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	C. difficile Infection Microchapters
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Latest revision as of 18:42, 18 September 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Guillermo Rodriguez Nava, M.D. [2]; Yazan Daaboul, M.D.

Overview

Treatment is generally recommended for average-risk patients who are symptomatic with positive lab findings for C. difficile infection. For patients with C. difficile risk factors, empiric therapy is recommended for symptomatic patients regardless of lab findings. Antimicrobial therapy is tailored acccording to the clinical severity of the infection. Administration of oral metronidazole is recommended for patients with mild symptoms, whereas oral vancomycin is recommended for severe disease.

Indications for Treatment

Symptomatic vs. Asymptomatic Individuals

Treatment is recommended only for average-risk, symptomatic patients (usually diarrhea) with positive lab findings (either ELISA or PCR) of C. difficile infection

In contrast, treatment is not recommended for average-risk, asymptomatic individuals OR patients with diarrhea and negative lab findings (either ELISA or PCR).

Average Risk vs. High Risk Patients

The negative predictive values of the diagnostic lab tests (either ELISA or PCR) are sufficiently high > 95% for patients among patients with average risk of developing C. difficile infection. Accordingly, empiric therapy is not recommended if diagnostic lab tests yield negative findings among average-risk patients.

In contrast the negative predictive values of the diagnostic lab tests (either ELISA or PCR) are NOT sufficiently high for patients at high risk of C. difficile infection. Accordingly, empiric therapy is recommended for high risk patients with high pre-test probability even when lab findings yield negative results.^[1] Common risk factors for the development of C. difficile infection are history of antibiotic administration within the past 12 weeks, advanced age > 65 years, immunodeficiency, exposure to healthcare facilities, or inflammatory bowel disease.

For more detailed list of C. difficile risk factors, click here

Principles of Antimicrobial Therapy for Clostridium difficile infection

According to the 2013 practice guidelines for the diagnosis, treatment, and prevention of C. difficile infections^[2], the choice of antimicrobial therapy is based on the severity of the clinical disease. Shown below is a table that defines the severity of C. difficile infection based on clinical features and lab findings:

▸ Click on the following categories to expand treatment regimens.^[1]^[3]^[2]^[4]^[5]

Initial episode

▸ Mild to moderate

▸ Severe

▸ Severe complicated

Recurrence

▸ First recurrence

▸ Second recurrence

Mild to moderate
Recommended treatment
▸ Metronidazole 500 mg orally q8h
If no improvement in 5-7 days
▸ Vancomycin 125 mg orally q6h

Severe
Recommended treatment
▸ Vancomycin 125 mg orally q6h

Severe complicated
Recommended treatment^†
▸ Vancomycin 500 mg orally q6h
PLUS
▸ Metronidazole 500 mg IV q8h
^† If ileus present, add Vancomycin 500 mg in 100 mL normal saline per rectum q6h as retention enema.

First recurrence
Recommended treatment
▸ Same as first episode but stratified by severity

Second recurrence

Recommended treatment

▸ Vancomycin in tapered and pulsed doses

     125 mg 4 times daily for 14 days

     125 mg 2 times daily for 7 days

     125 mg once daily for 7 days

     125 mg once every 2 days for 8 days (4 doses)

     125 mg once every 3 days for 15 days (5 doses)

Duration of antimicrobial therapy

Administer antimicrobial therapy for 10-14 days.
Continue antimicrobial therapy only for 10 days if there is clinical improvement within 5 to 7 days.^[2]

Do's

Suspend other antibiotic therapies during administration of antibiotics to treat C. difficile infection.
Administer vancomycin for mild-to-moderate patients who are intolerant/allergic to metronidazole and for pregnant/breastfeeding women.^[1].
Deliver supportive care to patients with severe or severe complicated CDI .^[1]
Perform diagnostic abdominal CT scan for patients with worsening diarrhea and/or abdominal pain to rule out C. difficile-associated complications.^[1]
Request surgical consultation and perform routine pre-surgical work-up for patients suspected to have complicated C. difficile infection. To view indications for surgical management of C. difficile infection, click here.
Consider fecal microbiota transplant if there is a third recurrence after a pulsed vancomycin regimen.^[1]
Consider vancomycin enema for patients whose oral antibiotic regimen cannot reach a segment of the colon, such as patients with Hartman's pouch, ileostomy, or colon diversion.
Administer intravenous immunoglobulins for recurrent C. difficile infection only if patient has hypogammaglobulinemia.
Manage C. difficile infection simultaneously with inflammatory bowel disease (IBD) flare-up among patients with IBD.
Continue immunosuppressive medications for IBD patients with C. difficile infection.

Don'ts

Do not administer metronidazole for a second recurrence episode of CDI or for long-term therapy because of the risk of neurotoxicity.^[4]

Do not administer anti-peristaltic agents to treat diarrhea in patients with CDI.^[1]
Do not administer intravenous immunoglobulins for recurrent C. difficile infection, except if patient has hypogammaglobulinemia.
Do not increase dose of immunosuppressive medications for IBD patients with untreated C. difficile infection.

Novel Pharmacologic Therapies

In 2011, fidaxomicin was FDA-approved for the treatment of C. difficile infection.^[6]
- Fidaxomicin is a poorly absorbed, bactericidal, macrocyclic antibiotic that acts against anaerobic, gram-positive bacteria.^[6]
- Fidaxomicin demonstrated non-inferior to vancomycin in the treatment of primary infection.^[6]
- Fidaxomicin was associated with significantly reduced rate of recurrence compared with vancomycin (15% vs. 25%), except among patients infected with BI/NAP1/027 strain where the recurrence rate was statistically similar between both therapies.^[6]

Fecal Bacteriotherapy

Fecal bacteriotherapy is a procedure related to probiotic research. It has been suggested as a potential cure for C. difficile infection.
It involves infusion of bacterial flora acquired from the feces of a healthy donor in an attempt to reverse bacterial imbalance responsible for the recurring nature of the infection.

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 ^1.4 ^1.5 ^1.6 Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH; et al. (2013). "Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections". Am J Gastroenterol. 108 (4): 478–98, quiz 499. doi:10.1038/ajg.2013.4. PMID 23439232.
↑ ^2.0 ^2.1 ^2.2 Knight, Christopher L.; Surawicz, Christina M. (2013). "Clostridium difficile Infection". Medical Clinics of North America. 97 (4): 523–536. doi:10.1016/j.mcna.2013.02.003. ISSN 0025-7125.
↑ Planche, Tim (2013). "Clostridium difficile". Medicine. 41 (11): 654–657. doi:10.1016/j.mpmed.2013.08.003. ISSN 1357-3039.
↑ ^4.0 ^4.1 Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC; et al. (2010). "Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA)". Infect Control Hosp Epidemiol. 31 (5): 431–55. doi:10.1086/651706. PMID 20307191.
↑ Kelly CP, LaMont JT (2008). "Clostridium difficile--more difficult than ever". N Engl J Med. 359 (18): 1932–40. doi:10.1056/NEJMra0707500. PMID 18971494.
↑ ^6.0 ^6.1 ^6.2 ^6.3 Louie TJ, Miller MA, Mullane KM, Weiss K, Lentnek A, Golan Y; et al. (2011). "Fidaxomicin versus vancomycin for Clostridium difficile infection". N Engl J Med. 364 (5): 422–31. doi:10.1056/NEJMoa0910812. PMID 21288078.

