Exam V (C. diff)

Question 1

While all antibiotics can technically cause C. diff infections, what are the main 4 classes that we should look out for?

Answer 1

Fluoroquinolones, clindamycin, carbapenems, and 3rd/4th generation cephalsporins

Question 2

C. diff infections typically occur during or right after antibiotic therapy, however, it can occur up to ______ months later.

Answer 2

3 month

Question 3

What are risk factors for C. diff?

Answer 3

Recent healthcare exposure, chemotherapy, recent GI surgery or tube feeding, PPI use, immunocompromised, previous C. diff infection, and age older than 65 years

Question 4

What type of bacteria is Clostridium Difficile?

Answer 4

C. diff is a gram + anaerobe

Question 5

What are the 3 phases of a C. diff infection?

Answer 5

A. disruption of the bowel flora
B. C. dif overgrowth from normal flora and toxin A and B release which damages colonic epithelial cells
C. Inflammatory cascade damages colonic tissue and causes diarrhea

Question 6

What is a classic finding in C. diff?

Answer 6

Pseudomembranes

Question 7

T or F: C. diff is part of the normal gut flora.

Answer 7

True! It only becomes and issue when it takes over the gut

Question 8

What is the general presentation of C. diff?

Answer 8

Watery diarrhea that may be bloody (more than 3 unformed stools in 24 hours), abdominal pain and distention, fever, signs of dehydration and elevated serum creatinine, and significant leukocytosis

Question 9

What categorizes nonsevere C. diff?

Answer 9

WBC 15K or less AND SCr less than 1.5

Question 10

What categorizes severe C. diff?

Answer 10

WBC greater than 15K OR SCr greater than 1.5

Question 11

What categorizes fulminant C. diff?

Answer 11

Hypotension or shock, ileus, or megacolon

Basically showing signs of end organ failure

Question 12

What test is started with to help diagnose C. diff?

Answer 12

GDH or NAAT testing.

Question 13

What is GDH testing?

Answer 13

This is glutamate dehydrogenase testing which is the enzyme that C. diff produces.

Question 14

What is NAAT testing looking for?

Answer 14

It is nucleic acid amplification testing that detects C. diff DNA. It tells you that C. diff if there, but not if that is what is causing the problem.

Question 15

If the GDH or NAAT testing for C. diff is positive, what test then needs to be ran?

Answer 15

Toxin EIA test (enzyme immunoassay test)

Question 16

What does the EIA test look for?

Answer 16

This is the enzyme immunoassay test that detects toxin A and B that are produced by C. diff

Question 17

If the EIA testing is negative, what does this mean?

Answer 17

This means the patient is likely colonized with C. diff, but it is not causing the signs and symptoms in the patients.

Question 18

If the EIA is positive, what does this mean?

Answer 18

This means that C.diff is active and infecting the patient.

Question 19

What are the two treatment options for nonsevere and severe C. diff?

Answer 19

Oral vancomycin or Fidaxomicin

Question 20

What is the dosing and duration for oral vancomycin in the treatment of nonsevere or severe C. diff?

Answer 20

Oral Vancomycin PO QID x 10 days

Question 21

What is the dosing and duration for fidaxomicin in the treatment of nonsevere or severe C. diff?

Answer 21

200 mg PO BID x 1o dys

Question 22

What is the positive aspect of using fidaxomicin for the treatment of C. diff instead of oral vancomycin?

Answer 22

Fidaxomicin has less risk for recurrent C. diff compared to oral vancomycin due to less disruption of the gut microbiome

Question 23

What is the treatment for fulminant C. diff?

Answer 23

PO and/or enema vancomycin 500 mg Q6H + metronidazole 500 mg IV Q8H until clinical resolution

Question 24

If someone with C. diff has an ileus, what form of vancomycin should be used?

Answer 24

Enema vancomycin

Question 25

What medication is not indicated in fulminant C. diff?

Answer 25

Fidaxomicin

Question 26

Besides antibiotics, what other supportive care should be given to those with C. diff?

Answer 26

Hydration, discontinue PPIs and, if still on antibiotic that causes the C. diff, discontinue or shorten that therapy. Avoid antidiarrheals and binders

Question 27

What is defined as C. diff recurrence?

Answer 27

Episodic C. diff within 8 weeks of the previous C. diff episode

Question 28

What are risk factors for C. diff reoccurence?

Answer 28

65 years or older, immunocompromised, or prior severe C. diff

Question 29

If someone has recurrent C. diff, what is the first line treatment?

