Monday AM report 05-10-10

Clostridium difficile infection

Introduction Clostridium difficile is an anaerobic gram-positive, spore-forming toxin-producing bacillus. Toxin A directly activates Neutrophils. Toxin B mediates colonic mucosal damage. Cardinal symptom is watery diarrhea up to 10-15 per day, abdominal pain, leukocytosis, low grade fever. Nr. 1 reason for unexplained leukocytosis in hospitalized pts. Even w/o diarrhea!!! Hypervirulent strain NAP1/BI/027 produces larger quantities of toxins.

Epidemiology Clostridium difficile associated disease (CDAD) is one of the most common hospital-acquired (nosocomial) infections. Infections doubled to 61/100000 between 1996 and 2003. 20-50% of hospitalized pts. and long term care pts. are carriers. 3% of healthy individuals. Risk factors: Antibiotic use, hospitalization, advanced age, PPIs, severe illness, enteral feeding, gastrointestinal surgery, chemo.

Assessment Initial step is cessation of the inciting antibiotic (mostly PCN, fluoroquinolones, cephalosporines and clindamycin) Switch to aminoglycosides, tetracyclines, chloramphenicol, metronidazol or vancomycin if pt. requires Abx treatment. Contact precautions and wash hands with soap and water. Severe or non-severe disease? No Consensus definition! WBC >20.000 cells/ml, Temp > 38.3*C, Albumin<2.5mg/dl, Age > 60 (each 1 point), 2 points for endoscopic evidence of pseudomembranous colitis or treatment in ICU. -> Severe disease = 2 or more points!

Treatment of initial episode Preferred: Metronidazole 500mg po tid or 250mg qid for 10-14 days. IV only if pt. with n/v. Alternative: Vancomycin 125mg po qid for 10-14 days.

Therapy for relapse 50% are reinfections rather than relapses and mostly occur within 1-2 weeks (up to 2-3 months) after Abx discontinuation. Since a positive stool toxin assay does not exclude asymptomatic carriage, other causes (infections, IBD, IBS) have to be investigated. Mild symptoms can be managed conservatively If Abx are needed repeat treatment of initial episode.

Second relapse Exclude other causes!!! Tapering and pulsed oral vancomycin: - 125mg po qid for 7 days - 125mg po bid for 7 days - 125mg po qd for 7 days - 125mg po q48h for 7 days - 125mg po q72h for 7 days A three week course of probiotics (eg, Saccharomyces boulardii 500mg bid) may be used.

Subsequent relapse Exclude other causes!!! Vancomycin 125mg po qid for 14 days followed by Rifaximin 400mg bid for 14 days.

Severe disease WBC >20.000 cells/ml, Temp > 38.3*C, Albumin <2.5mg/dl, Age > 60 (each 1 point), 2 points for endoscopic evidence of pseudomembranous colitis or treatment in ICU. -> Severe disease = 2 or more points! Watch out for toxic megacolon and perforation!!! (Call surgery) Metronidazole 500mg q8h IV!!! (cave: n/v) Vancomycin 500mg!!! Po qid + Vancomycin enemas (0.5-1g) q4h to q12h Treatment 10-14 days or if pt. on Abx for other diseases plus an additional week after discontinuation.

Pseudomembranous colitis

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