Template:WH Template:WS

Abdominal Aortic Aneurysm

Overview

Classification

Abdominal aortic aneurysms may be classified based on the size of the aneurysm:

Small aneurysm: Diameter < 4.0 cm
Medium aneurysm: Diameter between 4.0 and 5.5 cm
Large aneurysm: Diameter ≥ 5.5 cm
Very large aneurysm: Diameter ≥ 6.0 cm

Abdominal aortic aneurysms may also be classified based on the rate of aneurysm expansion:

Non-rapidly expanding aneurysm: Diameter increase of ≤ 0.5 cm within 6 months OR ≤ 1.0 cm within 12 months
Rapidly expanding aneurysm: Diameter increase of > 0.5 cm within 6 months OR > 1.0 cm within 12 months

Causes

Life Threatening Causes

Ruptured AAA
Infected (mycotic) aneurysm
Inflammatory AAA
Aortovenous fistula
Aortoenteric fistula
Lower extremity thromboembolism

Risk Factors for Development of AAA

Old age 50 > years
Greater height
Male gender
Caucasian race
Smoking
History of CAD and atherosclerotic cardiovascular disease
History of hypertension
Dyslipidemia
Family history of AAA
Personal history of peripheral artery aneurysms

Risk Factors for Rapid Expansion or Rupture of AAA

Female gender
Advanced age > 50 years
Smoking
Advanced atherosclerosis
History of prior stroke
Hypertension
Transplantation (cardiac or renal)
Known reduced FEV1 (obstructive pulmonary disease)

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate surgical intervention. Boxes in red signify that an urgent management is needed.

Identify cardinal findings that increase the pre-test probability of abdominal aortic aneurysm (AAA) rupture and development of complications

❑ Known large AAA > 5.5 cm
❑ Known rapid AAA expansion rate > 0.5 cm/6 months OR 1.0 cm/year
❑ Known infective endocarditis (high risk for infected aneurysm)
❑ Acute abdominal/back pain that may radiate to buttocks, groin region, or lower extremities

❑ Tearing/sharp quality

❑ Increasing in intensity

❑ Pulsating abdominal mass
❑ Hypotension or shock
❑ Oliguria or anuria
❑ Muscular weakness
❑ Lower extremity numbness and/or tingling
❑ Cold extremities
❑ Peripheral cyanosis
❑ Acute limb pain
❑ Fever or sepsis
❑ Altered mental status
❑ Unexplained syncope
❑ Coma
❑ Presence of risk factors associated with rapid expansion or rupture of AAA

❑ Female gender

❑ Advanced age > 50 years

❑ Smoking

❑ Advanced atherosclerosis

❑ History of prior stroke

❑ Hypertension

❑ Transplantation (cardiac or renal)

❑ Known reduced FEV1 (obstructive pulmonary disease)

❑ Esophageal rupture
(suggestive findings: vomiting, subcutaneous emphysema)

Stabilize and resuscitate the patient

❑ Attend to the patient's ABCs (Airway, Breathing, Circulation)

❑ Consider endotracheal intubation if the patient's airway is compromised, has a Glasgow coma scale (GCS < 8) or profound hemodynamic instability

❑ Administer oxygen and maintain a saturation >90%

❑ Secure 2 large-bore intravenous (IV) lines

❑ Administer fluids to reach a target systolic blood pressure (SBP) of 70 to 100 mm Hg. Excessive fluid administration in AAA is associated with worse outcomes

❑ Do NOT routinely administer vasopressors if patient is hypotensive at presentation. Vasopressor administration in AAA is controversial. Consider ANY of the following vasopressors only if patient remains hypotensive despite fluids

❑ Norepinephrine 0.05 microgram/kg/minute IV; titrate by 0.02 microgram/kg/minute every 5 minutes, OR

❑ Phenylephrine 100-180 microgram/minute; titrate by 25 microgram/minute every 10 minutes, OR

❑ Dopamine 5 microgram/kg/minute; titrate by 5 microgram/kg/minute every 10 minutes

❑ Obtain 12 lead ECG and place the patient on a cardiac monitor
❑ Place an indwelling urethral catheter and monitor urine output
❑ Frequently assess mental status and check for focal neurologic deficits
❑ Type and crossmatch 6 to 10 units of PRBC. FFP may also be needed in cases of massive transfusion

❑ Do not administer pre-op transfusions except if patient is unconscious or has signs or myocardial infarction

❑ Withdraw blood for CBC, electrolytes, BUN, serum creatinine, LFTS, PT, PTT, troponin I, CK, CK-MB, CRP or ESR, and multiple blood cultures
Pain management
❑ Assess pain severity (self-report NRS scale 0 to 10; unconscious BPS 3-12 or CPOT 0-8). Pain considered significant if NRS≥4, BPS<5, or CPOT≥3
❑ Administer IV opioids: Morphine 4-10 mg IV every 4 hours, infused over 4-5 minutes (dose range: 5-15 mg)
❑ Consider pre-op epidural catheter if patient meets ALL of the following criteria

❑ Patient hemodynamically stable, AND

❑ Contained leak, AND

❑ Satisfactory coagulation profile

❑ Maintain patient in a conscious state

❑ Monitor any significant undesired drop in blood pressure as pain medications are administered

Patient hemodynamically unstable despite resuscitation?

❑ Hypotension (SBP < 90 mm Hg) despite resuscitation

❑ Tachycardia (HR > 100 bpm) despite resuscitation

Yes. Patient is still hemodynamically unstable despite resuscitation.

No. Patient is hemodynamically stable following resuscitation

Is the patient known to have an AAA?

Can patient have CT scan with contrast?

Yes

No

Yes

No

❑ Proceed to operating room without further work-up

❑ Obtain focused bedside ultrasound

❑ Obtain CT scan with IV contrast of abdominal aorta and iliac arteries

❑ Obtain CT scan without IV contrast of abdominal aorta and iliac arteries

AAA confirmed on imaging?

Yes

No

Consider alternative diagnoses

Evaluate need for further management of the following AAA complications

For patients suspected to have thromboembolism
❑ Obtain Duplex ultrasound of affected extremities
❑ Consider CT scan of aorta from aortic valves to iliac bifurcation

For patients suspected to have infected (mycotic) aneurysm
❑ Consider gallium scanning or 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) to evaluate disease activity

For patients suspected to have aortovenous fistula
❑ Obtain CT angiography

For patients suspected to have aortoenteric fistula
❑ Perform EGD to rule out other possible etiologies of GI bleed among hemodynamically stable patients
❑ Obtain CT scan with IV contrast of the abdomen and iliac arteries

❑ Consider arteriography

Administer antimicrobial therapy

Once diagnosis of complicated AAA is confirmed, all patients require blood cultures and empirical antibiotic therapy for gram-positive and gram-negative coverage (even if afebrile at presentation)
❑ Withdraw multiple sets of blood culture (if blood cultures were not withdrawn initially)
❑ Administer empiric combination antibiotic therapy

❑ Vancomycin 1-1.5g IV every 12 hours

PLUS only one of the following:

❑ Ceftriaxone 2 g IV every 12 hours, OR

❑ Cefuroxime 1.5 g IV every 4 hours, OR

❑ Piperacillin-tazobactam

Proceed to further management

Diagnosis

Treatment

Shown below is an algorithm summarizing the management of abdominal aortic aneurysm.

Confirmed AAA

Symptoms present?

