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Treat C. difficile Based on Severity of Disease
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SAN DIEGO — Hospitalists should use multiple assessments to diagnosis Clostridium difficile and treat patients with confirmed disease based on its severity, according to a presentation at the ACP’s Internal Medicine Annual Meeting.
Infection control and prevention
“Antibiotic stewardship is important,” Colleen R. Kelly, MD, gastroenterologist at the Women’s Medicine Collaborative and assistant professor of medicine at Brown University’s Warren Alpert Medical School, said during her presentation. “Many antibiotics are still being prescribed inappropriately.”
Hospitalists should educate patients to be advocates for themselves and to ask whether they really need an antibiotic or if they could be watched, she continued.
Detecting patients early when they become symptomatic and isolating them in private rooms is crucial, she said. In addition, hospitalists need to maintain contact precaution by wearing a gown and gloves until diarrhea has resolved, she said.
Implementing hand hygiene measures and chlorhexidine bathing are also practices to control infection, she said.
Disinfecting environmental surfaces with sporicidal agents in the hospital setting, as well as advising patients with C. difficile upon discharge to make sure they thoroughly disinfect their home bathroom is essential because spores can exist on environmental surfaces for years, Kelly said.
Diagnosis of C. difficile
“No single test is going to be used as a stand-alone test,” Kelly said.
She advised that hospitalists start with a highly sensitive test such as a PCR or the glutamate dehydrogenase as a screening test. Patients with negative test results do not need any further testing; however, those with a positive test should be tested with a more specific toxin enzyme immunoassay. Patients testing positive on the second assessment should be treated for C. difficile, she said. Additional clinical testing and evaluation need to be considered in those with discordant results between the initial screening and the confirmatory test to determine if that patient is a carrier or if the enzyme immunoassay was a false negative and C. difficile is possible, she said.
To avoid common pitfalls of C. difficile diagnosis, hospitalists should be aware of and understand their laboratory’s testing methods, never send repeat PCR testing, consider false positives in colonized patients and not test for cure, Kelly said. Patients can be considered cured if they have formed stools and are feeling well at the end of the course of therapy, she said. While waiting for confirmatory tests, hospitalists can start patients on empiric therapy if it is believed that they clinically have C. difficile, she said.
“Very importantly, you want to consider alternative diagnoses,” she said. These include post-infectious irritable bowel syndrome, inflammatory bowel disease, bile salt malabsorption, lactose intolerance, celiac disease, Giardia infection, chronic pancreatitis, microscopic colitis or factitious diarrhea, Kelly added.
Treatment of C. difficile
“The way we decide treatment is through categorizing infection based on severity,” Kelly said.
Patients with mild-to-moderate infection should discontinue inciting antibiotics and be prescribed 500 mg of metronidazole four times a day for 10 days, she said. Hospitalists can also prescribe 125 mg vancomycin four times a day for 10 to 14 days, but this should be reserved for patients who are allergic to metronidazole, are pregnant or breastfeeding, or fail to respond to metronidazole within 5 to 7 days, she said. Anti-peristaltic agents should be avoided in these patients, she added.
Patients with severe infection should receive supportive care and continue enteral feeding, Kelly said. Oral vancomycin (125 mg four times a day for 10 days) is the drug of choice for these patients, she said. There is no reason to extend treatment to 14 days if patients are better by 10 days, she advised.
For patients with complicated infections, Kelly recommended performing a CT of the abdomen and pelvis to identify megacolon, perforation or severe colitis. These patients should be treated with high doses of oral vancomycin (500 mg) and IV metronidazole (500 mg). If a patient has significant abdominal distension or an ileus, rectal vancomycin should be used. Surgeons should be involved early in these complicated infections because delayed intervention increases the risk for mortality. When considering surgery, total abdominal colectomy and end ileostomy are the best procedural options. Candidates for the OR include those with hypotension requiring vasopressor therapy, patients with sepsis and organ dysfunction, patients with white blood cell count greater than 50,000, and patients with lactate greater than 5 and no improvement seen after 5 days of medical therapy.
Recurrent C. difficile
The first recurrence of C. difficile should be treated with the same regimen as the initial episode, while the second recurrence should be treated with pulsed dosing of vancomycin, according to Kelly.
“It’s also important to reassess the diagnosis,” she said.
After three episodes of recurrent C. difficile, fecal microbiota transplantation is the most effective therapy and should also be considered for patients who do not respond to other therapies and those with severe disease. – by Alaina Tedesco
Reference:
Kelly CR. MTP 038: Clostridium difficile: What the Hospitalist Needs to Know. Presented at: ACP Internal Medicine Annual Meeting; March 29-April 1, 2017; San Diego.
Disclosure: Kelly reports consulting for Summit Therapeutics and SeresHealth and receiving research support from Assembly Biosciences, Inc.