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UPTODATE
American College of Gastroenterology
210 Update by Society for Healthcare Epidemiology of America (SHEA ) and the Infectious Diseases Society of America
Center for Infectious Disease CGH Guidelines
L.S.W /96/ FEMALEADL DEPENDENT/ DUALLY
INCONTINENTSPICE
FEVER AND DIARRHEA
The Patient HTN AF CCF Osteoporosis TIA Dementia Depression Iron deficiency
anemia Gout
Recurrent admission for UTI,
Gout attacks 1/2014 : Pneumonia
-Augmentin Chlarithromycin
3/24/2014: Pneumonia Rocephine & Doxycyciine Moxifloxacin
10/4/2014 : Gastroenteritis Ceftriaxone Augmentin
Course in the Wards
Gastroenteritis with DehydrationIV fluidsIV Rocephine shifted to Augmentin
AKI and Hypernatremia
Deconditioning
Course in the Wards Gastroenteritis likely antibiotic related
Cd toxin not detectedAntibiotics discontinuedDiarrhea resolved
Delirium likely stroke disease
Poor Oral intake DepressionWorsening DementiaNGT was inserted
Course in the Wards
Recurrence of diarrheaCD toxin : CD PCR : Positive
Metronidazole 500 mg per NGT 6 hourly Vancomycin 250mg per NGT q6hourly
Epidemiology
Clostridium Difficile Anerobic gram positive
spore forming, toxin producing bacillus
Exists in spores and vegetative forms
causative pathogen for antibiotic associated diarrhea and colitis
NAP1/B1/027 – virulent strain
How C. Difficile Spreads
Few days later, persistence of diarrhea, retested for CD, which turns out to be positive. Was given proper antiobitiotics, with resolution of diarrhea
At Rehab facility – with no strict contact precaution. L.S.W. developed diarrhea, CD toxin was not tested at that time. health care worker attends to her, infects another patient
1 ½ month later : admitted to Pneumonia, given another course of antibiotics. A health care worker forgetting to wash hands /wear gloves after attending to a C. D. Infected
patient next to her bed, infecting patient
L.S.W . 96/female, went to doctor, diagnosed with Pneumonia, given antibiotics that put her at risk of developing antibiotic related diarrhea
Clostridium difficile Pathonegesis
FROM THE FOLLOWING ARTICLE:Clostridium difficile infection: new developments in epidemiology and pathogenesis
Maja Rupnik, Mark H. Wilcox & Dale N. GerdingNature Reviews Microbiology 7, 526-536 (July 2009)
Risk factorsAntibiotics
Hospitalization
Advanced age
Severe illness
Gastric acid suppression
Enteral feeding
Gastroentrointestinal conditions & procedures
Obesity
Cancer chemotheray
Hematopoetic transplantation
Antidepressant
Factors contributing to the development of Clostridium difficile colonization and diarrhea [adapted, with permission, from Johnson S, Gerding DN. Clostridium difficile-associated
diarrhea. Clin Infect Dis 1998;26:1027-36, published by the University of Chicago Press, Infectious Diseases Society of America; 1998]. Photo: Lianne Friesen and Nicholas Woolridge
Antimicrobial agents that may induce Clostridium difficile diarrhea and colitis
Frequently associate
Occasionally associated
Rarely associated
Fluoquinolones Macrolides Aminoglycosides
Clindamycin Trimethoprim Tetracyclines
Penicillins sulfonamides Chloramphenicol
Cephalosphorins Metonidazole
Vancomycin
Clinical Manifestations and Diagnosis
Carrier state
Diarrhea and colitis
Pseudomembranous colitis
Recurrent disease :
relapse vs reinfection
Fulminant colitis
Clinical Manifestations
96% of patients with symptoms had received antimicrobials with 14 days before the onset of diarrhea
Symptoms begin soon after colonization ( median time onset 2-3 days )
Fever, cramping, abdominal discomfort and peripheral leukocytosis are common
Arthritis, bacteremia Unexplained Leukocytosis
Diagnosis
Presence of moderate to severe diarrhea or ileus
And either
A stool positive for C. Difficile toxins or toxigeneic c. Dificile
Endoscopic or histologic findings of pseudomembranous colitis
Diagnostics Tests
Only stools from patient with diarrhea should be tested for CD
• ( strong recommendation, High Quality evidence )
NAAT ( PCR are superior to toxins A & B EIA testing as a standard diagnostic test for CDI
• (strong recommedation, moderate quality evidence )
Glutamate Dehydrogenase can be used in 2 to 3 step screening algorithms with subsequent toxin A and B EIA testing, but the sensitivity of such is lower than NAATS
• ( strong recommendation, moderate quality evidence )
Diagnostic testing
Repeat testing should be discourage
• Strong recommendation, moderate quality evidence
Testing for cure should not be done
• ( strong recommendation, moderate quality evidence )
Stool culture is most sensitive and essential in epidemiologic studies • ( good evidence to support recommendation)
Other Methodologies
Sigmoidoscopy or colonoscopy
• Detects pseudomembranous colitis in 51-55% of CDI cases
Histopathology
Abdominal CT SCAN – facilitate diagnosis, but not sensitive nor specific
MANAGEMENT OF MILD, MODERATE,
SEVERE CDI
CDI Severity Scoring System
Severity criteria
Mild to moderate Diarrhea + s/s not meeting severe or complicated criteria
Severe Disease <3g/dl + 1 of the ff:WBC >15,000 cells/mm3, abdominal tenderness
Severe and Complicated disease
Any of the following attributable to CDIAdmission to ICUHypotension +/- vasopressorsFever >38.5 CIleus or significant abdominal distentionMental status chnages WBC >35,0000or <2,000
Recurrent CDI Recurrent within 8 weeks of completion of therapy
Factors to Consider Before Treating
AGE
Peak White cell
count
Peak serum
creatinine
Treatment
•Metronidazole 500mg TDS or 250mg QDS for 10-14 days
•Vancomycin 125mg orally QDS 10-14 days.