No

Yes

❑ Perform imaging using ANY of the following imaging modalities for the abdominal aorta and iliac arteries:

❑ Ultrasound

❑ CT Scan

❑ MRI

Hemodynamically stable?

Adequate imaging?

No

Yes

Stabilize and resuscitate the patient

❑ Attend to the patient's ABCs (Airway, Breathing, Circulation)

❑ Consider endotracheal intubation if the patient's airway is compromised, has a Glasgow coma scale (GCS < 8) or profound hemodynamic instability

❑ Administer oxygen and maintain a saturation >90%

❑ Secure 2 large-bore intravenous (IV) lines

❑ Administer fluids to reach a target systolic blood pressure (SBP) of 70 to 100 mm Hg. Excessive fluid administration in AAA is associated with worse outcomes

❑ Do NOT routinely administer vasopressors if patient is hypotensive at presentation. Vasopressor administration in AAA is controversial. Consider ANY of the following vasopressors only if patient remains hypotensive despite fluids

❑ Norepinephrine 0.05 microgram/kg/minute IV; titrate by 0.02 microgram/kg/minute every 5 minutes, OR

❑ Phenylephrine 100-180 microgram/minute; titrate by 25 microgram/minute every 10 minutes, OR

❑ Dopamine 5 microgram/kg/minute; titrate by 5 microgram/kg/minute every 10 minutes

❑ Place an indwelling urethral catheter and monitor urine output

❑ Frequently assess mental status and check for focal neurologic deficits

No

Yes

Repeat imaging

AAA meets AT LEAST ONE of the following criteria for surgical or endovascular intervention?

❑ AAA > 5.5 cm, OR
❑ Rapidly expanding AAA, OR

❑ AAA plus peripheral arterial aneurysm or peripheral artery disease

Perform pre-operative work-up

❑ Obtain 12 lead ECG and place the patient on a cardiac monitor
❑ Perform CT scan of the abdominal aorta and iliac arteries. (CT scan preferably WITH contrast, but may be WITHOUT contrast for patients at high risk of contrast-induced complications).
❑ Type and crossmatch 6 to 10 units of PRBC. FFP may also be needed in cases of massive transfusion

❑ Do not administer pre-op transfusions except if patient is unconscious or has signs or myocardial infarction

❑ Withdraw blood for CBC, electrolytes, BUN, serum creatinine, LFTS, PT, PTT, troponin I, CK, CK-MB, CRP or ESR, and multiple blood cultures

No

Yes

Pain management

❑ Assess pain severity (self-report NRS scale 0 to 10; unconscious BPS 3-12 or CPOT 0-8). Pain considered significant if NRS≥4, BPS<5, or CPOT≥3
❑ Administer IV opioids: Morphine 4-10 mg IV every 4 hours, infused over 4-5 minutes (dose range: 5-15 mg)
❑ Consider pre-op epidural catheter if patient meets ALL of the following criteria

❑ Patient hemodynamically stable, AND

❑ Contained leak, AND

❑ Satisfactory coagulation profile

❑ Maintain patient in a conscious state

❑ Monitor any significant undesired drop in blood pressure as pain medications are administered

Manage modifiable risk factors of asymptomatic AAA

❑ Administer aspirin 80 to 100 mg once daily if patient has no contraindication to aspirin therapy

❑ Administer statin therapy (e.g. simvastatin 40 mg once daily) if patient has no contraindication to statin therapy

❑ Manage hypertension based on guidelines for the management of hypertension (There are currently no recommended antihypertensive pharmacologic therapies for the management of AAA)

❑ Recommend smoking cessation

❑ Recommend moderate physical activity at least 4 times per week (e.g. running, swimming, golfing)

❑ Do NOT recommend intense physical activity (e.g. heavy lifting) due to increased risk of AAA rupture

❑ Provide appropriate counseling for patients at high risk of AAA expansion and rupture

Administer antimicrobial therapy

Once diagnosis of complicated AAA is confirmed, all patients require blood cultures and empirical antibiotic therapy for gram-positive and gram-negative coverage (even if afebrile at presentation)
❑ Withdraw multiple sets of blood culture (if blood cultures were not withdrawn initially)
❑ Administer empiric combination antibiotic therapy

❑ Vancomycin 1-1.5g IV every 12 hours

PLUS only one of the following:

❑ Ceftriaxone 2 g IV every 12 hours, OR

❑ Cefuroxime 1.5 g IV every 4 hours, OR

❑ Piperacillin-tazobactam

Follow-Up

❑ Schedule routine follow-up visits with abdominal ultrasound imaging at regular time intervals to monitor patients who are candidates for surgical or endovascular repair.
❑ Do NOT schedule follow-up visits for patients who refuse either surgical or endovascular repair or who are not adequate candidates for either surgical or endovascular repair.

Optimal interval between visits has not yet been established and is controversial. Aneurysm size should determine the frequency of follow-up ultrasound, and the following intervals may be considered based on various guidelines.

Evaluate need for further management of the following AAA complications

For patients suspected to have thromboembolism
❑ Obtain Duplex ultrasound of affected extremities
❑ Consider CT scan of aorta from aortic valves to iliac bifurcation

For patients suspected to have infected (mycotic) aneurysm
❑ Consider gallium scanning or 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) to evaluate disease activity

For patients suspected to have aortovenous fistula
❑ Obtain CT angiography

For patients suspected to have aortoenteric fistula
❑ Perform EGD to rule out other possible etiologies of GI bleed among hemodynamically stable patients
❑ Obtain CT scan with IV contrast of the abdomen and iliac arteries
❑ Consider arteriography

Aneurysm size between 5 and 5.5 cm
❑ Consider routine ultrasound every 3 months

Aneurysm size between 4.5 and 4.9 cm
❑ Consider routine ultrasound every 12 months (1 year)

Aneurysm size between 4.0 and 4.4 cm
❑ Consider routine ultrasound every 24 months (2 years)

Aneurysm size between 3.5 to 3.8 cm
❑ Consider routine ultrasound every 36 months (3 years)

Aneurysm size between 2.6 to 2.9 cm
❑ Consider routine ultrasound every 60 months (5 years)

Evaluate patient's surgical risk

High surgical risk

Low to moderate surgical risk

Patient performed CT scan of the abdominal aorta and iliac arteries WITH contrast?

Yes

No

CT scan demonstrated adequate aortic anatomy and integrity suitable for endovascular procedure?

Yes

No

Consider any of the following:

❑ Endovascular repair, OR

❑ Open AAA repair

Open AAA Repair

Screening

Screening for AAA is currently recommended only once in the following patient groups:

Men between the age of 65 and 75 years and who have ever smoked
Men aged 60 years or older with a sibling or a parent with abdominal aortic aneurysm

There are currently no recommendations to screen AAA in women, but women are at increased risk of AAA expansion or rupture. Some experts recommend one-time screening in women with risk factors of developing AAA (such as smoking or positive family history)

Do's

Don'ts

[pmid23439232-1] 1.0 ^1.1 ^1.2 ^1.3 ^1.4 ^1.5 ^1.6 Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH; et al. (2013). "Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections". Am J Gastroenterol. 108 (4): 478–98, quiz 499. doi:10.1038/ajg.2013.4. PMID 23439232.

[KnightSurawicz2013-2] 2.0 ^2.1 ^2.2 Knight, Christopher L.; Surawicz, Christina M. (2013). "Clostridium difficile Infection". Medical Clinics of North America. 97 (4): 523–536. doi:10.1016/j.mcna.2013.02.003. ISSN 0025-7125.

