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Year 3 - Clinical > 2 - Clostridium Difficile Infection > Flashcards

2 - Clostridium Difficile Infection Flashcards

1
Q

What is clostridium difficile?

A
  • Anaerobic
  • Spore forming
  • Exotoxin-producing
  • Gram pos bacteria
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2
Q

How is C. diff transmitted?

A

Fecal-oral route

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3
Q

What causes the sx of CDI?

A

Enterotoxin A and cytotoxin B

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4
Q

NAP1 is associated w/ _______

A

Fluoroquinolone use

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5
Q

What is the significance of NAP1 C. diff strain?

A
  • Hyper-virulence due to hyper-production of C. perfringens-type toxin
  • Higher rates of tx failure, recurrence, complications and attributable mortality compared w/ non-NAP1
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6
Q

Over ___% of CDI associated w/ NAP1

A

30%

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7
Q

What are the risk factors for CDI?

A
  • Antimicrobial therapy that disrupts normal colonic flora, typically presents w/in 4-9 days
  • Previous CDI
  • Hospitalization > 72 h
  • Female, advanced age (65 and older)
  • Multiple co-morbidities, severe underlying disease, immunocompromised
  • Gastric acid suppression, enteral feeding, GI surgery, inflammatory bowel disease
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8
Q

Which antibiotics are associated w/ CDI?

A
  • Highest risk = clindamycin
  • High risk = fluoroquinolones (NAP1), cephalosporins, penicillins
  • Moderate risk = macrolides, sulfonamides
  • Low risk = tetracyclines, aminoglycosides
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9
Q

Clinical signs of CDI

A
  • Watery diarrhea w/ 3 or more unformed stools in 24 h

- N/V, abdominal pain, high fever, significant leukocytosis

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10
Q

Normal WBC levels

A

4.5-11 * 10^9 cells/L or 4,500-11,000 cells/uL

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11
Q

Normal neutrophils levels. When do they increase?

A
  • 1.8-5.2

- Increase significantly during bacterial infections

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12
Q

Normal lymphocyte levels. When do they increase?

A
  • 1.3-3.2

- Increase during viral infections

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13
Q

Normal monocyte levels

A

0.3-0.8

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14
Q

When do eosinophil levels increase?

A

Parasite infection or allergies

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15
Q

Complications of CDI

A
  • Most common = recurrence
  • Septic shock
  • Pseudomembranous or fulminant colitis
  • Ileus
  • Toxic megacolon (gut is immobile and expands)
  • Perforation
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16
Q

How is CDI diagnosed?

A
  • GI sx w/ diarrhea and positive C. difficile toxin in stool

- Stool culture and molecular typing during outbreaks

17
Q

What is the sensitivity and specificity of the C. difficile assay?

A
  • Sensitivity = 75-80%

- Specificity is very high, so false positives are very rare

18
Q

Strategies for preventing CDI

A
  • Infection control
  • Antimicrobial stewardship for clindamycin, fluoroquinolones, and other high-risk agents
  • Probiotics
19
Q

What can be done to prevent the spread of CDI?

A
  • Environment cleaning and disinfecting
  • Healthcare worker hygiene, handwashing (alcohol-based sanitizers not effective against spores)
  • Contact and barrier precautions when known or suspected CDI
  • Single pt rooms for those w/ known CDI
20
Q

General approach to treating CDI

A
  • Discontinue offending antimicrobial if possible, or replace w/ lower-risk agent (controversial)
  • Supportive measures for hydration and electrolyte balance
  • Avoid anti-motility agents
  • Antimicrobial therapy for CDI
  • Infection control measures
  • Surgery for severe, complicated disease
21
Q

Tx for non-severe CDI

A
  • Metronidazole 500 mg po/ng q8h x 10-14 days (w/ at least 7 days beyond d/c of offending agent)
  • Switch to vanco if tx failure
22
Q

What is the response and recurrence rate to metro for non-severe CDI?

A
  • 90%
  • Around 80% for NAP1 and more severe infection
  • Recurrence = over 20-25%
23
Q

What is considered a tx failure of metro for non-severe CDI?

A
  • Lack of clinical improvement w/in 2 days
  • Fever lasting 3 or more days
  • GI sx lasting 5 or more days
  • Worsening clinical status during therapy
24
Q

Adverse effects of metro for CDI

A
  • GI
  • Metallic taste
  • Disulfiram-reactions
  • CNS (headache, dizziness, confusion)
  • Neurotoxicity
25
Q

What tx would be used for CDI if PO isn’t available and why?

A

Metronidazole b/c it will reach the gut but vanco won’t

26
Q

When is CDI considered severe?

A

At least 2 of

  • Over 60 y/o
  • sCr > 1.5x baseline (normal = 50-100 mmol/L)
  • WBC > 15,000
  • Temp > 38.3 C
  • Albumin < 25 g/L
27
Q

Tx for severe CDI

A

Vanco 125 mg po/ng q6h x 10-14 (including at least 7 days beyond d/c of offending agent or other antimicrobial)

28
Q

Advantages to vanco over metro

A
  • Up to 20% more effective than metro esp for severe infection
  • Fewer adverse effects
  • Preferred in pregnancy and lactation
29
Q

Disadvantages to vanco

A
  • Same recurrence rate as metro

- Concerns w/ collateral resistance (ex: VRE)

30
Q

What is fidaxomicin and its dosing for CDI?

A
  • Macrocyclic bactericidal antimicrobial w/ poor po absorption
  • 200 mg po q12h x 10 days
31
Q

Advantage and disadvantages to fidaxomicin for CDI

A
  • Potentially lower recurrence rate
  • Non-inferior compared w/ vanco for initial episodes
  • Very high cost
32
Q

When is CDI considered severe-complicated?

A

Severe + one of:

  • Ileus
  • Toxic megacolon
  • Abdominal distention
  • Hypotension
33
Q

Tx for severe-complicated CDI

A
  • Vanco 500 mg po/ng/pr (via retention enema in 100 mL NS for 1 h) q6h x 10-14 days
  • AND metro 500 mg IV q8h for 5-7 days (until no longer critically ill)
34
Q

When is CDI considered recurrent?

A

Sx and positive C. difficile toxin w/in 8 weeks of initial episode

35
Q

What likely causes recurrent CDI

A
  • Persistent spores and/or low antitoxin antibodies

- NOT antimicrobial resistance (C. diff has low resistance to many antibiotics)

36
Q

When are probiotics contraindicated?

A

Immunocompromised px b/c they have weakened defenses and the probiotics could cause infection

37
Q

Tx for 1st recurrence of CDI if initial therapy was metro

A

Vanco

38
Q

Tx for 1st recurrence of CDI if initial therapy was vanco

A
  • Vanco tapered-pulsed regimen (125 mg q6h x 10-14 days, then q12h x 1 week, q24h x 1 week and q2-3d x 2-8 weeks
  • Or fidaxomicin
39
Q

Tx for 2nd recurrence of CDI

A

Vanco tapered-pulsed regimen or fidaxomicin

Year 3 - Clinical (30 decks)

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