Mild disease
•Vancomycin500mg 4x/day + metronidazole 500mg every 8 hours IV
•If complete ileus : add rectal vancomycin
Severe disease
•If symptoms is mild, conservative management may be appropriate
•If antibiotics are needed, repeat treatment as in initial episode
•Alternative : Fidaxomicin 200mg BD x 10 days
First Relapse
Treatment•Tapering and pulsed
vancomycin with or without probiotics
•125mg QDS for 7-14 days•125 TDS x 7 days•125 once x 7 days•125mg orally every other
day for 7 days•125mg orally every 3 days
x 14 days•Alternative : Fidaxomicin
200mg orally BD x 10days
Second Relapse
Treatment•Fidaxomicin
200mg Orally BD x 10 days
•Alternative : vancomycin 125mg QDS x 14 days followede by rifiximim 400mg BD x 14 days
Subsequent relapse
Fidoximicin
Macrolide, bactericidal Narrower antimicrobial spectrum than
Metronidazole & vancomycin 3RCT : in non severe C. Difficile ,
clinical cure rates with vacomycin were similar
Recurrence is less often among patients with non NAP1 strain ( 10 vs 28 % )
Probiotics May be effective for prevention and treatment
Alteration of intestinal floraAntimicrobrial activityIntestinal barrier protectionimmunomodulation
Administration consist only of regimens with demonstrated efficacy
Dosage of >10 billion CFU per day A cocrane review: insufficient evidence to
recommend as adjunct in treatment
RICE WATERThe advantage of using rice water is that rice is cooked daily in South East Asia.
WHO photograph by Dr Gramiccia In South East Asia, rice is prepared in two ways - to produce either dry, cooked rice or, with extra water, rice porridge. This leaves a fluid (rice water) on top of the cooked rice grains.
Professor Wong Hock Boon, a paediatrician working in Singapore, has been using rice water to rehydrate babies for several years. If the babies are bottle-fed rice water is given exclusively for the first 24 hours of treatment - breastfeeding can continue as normal (1).
Professor Wong and his colleagues have found that many babies who have not responded to other rehydration solutions respond well to rice water. If diarrhoea starts again with the re-introduction of milk, extra rice water is given with additional rice porridge. Older babies are sometimes given rice porridge alone.
Rice water and diarrhoea
Treatment
Antimotility Agents and OpoidsAssociated with increase risk of toxic
megacolon IVIG
No effective immunotherapy is currently available
Does not a tole a s sole therapy for RCDIMay be helpful in patient with
hypogammaglobulimenia
Colectomy
Consider in severely ill patients
Monitoring serum lactate and White cell may be helpful in prompting a decision to operate
FECAL MICROBIOTA TRANSPLANTATION IN
THE TREATMENT OF RECURRENT CDI
Fecal Microbiota Transplantation
Patient selectionSevere and Recurrent C. Difficile infection
Cure rates 81-94% in patients with recurrent disease
Response within 24h to 12 days Only method capable of providing
durable implantation of probiotics Route of administration :
Colonoscopy, nasogastric, enema
Prognosis
Mild disease, may recover without specific therapy
Debilitating and can last for several weeks 20-27% treated for first episode , relapse
after successful completing the antibiotics , 3days -3week after treatment
65%- relapse rate with patient with 2 or more relapses
Infection Control, & Prevention
A hospital – based infection contol program can help decrease the incidence of CDI
Routine screening for C. Difficile in hospitalized patients without diarrhea is not recommended and asymptomatic carriers should not be treated
Antibiotic stewardship is recommended to reduce the risk of CDI
Infection Control and Prevention
Gloves and gowns upon entry to a room Emphasize compliance with practice of
hand hygiene Hand wash with soap and water after
caring for or contacting patient with CDI Accommodate patients with CDI in
private room with contact precaution
Environmental Cleaning and Disinfection
Identification and removal of environmental sources of C. Dificille including replacement of electronic rectal thermometers
with disposable, can reduce the incidence of CDI
Use chlorine-containing cleaning agents or other sporicidal agents to address environmental contamination in area associated with increased rates CDI
Prognosis Adverse outcomes
Treatment failureSevere or severe complicated infectionSepsisNeed for admission to ICUNeed for colectomyIncrease length of hospital stay Need for hospitalization for community acquired
CDIMortality 4.2-6.9%
THANK
YOU
Differential Diagnosis
Osmotic diarrhea Antibiotics alter colonic microflora
Impaired carbohydrate fermentation
Increased osmotic concentration in colonic lumen
Prevention strategies
Early detection and isolationRapid implementation of contact precautionsVigilant screening for new onset diarrhea in
patients at risk and rapid and accurate testing
Contact precaution
Prevention and strategies Hand Hygiene
Healthcare personel should hand wash hands with soap and water
Alcohol based hand rub does NOT eradicate C. Difficile spores
Adherance to gloves is also important