[Planche2013-3] Planche, Tim (2013). "Clostridium difficile". Medicine. 41 (11): 654–657. doi:10.1016/j.mpmed.2013.08.003. ISSN 1357-3039.

[pmid20307191-4] 4.0 ^4.1 Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC; et al. (2010). "Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA)". Infect Control Hosp Epidemiol. 31 (5): 431–55. doi:10.1086/651706. PMID 20307191.

[pmid18971494-5] Kelly CP, LaMont JT (2008). "Clostridium difficile--more difficult than ever". N Engl J Med. 359 (18): 1932–40. doi:10.1056/NEJMra0707500. PMID 18971494.

[pmid21288078-6] 6.0 ^6.1 ^6.2 ^6.3 Louie TJ, Miller MA, Mullane KM, Weiss K, Lentnek A, Golan Y; et al. (2011). "Fidaxomicin versus vancomycin for Clostridium difficile infection". N Engl J Med. 364 (5): 422–31. doi:10.1056/NEJMoa0910812. PMID 21288078.

[1]

[2]

[3]

[4]

[5]

[6]

@@ Line 1: / Line 1: @@
-==Coronary Angiography and Revascularization==
+__NOTOC__
+{{Siren|Clostridium difficile infection}}
+{{Clostridium difficile infection}}
+{{CMG}}; {{AE}} {{GRN}}; {{YD}}
 ==Overview==
-==Algorithm==
+Treatment is generally recommended for average-risk patients who are symptomatic with positive lab findings for ''C. difficile'' infection. For patients with ''C. difficile'' [[Clostridium difficile risk factors|risk factors]], empiric therapy is recommended for symptomatic patients regardless of lab findings. Antimicrobial therapy is tailored acccording to the clinical severity of the infection. Administration of oral metronidazole is recommended for patients with mild symptoms, whereas oral vancomycin is recommended for severe disease.
-{{familytree/start}}
+==Indications for Treatment==
-{{familytree | | | A01 | | | | | | | | | | | | | | | | | | | | | | | |A01=Is cardiac catheterization an emergency?}}
+===Symptomatic vs. Asymptomatic Individuals===
-{{familytree | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | | | | |}}
+*Treatment is recommended only for average-risk, symptomatic patients (usually diarrhea) with positive lab findings (either ELISA or PCR) of ''C. difficile'' infection
-{{familytree | B01 | | B02 | | | | | | | | | | | | | | | | | | | | | |B01=Yes|B02=No}}
-{{familytree | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | |}}
-{{familytree | C01 | | C02 | | | | | | | | | | | | | | | | | | | | | |C01=Refer to management of [[Acute coronary syndrome resident survival guide|acute coronary syndromes]] | C02='''Confirm that the patient has ANY of the following indications for cardiac catheterization'''<br>
-❑ Canadian cardiovascular society (CCS) class III (i.e. symptoms with everyday living activities) or class IV angina (i.e. inability to perform any activity without angina or angina at rest) despite medical therapy, '''OR'''<br>
-❑ Angina plus systolic dysfunction, '''OR'''<br>
-❑ Uncertain diagnosis following non-invasive test and need to confirm diagnosis, '''OR'''<br>
-❑ Systolic dysfunction with unexplained cause, '''OR'''<br>
-❑ Survivor of sudden cardiac death, polymorphic VT, or sustained monomorphic VT, '''OR'''<br>
-❑ Suspected spasm or non-atherosclerotic cause of ischemia, '''OR'''<br>
-❑ High-risk stress test finding, defined as '''ANY''' of following <ref name="pmid22326193">{{cite journal| author=Marso SP, Teirstein PS, Kereiakes DJ, Moses J, Lasala J, Grantham JA| title=Percutaneous coronary intervention use in the United States: defining measures of appropriateness. | journal=JACC Cardiovasc Interv | year= 2012 | volume= 5 | issue= 2 | pages= 229-35 | pmid=22326193 | doi=10.1016/j.jcin.2011.12.004 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22326193  }} </ref>:<br>
-:❑ Resting LVEF < 35%
-:❑ High-risk treadmill score (≤ 11)
-:❑ Severe exercise LVEF < 35%
-:❑ Stress-induced large perfusion defect
-:❑ Stress-induced multiple perfusion defects
-:❑ Large, fixed perfusion defect with LV dilation OR increased lung uptake
-:❑ LV dilation or increased lung uptake
-:❑ Stress-induced moderate perfusion defect with LV dilation or increased lung uptake
-}}
-{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}}
-{{familytree | | | | | D01 | | | | | | | | | | | | | | | | | | | | | |D01='''Obtain a detailed history'''<br><br>
-'''''History of Present Illness'''''<br>
+*In contrast, treatment is not recommended for average-risk, asymptomatic individuals OR patients with diarrhea and negative lab findings (either ELISA or PCR).
-❑ Age<br>
+===Average Risk vs. High Risk Patients===
-❑ Chest pain or chest discomfort<br>
+*The negative predictive values of the diagnostic lab tests (either ELISA or PCR) are sufficiently high > 95% for patients among patients with average risk of developing ''C. difficile'' infection. Accordingly, empiric therapy is not recommended if diagnostic lab tests yield negative findings among average-risk patients.
-❑ Onset of symptoms<br>
+*In contrast the negative predictive values of the diagnostic lab tests (either ELISA or PCR) are NOT sufficiently high for patients at high risk of ''C. difficile'' infection. Accordingly, empiric therapy is recommended for high risk patients with high pre-test probability even when lab findings yield negative results.<ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 |pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref> Common risk factors for the development of ''C. difficile'' infection are history of antibiotic administration within the past 12 weeks, advanced age > 65 years, immunodeficiency, exposure to healthcare facilities, or inflammatory bowel disease.
+For more detailed list of ''C. difficile'' risk factors, click [[Clostridium difficile risk factors|here]]
-❑ Sensation of heaviness, tightness, pressure, or squeezing<br>
+==Principles of Antimicrobial Therapy for ''Clostridium difficile'' infection==
+According to the 2013 practice guidelines for the diagnosis, treatment, and prevention of ''C. difficile'' infections<ref name="KnightSurawicz2013" />, the choice of antimicrobial therapy is based on the severity of the clinical disease. Shown below is a table that defines the severity of ''C. difficile'' infection based on clinical features and lab findings:
-❑ Duration of each episode<br>
+<font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font><ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 |pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref><ref name="Planche2013">{{cite journal|last1=Planche|first1=Tim|title=Clostridium difficile|journal=Medicine|volume=41|issue=11|year=2013|pages=654–657|issn=13573039|doi=10.1016/j.mpmed.2013.08.003}}</ref><ref name="KnightSurawicz2013">{{cite journal|last1=Knight|first1=Christopher L.|last2=Surawicz|first2=Christina M.|title=Clostridium difficile Infection|journal=Medical Clinics of North America|volume=97|issue=4|year=2013|pages=523–536|issn=00257125|doi=10.1016/j.mcna.2013.02.003}}</ref><ref name="pmid20307191">{{cite journal|author=Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC et al.| title=Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). |journal=Infect Control Hosp Epidemiol | year= 2010 | volume= 31 | issue= 5 | pages= 431-55 | pmid=20307191 | doi=10.1086/651706 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20307191  }} </ref><ref name="pmid18971494">{{cite journal| author=Kelly CP, LaMont JT| title=Clostridium difficile--more difficult than ever. | journal=N Engl J Med |year= 2008 | volume= 359 | issue= 18 | pages= 1932-40 | pmid=18971494 | doi=10.1056/NEJMra0707500 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18971494  }} </ref>