Answer 29

Fidaxomicin (even if they got that the last episode)

Question 30

What are the two different types of dosing that can be used for recurrent C. diff with fidaxomicin?

Answer 30

The standard dose that is 200 mg BID x 10 days OR Pulse dosing which is 200 mg PO BID x 5 days then every other day for 20 days.

Question 31

What is the other treatment option for recurrent C. diff?

Answer 31

Oral vancomycin but only if fidaxomicin is not available or the patient can't afford it.

Question 32

If oral vancomycin had to be used for recurrent C. diff infection, what is the dosing?

Answer 32

125 mg PO QID x 10-14 days followed by BID x 7 days, then every 2-3 days for 2-8 more weeks

Question 33

Is C. diff prophylaxis recommended for those taking antibiotics?

Answer 33

Oral vancomycin prophylaxis can be considered during antibiotic use in patients with a history of C. diff or high risk for recurrence.

Question 34

If oral vancomycin were to be used for C. diff prophylaxis, what is the dosing?

Answer 34

125 mg PO QD or BID, stopped 5 days after the antibiotic is stopped.

Question 35

When are fecal microbiome replacement recommended?

Answer 35

In those with at least one C. diff reoccurrence, and should definitely be considered in those with a second or third C. diff recurrence episode.

Question 36

What are the two FDA approved medications that act as fecal microbiome replacements?

Answer 36

Vowst and Rebyota

Question 37

What is Vowst?

Answer 37

This is an oral capsule that contains live fecal microbiota. It is administered orally 48-96 hours after C. diff has been treated.

Question 38

What is Rebyota?

Answer 38

This is an enema version of a live fecal microbiota transplant. It is administed as an enema 24-72 hours after C. diff has been treated.

Question 39

What can be used to treat severe or fulminant C. diff that does not respond to antibiotics?

Answer 39

The live fecal microbiota transplant where donor stool is delivered into the colon via colonoscopy

Question 40

For those with recurrent C. diff who are mild-moderately immunocompromised, what are the guidelines surround fecal microbiota transplant?

Answer 40

Can be done upon completion of SOC antibiotics

Question 41

For those with recurrent C. diff who are severely immunocompromised, what are the guidelines surround fecal microbiota transplant?

Answer 41

Do not use the transplant upon completion of antibiotic course

Question 42

What are the two common complications of C. diff infections?

Answer 42

Pseudomembranous colitis and toxic megacolon

Question 43

What is pseudomembranous colitis?

Answer 43

This is when plaques filled with debri and pus are on the colon. This characterizes the inflammation in the colon.

Question 44

What is toxic megacolon?

Answer 44

This is when the inflammation in the gut impairs the muscles of the colon causing gas and stool to build up which distends the colon increasing the risk for perforations, peritonitis, and bacteremias.

Question 45

What is the best way to prevent C. diff?

Answer 45

Hand-washing as alcohol does NOT kill C. diff spores and antimicrobial stewardship

Question 46

T or F: Probiotics are recommended for all patients with C. diff.

Answer 46

False. Probiotics are not formally recommended but this may be some evidence that it is helpful when given with antibiotics in those with a history of C. diff

Question 47

A 72-year-old woman presents with watery diarrhea ≥3 times/day, abdominal pain, and WBC 13,000. SCr is 1.2 mg/dL. She recently completed clindamycin. What is her disease severity? A. Nonsevere B. Severe C. Fulminant D. Recurrent E. Indeterminate

Answer 47

A. Nonsevere Nonsevere has WBC count less than 15K and SCr less than 1.5

Question 48

A 65-year-old man presents with diarrhea and the following labs: WBC: 18,000 SCr: 1.3 What is the classification? A. Nonsevere B. Severe C. Fulminant D. Chronic E. Recurrent

Answer 48

B. Severe Severe has WBC 15K + OR SCr 1.5+

Question 49

A patient is started on IV vancomycin for C. diff. What is the issue? A. Too broad spectrum B. Causes resistance C. Does not reach colon D. Not bactericidal E. Causes HUS

Answer 49

C. Does not reach colon

Question 50

A patient improves after treatment but still tests positive for C. diff toxin. What should you do? A. Restart antibiotics B. Continue therapy longer C. Switch to fidaxomicin D. Do nothing E. Add loperamide

Answer 50

D. Do nothing This is why we do not retest patients we only use signs and symptoms of remission.