated)
- Negative → do not treat (no further testing indicated)
- Send stool for C. diff toxin assay
- High suspicion
- Send stool for C. diff toxin assay AND treat empirically
- Positive → treat (no further testing indicated)
- Negative → Consider discussion with ID (false negative tests may occur); eval for other causes of diarrhea
- Send stool for C. diff toxin assay AND treat empirically
Repeat testing
- Never a need for repeat testing within 7 days of a previous test
- NO NEED to repeat positive tests as symptoms resolve as a “test of cure”
- NO NEED to repeat test soon after initial negative test (more likely to be a false positive test than a true positive test)
Severe Criteria[4][5][6]
- Leukocytosis with a white blood cell count of ≥15000 cells/mL
- Serum creatinine level >1.5 mg/dL
- Serum lactate levels >2.2 mmol/l
- Mental status changes
- WBC ≥35,000 cells/mm3 or <2,000 cells/mm3
- Patient requiring ICU admission
- End organ failure (mechanical ventilation, renal failure, etc.)
Severe Fulminant Criteria[7]
- Hypotension with or without required use of vasopressors
- Ileus or significant abdominal distention
- Megacolon
Management
Asymptomatic
- No diagnostic testing or treatment required[8]
- Consider discontinuing offending antibiotics
Non-Severe
- Vancomycin 125 mg PO four times daily for 10 days
- Fidaxomicin 200 mg PO two times daily for 10 days
- Metronidazole 500mg PO or IV four times daily for 10 days (third line therapy)
Severe
- Vancomycin 125 mg PO four times daily for 10 days
- Fidaxomicin 200 mg PO two times daily for 10 days
Severe Fulminant
See criteria above (Evaluation section)
- Vancomycin 500 mg PO or NG four times daily for 10 days
- Considered rectal instillation of Vancomycin
- Metronidazole 500 mg IV every 8 hours, particularly if ileus is present.
- Consider emergency colectomy if:
- WBC >20K
- Lactate >5
- Age >75
- Immunosuppression
- Toxic megacolon
- Colonic perforation
- Multi-organ system failure
Recurrent Infection
Relapse occurs in 10-25% of patients
- Occurs <=4 weeks after the completion of therapy
- Otherwise consider other (more common) causes
- 1st recurrence: same agent as used to treat initial episode (antimicrobial resistance is not clinically problematic)
- 2nd recurrence: tapered vancomycin with pulse doses
- 3rd recurrence: PO vancomycin 10-14 days followed immediately by rifaximin "chaser" 400mg TID x20 days [9]
- Other options:
- IVIG
- Fecal transplant
- Fidaxomicin 200mg BID x10 days noninferior to PO vancomycin, and reduces recurrences at 4 weeks after treatment (~15% vs 25%) [10]
Disposition
- Admit:
- Severe diarrhea
- Outpatient antibiotic failure
- Systemic response (fever, leukocytosis, severe abdominal pain)
Antibiotic Sensitivities[11]
See Also
References
- ↑ Leffler DA and Lamont JT. Clostridium difficile Infection. N Engl J Med. 2015; 372:1539-1548.
- ↑ Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
- ↑ Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) McDonald CL, et al. Clinical Infectious Diseases, Volume 66, Issue 7, 1 April 2018, Pages e1–e48, https://doi.org/10.1093/cid/cix1085
- ↑ IDSA Guidelines PDF
- ↑ ACG Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections http://gi.org/guideline/diagnosis-and-management-of-c-difficile-associated-diarrhea-and-colitis/
- ↑ McDonald LC, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases. 2018;66:e1.
- ↑ McDonald LC, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases. 2018;66:e1.
- ↑ Bagdasarian, N, et al. Diagnosis and Treatment of Clostridium difficile in Adults. JAMA. 2015; 313(4):398-408.
- ↑ Melville NA. Rifaximin 'Chaser' Reduces C difficile Recurrent Diarrhea. June 07, 2011. http://www.medscape.com/viewarticle/744157
- ↑ Louie TJ et al. Fidaxomicin versus Vancomycin for Clostridium difficile Infection. N Engl J Med 2011; 364:422-431.
- ↑ Sanford Guide to Antimicrobial Therapy 2014