+{|
-❑ Radiation to the left arm, jaw, neck, right arm, back or epigastrium<br>
+| valign=top |
-❑ Timing of symptoms (morning vs. evening vs. wake patient at night)<br>
+<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
-❑ Alleviating factors (e.g. medications or rest)<br>
+<font color="#FFF">
-❑ Exacerbating factors<br>
+'''Initial episode'''
-❑ Association of symptoms to food intake<br>
+</font>
-❑ Palpitations<br>
+</div>
+<div class="mw-customtoggle-table01" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background:#4479BA;">
-❑ Nausea or vomiting<br>
+<font color="#FFF">
-❑ Sweating<br>
+&nbsp;&nbsp;▸&nbsp;&nbsp;'''Mild to moderate'''
-❑ Dyspnea<br>
+</font>
-❑ Orthopnea<br>
+</div>
+<div class="mw-customtoggle-table02" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background:#4479BA;">
-❑ Dizziness<br>
+<font color="#FFF">
-❑ Weakness of extremities<br>
+&nbsp;&nbsp;▸&nbsp;&nbsp;'''Severe'''
-❑ Numbness of tingling of extremities<br>
+</font>
-❑ Lightheadedness<br>
+</div>
+<div class="mw-customtoggle-table03" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background:#4479BA;">
-❑ Syncope or presyncope<br>
+<font color="#FFF">
-❑ Increased frequency of symptoms<br>
+&nbsp;&nbsp;▸&nbsp;&nbsp;'''Severe complicated'''
-❑ Worsening of symptom severity<br>
+</font>
-❑ Previous episodes<br>
+</div>
+<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
-❑ Recent infections<br>
+<font color="#FFF">
-❑ Fever<br>
+'''Recurrence'''
-❑ Weight or appetite changes<br>
+</font>
-❑ Stress<br>
+</div>
+<div class="mw-customtoggle-table04" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background:#4479BA;">
-❑ Fatigue<br><br>
+<font color="#FFF">
-'''''Possible Symptom Triggers'''''<br>
+&nbsp;&nbsp;▸&nbsp;&nbsp;'''First recurrence'''
-❑ Physical exertion<br>
+</font>
-❑ Air pollution or fine particulate matter<br>
+</div>
+<div class="mw-customtoggle-table05" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background:#4479BA;">
-❑ Recent infection<br>
+<font color="#FFF">
-❑ Heavy meal intake<br>
+&nbsp;&nbsp;▸&nbsp;&nbsp;'''Second recurrence'''
-❑ Cocaine<br>
+</font>
-❑ Marijuana<br><br>
+</div>
+| valign=top |
-'''''Cardiovascular Risk Factors'''''<br>
+{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table01" style="background: #FFFFFF;"
-❑ Known CAD (review available catheterizations or CABG reports)<br>
+| valign=top |
-❑ Smoking history<br>
+{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
-❑ Baseline blood pressure (Duration, antihypertensive therapy, compliance with medications)<br>
+! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Mild to moderate}}
-❑ History of diabetes mellitus (Duration, DM control, compliance, antidiabetic medications, recent HbA1c, screening for micro- and macrovascular DM complications)<br>
+|-
-❑ Dyslipidemia<br>
+| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Recommended treatment'''''
-❑ Obesity (BMI > 30 kg/m2)<br><br>
+|-
-'''''Past Medical History'''''<br>
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 500 mg orally q8h'''''
-❑ Congenital heart disease<br>
+|-
-❑ Left to right shunts<br>
+| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''If no improvement in 5-7 days'''''
-❑ Dextrocardia<br>
+|-
-❑ Situs inversus<br>
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Vancomycin]] 125 mg orally q6h'''''
-❑ History of renal disease (CrCl < 60 mL/min)? Does the patient currently have a stable renal function?<br>
+|-
-❑ History of bleeding tendency<br>
+|}
-❑ Known significant anemia (Hct < 30%)<br>
+|}
-❑ History of heparin-induced thrombocytopenia (HIT)<br>
+{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table02" style="background: #FFFFFF;"
-❑ History of pulmonary disease<br>
+| valign=top |
-❑ History of major surgery in the past month<br>
+{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
-❑ Anticipated major surgery in the next year<br><br>
+! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Severe}}
-'''''Medications'''''<br>
+|-
-❑ Prescribed drug<br>
+| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Recommended treatment'''''
-❑ Home oxygen therapy<br>
+|-
-❑ Over-the-counter drugs<br>
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Vancomycin]] 125 mg orally q6h'''''
-❑ Herbs and supplements<br>
+|-
-❑ Administration of ANY of the following medications within the last 48 hours prior to catheterization?<br>
+|}
-:❑ Aspirin
+|}
-:❑ Clopidogrel
+{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table03" style="background: #FFFFFF;"
-:❑ Metformin
+| valign=top |
-:❑ Phosphodiesterase inhibitors (e.g. Tadalafil, sildenafil, or similar drugs)
+{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
-:❑ Warfarin. If yes, what is most recent INR?
+! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Severe complicated}}
-:❑ Low molecular weight heparin (LMWH). If yes, when was last dose?
+|-
-:❑ Other chronic anticoagualants (e.g. dabigatran, NOACs, fondaparinux)<br><br>
+| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Recommended treatment'''''<sup>†</sup>
-'''''Allergies'''''<br>
+|-
-❑ List of allergies, including severity and manifestations (pruritus, rash, hives, stridor, or anaphylactic shock)<br>
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Vancomycin]] 500 mg orally q6h'''''
-❑ Known drug allergies
+|-
-:❑ Allergy to aspirin or history of nasal polyps or aspirin desensitization
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
-:❑ Allergy to heparin
+|-
-:❑ Allergy to sedation medications
-:❑ Other drug allergies
-:❑ Contrast allergy
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 500 mg IV q8h'''''
-:❑ Latex allergy
-:❑ Allergy to Shellfish (controversial association between shellfish allergy and contrast allergy)
+|-
-:❑ Other known environmental and food allergies<br><br>
+| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=left | <SMALL><sup>†</sup> If '''''[[ileus]]''''' present, add '''''[[Vancomycin]] 500 mg in 100 mL normal saline per rectum q6h as retention enema'''''.</SMALL>
-'''''Family History'''''<br>
+|-
-❑ Family history of premature cardiovascular diseases<br><br>
+|}
-'''''Social and Sexual History'''''<br>
+|}
-❑ Healthcare proxy and available family members for patient care<br>
+{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table04" style="background: #FFFFFF;"
-❑ Barrier to tolerate or adhere to dual antiplatelet therapy (DAPT) or follow-up visits<br>
+| valign=top |
-❑ Pregnancy or possible pregnancy<br><br>
+{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
-'''''Advanced Directives'''''<br>
+! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|First recurrence}}
-❑ DNR status<br>
+|-
-❑ DNI status}}
+| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | Recommended treatment'''''
-{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}}
