C. diff - Block 2

Question 1

Describe chracterisitcs of c diff?

Answer 1

Spore forming, toxin producing, G+ anaerobic bacteria

Colonizes in the colon -> ABX associated diarrhea and colitis
Transmission: fecal oral

Question 2

Describe the pathology of C diff?

Answer 2

1. Spores live on surface
2. Spores are ingested and lays dormant in intestines
3. Disruption of normal flora
4. C diff produces toxins A and B -> damage to colon -> inflammation/tissue damage -> diarrhea

Question 3

Ways you can prevent C diff?

Answer 3

1. Soap and water handwashing
2. Alcohol based hand sanitizers is NOT effective against spores

Question 4

What are the precautions taken when encountering Cdiff?

Answer 4

1. Clean hands with soap and water
2. Wear gloves
3. Wear gown

Question 5

What common RF for C diff infection?

Answer 5

1. ABX use
2. Age
3. Hospitalization and length of stay
4. PPI
5. Immunocompromised
6. IBD
7. GI surgery

Question 6

What are the most common ABX that cause C diff?

Answer 6

3rd and 4th gen cephalosporins

Any ABX has a risk killing good bacteria

Question 7

Sx of C diff?

Answer 7

1. Diarrhea (soft and unformed, strong odor, 20+ movements)
2. Ab pain
3. N/V

Question 8

Signs of C diff?

Answer 8

Leukocytosis >15000
Fever

Question 9

Complications of C diff?

Answer 9

1. Dehydration and electrolyte disturbances
2. Pseudomembranous colitis
3. Toxic megacolon
4. Bowel perforation
5. Death in 30 days

Question 10

Diagnostic elements of target CDI population?

Answer 10

1. Unexplained
2. New onset
3. ≥3 unformed stools in 24 hrs

Question 11

What are the diagnostic lab assays of C diff?

Answer 11

1. GDH antigen
2. Toxins A and B
3. NAAT

Question 12

What are the tx goals for C diff?

Answer 12

1. Alleviate GI sx
2. Avoid complications from infection
3. Minimize transmission

Question 13

What are the non pharm recommendatiosn for c diff?

Answer 13

1. Hand hygiene
2. Use of gloves and gowns
3. Isolation
4. Contact precautions
5. Avoid antidiarrheal agents and PPIs
6. Antibiotic stewardship

Question 14

Usage of probiotics for C diff tx?

Answer 14

Some reduction but insufficient data to use as a recommendation

Question 15

Tx used for C diff?

Answer 15

Fidaxomicin
Vancomycin
Metronidazole
Rifaximin
Benzlotoxumab

Question 16

Benefits of using fidaxomicin?

Answer 16

Post-ABX effect for 6-10 hr
Minimal systemic absorption

Question 17

CP of Vancomycin?

Answer 17

Increased GI sx
Poor systemic absorption

Question 18

Cp for Flagyl?

Answer 18

CNS effects -> well absorbed systemically
Superinfection risk
Rising resistance rates

Question 19

CI for Flagyl?

Answer 19

1. Firsttrimester pregnancys
2. Disulfiram within past 2 weeks
3. Alcohol or propylene glycol within 3 days

Question 20

Why do we use Fidaxomicin over PO vanc?

Answer 20

Fewer recurrences of CDI

Question 21

Indications for Bezlotoxumab?

Answer 21

Zinplava (adjunct) is indicated >18 YO to reduce recurrence (secondary prevention) of CDI in patients recievign ABX tx and at high risk for recurrance:
* Hx of CDI
* ≥65 YO
* Immunocompromised
* Severe CDI (Zar ≥2)

Question 22

What are the components of Zar criteria?

Answer 22

1. > 60YO
2. Temp >38.3
3. Albumin <2.5
4. WBC >15,000
5. Endoscopic evidence of pseudomembranous colitis
6. ICU stay

Severe dx is ≥2

Question 23

ADR and Caution of Bezlotoxumab?

Answer 23

ADR: N, pyrexia, HA
Caution: CHF -> frequent exacerbations and more deaths than placebo

Question 24

What is the tx protocol for CDI?

Answer 24

1. DC offending ABX agent asap
2. Adminsiter fluid and electrolyte
3. Start empiric ABX therapy

Question 25

What is the difference between non-severe and severe/fulminant?

Answer 25

**Non:** doesn't meed criteria **S/F:** * WBC ≥15000 OR * sCr >1.5

Question 26

Distinguish severe from fulminant?

Answer 26

**Severe:** doesn't meet criteria **Fulminant:** * Hypotension/shock * Ileus * Toxic megacolon

Question 27

Tx for intial CDI episode (severe and non-severe)?

Answer 27

**1st:** Fidaxomycin BID x 10 days **Alt:** * Vancomycin PO x 10 days * Metronidazole PO x 10 days (non-severe CDI and other agents are unavailable)

Question 28

Tx for intial CDI episode (fulminant)

Answer 28

**1st:** Vancomycin PO + Metronidazole IV **Ileus is present:** Vanc retention enema Vanc > fidaxomicin for fulminant

Question 29

Tx for first CDI recurrence?

Answer 29

**1st:** fidaxomicin PO **Alt:** * Vancomycin PO tapered and pulsed * Vancomycin PO x 10 days (standard if metronidazole is used in 1st episode) **Adj:** Bezlotoxumab IV w/ SOC ABX and episode is within 6 months (CHF caution)

Question 30

Tx for second or subsequent CDI recurrence?

Answer 30

**1st:** Fidaxomicin PO **Alt:** * Vanc PO tapered and pulsed * Vanc PO x 10 days followed by rifaximin x 20days * Fecal microbiota transplantation (at least 2 recurrences, but ABX should be tried first) **Adj:** Bezlotoxumab IV w/ SOC ABX and episode is within 6 months (CHF caution)