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Monday AM report 05-10-10

Monday AM report 05-10-10. Clostridium difficile infection. Introduction. Clostridium difficile is an anaerobic gram-positive, spore-forming toxin-producing bacillus. Toxin A directly activates Neutrophils. Toxin B mediates colonic mucosal damage.

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Monday AM report 05-10-10

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  1. Monday AM report 05-10-10

  2. Clostridium difficile infection

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

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

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

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

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

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

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

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

  11. Pseudomembranous colitis

  12. Thank you

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