-{{familytree | | | | | E01 | | | | | | | | | | | | | | | | | | | | | |E01='''Examine the patient'''<br><br>
-❑ Vital signs, including BP, HR, RR, T, room air SpO2<br>
+|-
-❑ Height (in meters), weight (in kilograms), and body mass index (BMI)<br>
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''Same as first episode but stratified by severity'''''
-❑ Level of consciousness, orientation, and ability to cooperate and communicate<br><br>
+|-
-'''''Skin'''''<br>
+|}
-❑ Xanthelesma or xanthoma (suggestive of dyslipidemia)<br>
+|}
-❑ Edema (suggestive of congestive heart failure)<br>
+{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table05" style="background: #FFFFFF;"
-❑ Acral and/or central cyanosis<br><br>
+| valign=top |
-'''''HEENT'''''<br>
+{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
-❑ Head and neck range of motion<br>
+! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Second recurrence}}
-❑ Modified Mallampati score<br>
+|-
-:❑ Class I: Soft palate, uvula, fauces, pillars visible
+| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Recommended treatment'''''
-:❑ Class II: Soft palate, uvula, fauces visible
+|-
-:❑ Class III: Soft palate, base of uvula present
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Vancomycin]] in tapered and pulsed doses'''''
-:❑ Class IV: Only hard palate visible<br><br>
+mg 4 times daily for 14 days
-'''''Cardiothoracic'''''<br>
+mg 2 times daily for 7 days
-❑ Auscultation of heart sounds (including number of sounds, pitch, interval, murmurs, gallops, or rubs) over 4 precordial regions in sitting position (stethoscope diaphragm) and auscultation of mitral area while in left lateral decubitus position (stethoscope bell)<br>
+mg once daily for 7 days
-:❑ Normal S1 and S2
+mg once every 2 days for 8 days (4 doses)
-:❑ S3 may be pathologic or may be a normal finding in young or pregnant
+mg once every 3 days for 15 days (5 doses)
-:❑ S4 may be pathologic or may be a normal finding in elderly
+|-
-:❑ Murmur may be physiologic or may suggest valvulopathy or hemodynamic derangement (e.g. anemia)
+|}
-:❑ Pericardial friction rub may suggest pericarditis<br>
+|}
-❑ Point of maximal impulse (PMI) (normally one, non-sustained, tapping impulse per cardiac cycle located less than 2-3 cm from midclavicular line at 5th intercostal space)<br>
+|}
-❑ Auscultation of anterior and posterior pulmonary regions bilaterally<br>
-:❑ Crackles suggest pulmonary edema, which might be attributed to congestive heart failure
+=== '''Duration of antimicrobial therapy''' ===
+* Administer antimicrobial therapy for 10-14 days.
+* Continue antimicrobial therapy only for 10 days if there is clinical improvement within 5 to 7 days.<ref name="KnightSurawicz2013">{{cite journal|last1=Knight|first1=Christopher L.|last2=Surawicz|first2=Christina M.|title=Clostridium difficile Infection|journal=Medical Clinics of North America|volume=97|issue=4|year=2013|pages=523–536|issn=00257125|doi=10.1016/j.mcna.2013.02.003}}</ref>
-:❑ If pulmonary auscultation abnormal, egophony, tactile fremitus, and thoracic percussion may be needed<br><br>
+===Do's===
+*Suspend other antibiotic therapies during administration of antibiotics to treat ''C. difficile'' infection.
+*Administer [[vancomycin]] for mild-to-moderate patients who are intolerant/allergic to [[metronidazole]] and for pregnant/breastfeeding women.<ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 |volume= 108 | issue= 4 | pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref>.
+*Deliver supportive care to patients with severe or severe complicated CDI .<ref name="pmid23439232">{{cite journal|author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 | pages= 478-98; quiz 499 |pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref>
+*Perform diagnostic abdominal CT scan for patients with worsening diarrhea and/or abdominal pain to rule out ''C. difficile''-associated complications.<ref name="pmid23439232">{{cite journal|author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 | pages= 478-98; quiz 499 |pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref>
+*Request surgical consultation and perform routine pre-surgical work-up for patients suspected to have complicated ''C. difficile'' infection. To view indications for surgical management of ''C. difficile'' infection, click [[Clostridium difficile surgery|here]].
+* Consider fecal microbiota transplant if there is a third recurrence after a pulsed [[vancomycin]] regimen.<ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 | pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref>
+* Consider vancomycin enema for patients whose oral antibiotic regimen cannot reach a segment of the colon, such as patients with Hartman's pouch, ileostomy, or colon diversion.
+* Administer intravenous immunoglobulins for recurrent ''C. difficile ''infection only if patient has hypogammaglobulinemia.
+* Manage ''C. difficile'' infection simultaneously with inflammatory bowel disease (IBD) flare-up among patients with IBD.
+* Continue immunosuppressive medications for IBD patients with ''C. difficile'' infection.
-'''''Vascular'''''<br>
+===Don'ts===
+*Do not administer [[metronidazole]] for a second recurrence episode of CDI or for long-term therapy because of the risk of neurotoxicity.<ref name="pmid20307191">{{cite journal|author=Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC et al.| title=Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). |journal=Infect Control Hosp Epidemiol | year= 2010 | volume= 31 | issue= 5 | pages= 431-55 | pmid=20307191 | doi=10.1086/651706 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20307191  }} </ref>
-❑ Pulses of both upper extremities (radial, ulnar, brachial) and lower extremities (dorsalis pedis, posterior tibial, popliteal)<br>
+*Do not administer anti-peristaltic agents to treat [[diarrhea]] in patients with CDI.<ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 | pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref>
+* Do not administer intravenous immunoglobulins for recurrent ''C. difficile ''infection, except if patient has hypogammaglobulinemia.
+* Do not increase dose of immunosuppressive medications for IBD patients with untreated ''C. difficile'' infection.
-❑ Femoral pulses bilaterally<br>
+== Novel Pharmacologic Therapies ==
+* In 2011, [[fidaxomicin]] was FDA-approved for the treatment of ''C. difficile'' infection.<ref name="pmid21288078">{{cite journal| author=Louie TJ, Miller MA, Mullane KM, Weiss K, Lentnek A, Golan Y et al.| title=Fidaxomicin versus vancomycin for Clostridium difficile infection. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 5 | pages= 422-31 | pmid=21288078 | doi=10.1056/NEJMoa0910812 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21288078  }} </ref>
+** [[Fidaxomicin]] is a poorly absorbed, [[bactericidal]], [[macrocyclic]] antibiotic that acts against [[anaerobic]], [[gram-positive bacteria]].<ref name="pmid21288078">{{cite journal| author=Louie TJ, Miller MA, Mullane KM, Weiss K, Lentnek A, Golan Y et al.| title=Fidaxomicin versus vancomycin for Clostridium difficile infection. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 5 | pages= 422-31 | pmid=21288078 | doi=10.1056/NEJMoa0910812 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21288078  }} </ref>
