Paul Wade C Diff

Question 1

What is the criteria for diagnosing C.difficile?

Answer 1

Diarrhoea and one of the following:

• +ve C.difficle test
• if pending results, need clinical suspicion of CDI

Question 2

What do you do in both types of CDI?

Answer 2

• Continue non-difficile ABX to allow normal intestinal flora to be re-established
• Isolate patient
• Daily assessment

Question 3

When should diarrhoea resolve in CDI?

Answer 3

within 1-2 weeks

Question 4

How do you treat non-severe CDI and what parameters are in this type?

Answer 4

• WCC < 15
• No rising creatinine
• No colitis

ORAL METRONIDAZOLE 400MG TDS for 10-14 days

Question 5

What do you do if symptoms don’t improve in non-severe CDI?

Answer 5

• After 7 days or symptoms of severe CDI
• Oral vancomycin 125mg QDS 10-14 days

Question 6

What should not be prescribed in acute CDI?

Answer 6

Antimotility agents e.g. Loperamide

Question 7

How do you treat severe CDI and what parameters are in this type?

Answer 7

• WCC > 15
• Acute rising creatinine
• Colitis

ORAL VANCOMYCIN 125MG QDS for 10-14 days

Question 8

What do you do if symptoms don’t improve in severe CDI?

Answer 8

• After 7 days
• Surgery/GI/microbiology/ infectious diseases consultation
• Consider intracolonic vancomycin
• Vancomycin 500mg WDS
• Consider IV immunoglobulin 400mg/kg 1 dose

Question 9

How do you treat recurrent Clostridium difficile infection?

Answer 9

• Within 30 days and +ve C.difficile test
• Discontinue non-difficile ABX. Review all drugs with GI side effects
• Isolate patient
• Oral fidaxomicin 200mg BD 10-14 days

Question 10

If multiple recurrences (especially if evidence of wasting, malnutrition), what do you do?

Answer 10

1. Review all drug therapy
2. Consider supervised trial of antimotility agents alone
3. Fidaxomicin 200mg BD 10-14 days if not used yet
4. Vancomycin pulse therapy 4-6 weeks
5. IV immunoglobin
6. Donor stool transplant –> faecal microbiota transplantation via colonoscopy

Question 11

Outline how we control the infection of C Difficile

Answer 11

• Patients infected with C. difficile need to be isolated:
  
  • Single rooms or cohort isolation
  • Need individual toilet facilities – need their own toilet to ensure no transmission to other patients.
• Washing hands with soap & water is recommended: rubbing and washing spores away
  
  • Mechanical removal of spores
• In hospital: soap and water for anyone who’s dealing with patients with diarrhoea (recommendation) as there’s no way of knowing if its C diff or not
• Antimicrobial stewardship is also crucial in reducing CDI

Question 12

Can we use alcohol based products for C difficule?

Answer 12

C. difficile spores can’t be inactivated by alcohol-based products such as alcohol hand gels that are recommended for everything and everyone within hospitals and primary care.

Question 13

Risk factors for CDI?

Answer 13

• Prolonged use of broad-spectrum antibiotics
  
  • Can kill other gut flora & allow C. difficile to multiply & overgrow
• Acid-suppressive agents (e.g. PPIs, H₂-antagonists) the more potent – higher risk of Cdiff.
  
  • (Can significantly increase risk – up to 74% (doubling risk): mechanism isn’t clear but perhaps could allow more of the Cdiff spores to be able to get through and increasing risk of spores getting to large intestine, germinating and causing infection.)
• Patient age
  
  • Patients over age of 65 are significantly more vulnerable to CDI
• Co-morbidities: Chronic inflammatory GI diseases, ulcerative colitis, crohn disease, diabetes,
• Immunosuppression
• Long Hospital stay (risk will rise)
• Infection occurs by ingestion of spores via fecal-oral route

Question 14

what is Clostridumm Difficile? include details on virulence

Answer 14

• Gram-positive (bacillus), spore-forming, anaerobe which colonizes the gut of humans
• In severe cases, infection with Cdiff can lead to Pseudomembranous colitis. A membrane forms over the gut lining causing inflammation of the large intestine and gut cell damage -widening of cell junctions- allowing significant leakage from body fluids into gut lumen. This causes watery and perfused diarrhoea making the patient severely dehydrated and malnourished. If gut damage is severe, patient may even require surgery. Or Antibiotic Associated Colitis
• Only toxin-producing strains cause diarrhoea as it’s the toxins that produce the pathogenic effect
  
  • Toxin A – enterotoxin (in the gut)
  • Toxin B – cytotoxin- causes cell damage

Question 15

How can we lower the chances of CDI through Antimicrobial Stewardship?

Answer 15

• All Trusts need to have an antimicrobial management team:
  
  • Need to ensure prudent use of antimicrobials
  • Need to feed data back (on prescribing) to directorates & other wards on antimicrobial use & CDI rates
• Trusts should develop restrictive antibiotic guidelines
  
  • Use narrow-spectrum agents alone or in combination
  • Avoid clindamycin, 2^nd & 3^rd generation cephalosporins
  • Minimise use of quinolones, carbapenems & prolonged courses of aminopenicillins