Clostridium difficile infection medical therapy: Difference between revisions
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Patients should be treated as soon as possible when the diagnosis of ''Clostridium difficile'' colitis (CDC) is made to avoid frank [[sepsis]] or bowel perforation. | Patients should be treated as soon as possible when the diagnosis of ''Clostridium difficile'' colitis (CDC) is made to avoid frank [[sepsis]] or bowel perforation. | ||
== | ==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.<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. <br><br> For more detailed list of ''C. difficile'' risk factors, click [[Clostridium difficile risk factors|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, 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: | |||
{| style="font-size: 85%;" | {| style="font-size: 85%;" | ||
! style="width: 80px; background: #4479BA; text-align: center;"|{{fontcolor|#FFF|Severity}} | ! style="width: 80px; background: #4479BA; text-align: center;"|{{fontcolor|#FFF|Severity}} | ||
| Line 45: | Line 43: | ||
* Duration: recommendations establish a 10-14 days treatment. Complete only 10 days of treatment if there is clinical improvement in 5-7 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> | * Duration: recommendations establish a 10-14 days treatment. Complete only 10 days of treatment if there is clinical improvement in 5-7 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> | ||
* | ===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>. | ||
* | *Administer 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 imaging modalities, such as abdominal CT scans, 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 | ||
* 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>. | |||
===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> | |||
*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> | |||
Indications for surgery: hypotension requiring vasopressor therapy; sepsis and organ failure; mental status changes; leukocytosis >50,500 cell/µl, lactate >5 mmol/l; or complicated infection without response of the medical therapy after 5 days.<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> | |||
==Medical Therapy== | ==Medical Therapy== | ||
| Line 266: | Line 273: | ||
|} | |} | ||
==Fecal Bacteriotherapy== | |||
[[Fecal bacteriotherapy]], a procedure related to probiotic research, has been suggested as a potential cure for the disease. 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]]. It has a success rate of nearly 95% according to some sources.<ref name=Schwan_1983>{{cite journal | author = Schwan A, Sjölin S, Trottestam U, Aronsson B | title = Relapsing clostridium difficile enterocolitis cured by rectal infusion of homologous faeces. | journal = Lancet | volume = 2 | issue = 8354 | pages = 845 | year = 1983 | id = PMID 6137662}}</ref><ref name=Schwan_1994>{{cite journal | author = Paterson D, Iredell J, Whitby M | title = Putting back the bugs: bacterial treatment relieves chronic diarrhoea. | journal = Med J Aust | volume = 160 | issue = 4 | pages = 232-3 | year = 1994 | id = PMID 8309401}}</ref><ref name=Borody_2000>{{cite journal | author = Borody T | title = "Flora Power"-- fecal bacteria cure chronic C. difficile diarrhea. | journal = Am J Gastroenterol | volume = 95 | issue = 11 | pages = 3028-9 | year = 2000 | url = http://www.cdd.com.au/pdf/paper32.pdf | id = PMID 11095314}}</ref> | [[Fecal bacteriotherapy]], a procedure related to probiotic research, has been suggested as a potential cure for the disease. 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]]. It has a success rate of nearly 95% according to some sources.<ref name=Schwan_1983>{{cite journal | author = Schwan A, Sjölin S, Trottestam U, Aronsson B | title = Relapsing clostridium difficile enterocolitis cured by rectal infusion of homologous faeces. | journal = Lancet | volume = 2 | issue = 8354 | pages = 845 | year = 1983 | id = PMID 6137662}}</ref><ref name=Schwan_1994>{{cite journal | author = Paterson D, Iredell J, Whitby M | title = Putting back the bugs: bacterial treatment relieves chronic diarrhoea. | journal = Med J Aust | volume = 160 | issue = 4 | pages = 232-3 | year = 1994 | id = PMID 8309401}}</ref><ref name=Borody_2000>{{cite journal | author = Borody T | title = "Flora Power"-- fecal bacteria cure chronic C. difficile diarrhea. | journal = Am J Gastroenterol | volume = 95 | issue = 11 | pages = 3028-9 | year = 2000 | url = http://www.cdd.com.au/pdf/paper32.pdf | id = PMID 11095314}}</ref> | ||
Revision as of 15:48, 24 April 2015
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Clostridium difficile Microchapters |
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Clostridium difficile infection medical therapy On the Web |
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American Roentgen Ray Society Images of Clostridium difficile infection medical therapy |
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Risk calculators and risk factors for Clostridium difficile infection medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Guillermo Rodriguez Nava, M.D. [2]
Overview
Many persons will also be asymptomatic and colonized with Clostridium difficile. Treatment in asymptomatic patients is controversial, also leading into the debate of clinical surveillance and how it intersects with public health policy.