+** [[Fidaxomicin]] demonstrated non-inferior to vancomycin in the treatment of primary infection.<ref name="pmid21288078">{{cite journal| author=Louie TJ, Miller MA, Mullane KM, Weiss K, Lentnek A, Golan Y et al.| title=Fidaxomicin versus vancomycin for Clostridium difficile infection. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 5 | pages= 422-31 | pmid=21288078 | doi=10.1056/NEJMoa0910812 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21288078  }} </ref>
+** [[Fidaxomicin]] was associated with significantly reduced rate of recurrence compared with [[vancomycin]] (15% vs. 25%), except among patients infected with BI/NAP1/027 strain where the recurrence rate was statistically similar between both therapies.<ref name="pmid21288078">{{cite journal| author=Louie TJ, Miller MA, Mullane KM, Weiss K, Lentnek A, Golan Y et al.| title=Fidaxomicin versus vancomycin for Clostridium difficile infection. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 5 | pages= 422-31 | pmid=21288078 | doi=10.1056/NEJMoa0910812 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21288078  }} </ref>
-❑ Femoral auscultation bilaterally for bruits<br>
+==Fecal Bacteriotherapy==
+* [[Fecal bacteriotherapy]] is a procedure related to probiotic research. It has been suggested as a potential cure for ''C. difficile ''infection.
+* It involves infusion of [[bacterial flora]] acquired from the feces of a healthy donor in an attempt to reverse bacterial imbalance responsible for the recurring nature of the [[infection]].
-❑ Modified Allen test bilaterally to evaluate adequacy of radial access<br>
+==References==
-❑ Carotid auscultation bilaterally<br>
+{{Reflist|2}}
-❑ Jugular venous pressure<br><br>
+[[Category:Disease]]
+[[Category:Gastroenterology]]
-'''''Neurological'''''<br>
+[[Category:Bacterial diseases]]
-❑ Upper/lower extremity motor strength<br>
+{{WH}}
+{{WS}}
-❑ Upper/lower extremity sensory exam<br>
-❑ Spasticity or rigidity<br>
-❑ Deep tendon reflexes<br>
-❑ Bilateral Babinski<br>
-❑ CN assessment<br>
-❑ Coordination and cerebellar exams (Finger to nose, Romberg, Heel to shin, alternating movement)<br>
-❑ Gait}}
-{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}}
-{{familytree | | | | | F01 | | | | | | | | | | | | | | | | | | | | | |F01='''Provide appropriate counseling before catheterization'''<br><br>
-❑ Address individual concerns and questions<br><br>
-'''''Hold Food Intake Before Procedure'''''<br>
-❑ Keep patient NPO at least 6 hours before elective coronary angiography<br><br>
-'''''Hold Certain Medications Before Procedure'''''<br>
-''Warfarin''<br>
-❑ Hold warfarin for at least 2 to 6 days before elective coronary angiography (to prevent bleeding)<br>
-❑ Confirm INR < 1.8 (preferable INR < 1.4) within 24 hours before arterial puncture<br>
-❑ Restart warfarin 12 to 24 hours following catheterization (warfarin requires 2 to 3 days for INR to become therapeutic range)<br>
-❑ Consider heparin bridging 3 days before planned catheterization for high risk patients to prevent prolonged subtherapeutic INR<br>
-:❑ Therapeutic dose LMWH 1 mg/kg subcutaneously twice daily for high-risk patients who are not at high risk of bleeding
-:❑ Intermediate dose LMWH 40 mg subcutaneously twice daily for high-risk patients at high risk of bleeding<br><br>
-''Novel Oral Anticoagulants''<br>
-❑ Hold NOAC before catheterization as follow<br>
-❑ Rivaroxaban: Hold rivaroxaban for 2 days in patients with low bleeding risk OR for 3 days in patients with high bleeding risk<br>
-❑ Apixaban: Hold apixaban for 2 days in patients with low bleeding risk OR for 3 days in patients with high bleeding risk<br>
-❑ If patient does not develop any hematoma, restart NOAC 1 day after the catheterization for patients with low bleeding risk OR 2-3 days after the catheterization for patients with high bleeding risk<br><br>
-''Dabigatran''<br>
-❑ Hold dabigatran based on renal function as shown below<br>
-:❑ CrCl > 50 ml/min: Hold dabigatran for 1 day if low/intermediate bleeding risk or 3 days if high bleeding risk (e.g. major surgery)
-:❑ CrCl between 30 and 50 ml/min: Hold dabigatran for 3 days if low/intermediate bleeding risk or 5 days if high bleeding risk (e.g. major surgery)
-❑ CrCl < 30 ml/min: Hold dabigatran for 2 to 5 days if low/intermediate bleeding risk or > 5 days if high bleeding risk (e.g. major surgery)<br>
-❑ If patient does not develop any hematoma, restart dabigatran 1 day after the catheterization for patients with low bleeding risk OR 2-3 days after the catheterization for patients with high bleeding risk<br><br>
-''LMWH''<br>
-❑ Hold LMWH for 12 hours before cardiac catheterization<br>
-❑ Resume LMWH 12-24 hours following cardiac catheterization<br><br>
-''Metformin''<br>
-❑ Hold metformin 2 days before elective coronary angiography<br>
-❑ Restart metformin 2 days post-procedure OR until creatinine is stable (to prevent lactic acidosis and contrast-induced renal failure)<br><br>
-''Phosphodiesterase inhibitors''<br>
-❑ Hold sildenafil/tadalafil/vardenafil for at least 2 days before elective coronary angiography<br>
-❑ Restart sildenafil/tadalafil/vardenafil one day after catheterization }}
-{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}}
-{{familytree | | | | | G01 | | | | | | | | | | | | | | | | | | | | | |G01='''Identify ASA physical status'''<br>
-❑ 1=Healthy individual with no systemic diseases<br>
-❑ 2=Mild systemic disease<br>
-❑ 3=Severe systemic disease<br>
-❑ 4=Severe systemic disease that poses a constant   threat to the patient’s life<br>
-❑ 5=Moribund patient not expected to survive   without the operation/procedure<br>
- ❑ 6=Patient declared brain-dead or whose organs   are being removed for donation}}
-{{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | | |}}
-{{familytree | | | I01 | | I02 | | | | | | | | | | | | | | | | | | | |I01=ASA physical status ≥ 4|I02=ASA physical status < 4}}
-{{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | |}}
-{{familytree | | | J01 | | |!| | | | | | | | | | | | | | | | | | | | |J01=Consult anesthesia}}
-{{familytree | | | |`|-|v|-|'| | | | | | | | | | | | | | | | | | | | |}}
-{{familytree | | | | | K01 | | | | | | | | | | | | | | | | | | | | | |K01='''Perform pre-procedure routine work-up'''<br>
-❑ Complete blood count (CBC)<br>
-❑ Platelet count (Administration of unfractionated heparin, low molecular weight heparinoids, and parenteral glycoprotein 2b3a inhibitors are associated with thrombocytopenia. Thrombocytopenia is a contraindication to the administration of parenteral glycoprotein 2b3a inhibitors)<br>
-❑ Electrolytes panel<br>
-❑ Baseline serum creatinine and BUN. Calculate and record estimated creatinine clearance/eGFR (creatinine clearance/eGFR may significantly be different from true GFR in patients with unstable renal function) <br>
-❑ Glycemia<br>
-❑ Beta-HCG within 2 weeks of procedure for women of child-bearing age<br>
-:❑ Baseline ECG within 24 hours of procedure
-:❑ Assess baseline ischemic changes
-❑ Presence of baseline bundle branch block (BBB) (Cardiac catheterization may damage HIS   system and induce BBB)<br>