It is possible that mild cases do not need treatment.[1]
Patients should be treated as soon as possible when the diagnosis of Clostridium difficile colitis (CDC) is made to avoid frank sepsis or bowel perforation.
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.[2] 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, 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:
| Severity | Criteria |
|---|---|
| Mild | Diarrhea as the only symptom |
| Moderate | Raised white cell count but <15,000 cells/mL and serum creatine <1.5 times baseline |
| Severe | Leucocytosis >15,000 cells/mL OR serum creatinene level >1.5 times baseline or abdominal tenderness and serum albumin < 3 g/dL |
| Severe complicated | Hypotension or shock, ileus, megacolon, leucocytosis >20,000 cells/mL OR leucopenia <2,000, lactate >2.2 mmol/L, delirium, fever ≥ 38.5 °C, organ failure |
- Duration: recommendations establish a 10-14 days treatment. Complete only 10 days of treatment if there is clinical improvement in 5-7 days.[3]
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.[2].
- Administer supportive care to patients with severe or severe complicated CDI .[2]
- Perform diagnostic imaging modalities, such as abdominal CT scans, for patients with worsening diarrhea and/or abdominal pain to rule out C. difficile-associated complications.[2]
- Request surgical consultation and perform routine pre-surgical work-up for patients suspected to have complicated C. difficile infection
- Consider fecal microbiota transplant if there is a third recurrence after a pulsed vancomycin regimen.[2].
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]
Indications for surgery: hypotension requiring vasopressor therapy; sepsis and organ failure; mental status changes; leukocytosis >50,500 cell/µl, lactate >5 mmol/l; or complicated infection without response of the medical therapy after 5 days.[2]
Medical Therapy
▸ Click on the following categories to expand treatment regimens.[2][5][3][4][6]
|
Initial episode
▸ Mild to moderate
▸ Severe
▸ Severe complicated
Recurrence
▸ First recurrence
▸ Second recurrence
|
|
Fecal Bacteriotherapy
Fecal bacteriotherapy, a procedure related to probiotic research, has been suggested as a potential cure for the disease. 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. It has a success rate of nearly 95% according to some sources.[7][8][9]
References
- ↑ Nelson R. Antibiotic treatment for Clostridium difficile-associated diarrhea in adults. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004610. PMID 17636768
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 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.
- ↑ 3.0 3.1 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.
- ↑ 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.
- ↑ Planche, Tim (2013). "Clostridium difficile". Medicine. 41 (11): 654–657. doi:10.1016/j.mpmed.2013.08.003. ISSN 1357-3039.
- ↑ 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.
- ↑ Schwan A, Sjölin S, Trottestam U, Aronsson B (1983). "Relapsing clostridium difficile enterocolitis cured by rectal infusion of homologous faeces". Lancet. 2 (8354): 845. PMID 6137662.
- ↑ Paterson D, Iredell J, Whitby M (1994). "Putting back the bugs: bacterial treatment relieves chronic diarrhoea". Med J Aust. 160 (4): 232–3. PMID 8309401.
- ↑ Borody T (2000). ""Flora Power"-- fecal bacteria cure chronic C. difficile diarrhea" (PDF). Am J Gastroenterol. 95 (11): 3028–9. PMID 11095314.