-❑ PT/INR within 24 hours, especially if patient is receiving warfarin (INR > 1.8 is a relative contraindication of cardiac catheterization)<br>
-❑ CXR if patient suspected to have pulmonary edema or other diseases}}
-{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}}
-{{familytree | | | | | L01 | | | | | | | | | | | | | | | | | | | | | |L01='''Address relevant and significant comorbidities'''<br><br>
-❑ Prolonged INR (>1.8) 24 hours prior to procedure<br>
-:❑ Administer low-dose vitamin K 1-2 mg PO
-:❑ Repeat INR and confirm new INR < 1.8 (preferable INR ≤ 1.4). If INR still > 1.8
-::❑ Administer additional vitamin K 2-4 mg PO if anticipated procedure is > 24 hours later. Administer more   doses of low-dose vitamin K (1-2 mg PO) if INR still high
-::❑ Cancel transfemoral approach (except if emergency) if INR does not normalize in time of procedure
-::❑ Consider transradial approach if radial artery accessible to reduce risk of bleeding
-::❑ Consider transfusion of fresh frozen plasma (FFP)<br>
-❑ Renal insufficiency (CrCl < 60 ml/min)<br>
-:❑ Saline administration
-::❑ In patients with no CHF, administer 0.9% or 0.45% normal saline: 1 mL/ kg/ hour (MAX 100 ml/hour) for   12 hours before contrast AND 12 hours after contrast ) in patients with no CHF
-::❑ In patients with CHF, administer 0.45% normal saline: 0.5 ml/kg/hr (MAX 50 ml/hr) 12 hrs before contrast   AND 12 hours after contrast
-:❑ Consider administration of NaHCO3
-::❑ Mix 150 mEq of NaHCO3  in 1 liter of D5W in non-diabetic patients OR mix 150 mEq of NaHCO3 in 1 liter of   sterile water in diabetic patients.
-::❑ Administer 3 ml/kg bolus (MAX 300 ml) for 1 hour prior to procedure AND 1 mL/kg/hour (MAX 100 ml/hr)   during the procedure AND 1 mg/kg/hour for 6 hours post-procedure
-:❑ Follow-up serum creatinine 2 to 5 days following catheterization<br>
-❑ Contrast allergy<br>
-:❑ Administer the following regimen before the procedure (controversial timing)
-:❑ Regimen 1
-::❑ Methylprednisolone 60 mg IV once, '''AND'''
-::❑ Diphenhydramine 50 mg IV once, '''AND'''
-::❑ Cimetidine 300 mg (or alternative H2 blocker) IV once
-:❑ Regimen 2
-::❑ Prednisolone 50 mg PO at 13 hours, 7 hours, and 1 hour (total of 3 doses) before procedure}}
-{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}}
-{{familytree | | | | | M01 | | | | | | | | | | | | | | | | | | | | | |M01='''Confirm pre-cath checklist on the day of the procedure'''
-❑ Confirm patient full name<br>
-❑ Identify indication for procedure<br>
-❑ Planned procedure<br>
-:❑ Diagnostic cardiac catheterization
-:❑ Diagnostic cardiac catheterization with possible PCI
-:❑ PCI
-❑ Appropriate history and physical examination documented in patient record<br>
-❑ Informed consent is filled within 30 days, complete, signed, and available in patient record<br>
-❑ Candidacy for DES<br>
-:❑ Does the patient have significant anemia (Hct < 30%)
-:❑ Has the patient had any major surgery in the past month or is anticipating any major surgery in the next year?
-:❑ Does the patient have clinically overt bleeding?
-:❑ Is the patient receiving chronic anticoagulation (e.g. warfarin or dabigatran)
-:❑ Does the patient have a history of medications non-adherence?
-:❑ Does the patient have someone available to transport to and from the hospital?<br>
-❑ Allergies and adverse drug reactions<br>
-:❑ Contrast allergy. If yes, was the patient pre-treated?
-:❑ Aspirin allergy. If yes, does the patient need desensitization?
-:❑ Latex allergy: If yes, remove all latex products from procedural use
-:❑ Heparin induced thrombocytopenia (HIT): If yes, consider alterative antithrombotic agent
-:❑ Patient known to have multiple allergies? If yes, did you consider pretreatment?<br>
-❑ Medications<br>
-:❑ Was the patient administered ANY of the following medications within the last 48 hours prior to catheterization?
-::❑ Aspirin
-::❑ Clopidogrel
-::❑ Metformin
-::❑ Phosphodiesterase inhibitors (e.g. Tadalafil, sildenafil, or similar drugs)
-::❑ Warfarin. If yes, what the patient’s pre-op (within 48 hours) INR?
-::❑ Low molecular weight heparin (LMWH). If yes, when was last dose?
-::❑ Other chronic anticoagualants (e.g. dabigatran, NOACs)
-❑ ASA physical status available<br>
-❑ Modified mallampati score available<br>
-❑ Does patient have any contraindication to sedation? Contraindications to sedation include allergy, < 6 hours of NPO for solid food/non-clear liquids, < 2 hours of NPO for clear liquids, abnormal ECG findings, any condition that might compromise airway patency or that would interfere with intubation, hemodynamic instability, or clinically significant comorbidities <br>
-❑ Patient's height (in meter) and weight (in kilograms) recorded? <br>
-❑ Pre-procedural work-up available AND reviewed (CBC, electrolytes, glycemia, PT/INR, creatinine, BUN, PT/INR within 24 hours if receiving warfarin, ECG within 24 hours, CXR if applicable)
-:❑ Renal function (serum creatinine, BUN, creatinine clearance/eGFR)
-:❑ Bleeding risk (anemia, thrombocytopenia, prolonged INR/PT)
-:❑ Cardiac assessment (ECG)}}
-{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}}
-{{familytree | | | | | N01 | | | | | | | | | | | | | | | | | | | | | |N01='''Administer Preprocedural Drugs'''<br><br>
-'''''Dual antiplatelet therapy'''''<br>
-❑ Administer aspirin 325 mg PO once at least 2 hours before the procedure, AND<br>
-❑ Administer clopidogrel 600 mg PO once at least 2 to 6 hours before the procedure<br><br>
-'''''Conscious Sedation'''''<br>
-Contraindications to sedation include allergy, < 6 hours of NPO for solid food/non-clear liquids, < 2 hours of NPO for clear liquids, abnormal ECG findings, any condition that might compromise airway patency or that would interfere with intubation, hemodynamic instability, or clinically significant comorbidities<br>
-❑ Administer diazepam 5-10 mg PO once<br>
-❑ Additional drugs may be administered pre-procedure, but are usually administered once patient is inside the cath lab. These drugs (combination) include:<br>
-:❑ Fentanyl 25 to 50 microgram IV, '''AND'''
-:❑ Midazolam 1 to 2 mg IV <br><br>
-'''''Consider antihistamine'''''<br>
-❑ Consider administration of diphenhydramine (Bendaryl) 25 mg PO once<br><br>
-'''''Consider anti-nausea agents'''''<br>
-❑ Consider administration of ondansetron (Zofran) 4 mg IV once}}
-{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}}
-{{familytree | | | | | O01 | | | | | | | | | | | | | | | | | | | | | |O01=Transfer patient to cath lab}}
-{{familytree/end}}
-==Do's==
-==Don'ts==

Sandbox Yaz: Difference between revisions

Latest revision as of 18:42, 18 September 2017

Overview

Indications for Treatment

Symptomatic vs. Asymptomatic Individuals

Average Risk vs. High Risk Patients

Principles of Antimicrobial Therapy for Clostridium difficile infection

Duration of antimicrobial therapy

Do's

Don'ts

Novel Pharmacologic Therapies

Fecal Bacteriotherapy

References

Abdominal Aortic Aneurysm

Overview

Classification

Causes

Life Threatening Causes

Risk Factors for Development of AAA

Risk Factors for Rapid Expansion or Rupture of AAA

FIRE: Focused Initial Rapid Evaluation

Diagnosis

Treatment

Screening

Do's

Don'ts

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