Tuesday, March 28, 2017

Clostridium difficile Infection

During morning report we discussed a case of Clostridium difficile Infection (CDI). Here are some key points about the risk factors, diagnosis, risk stratification, and management of CDI.

Pathophysiology and Risk factors:

-          Clostridium difficile is an anaerobic Gram-positive spore-forming bacillus
-          Transmitted through the fecal-oral route by spores that are resistant to heat, acid, and antibiotics
-          Colonizes the large intestine and makes exotoxins that cause colitis in susceptible patients
-          In a healthy host, colonization is prevented by barrier properties of a health fecal microbiota
-          Most of the risk factors for CDI have to do with a weakened fecal microbiota
-          Risk factors:
o   Antibiotics (Most important risk factor!)
§  Almost all antibiotics are a risk factor but classically think of fluoroquinolones, cephalosporins, clindamycin, ampicillin and amoxicillin (1)
§  Interestingly, a recent cohort study in JAMA Internal Medicine, showed that even the receipt of antibiotics by prior hospital bed occupants can increase the risk for CDI in subsequent patients who occupy the same bed! (2)
o   Advanced age
o   Chemotherapy
o   Underlying diseases (such as inflammatory bowel disease, immunosuppression) (1)

Diagnosis:

-          The diagnosis of CDI is usually made by C diff toxin assays in stool (either an enzyme immunoassay for toxins or a PCR test for microbial toxin genes)
-          Culturing Clostridium difficile in stool is not widely available and is not often used
-          Note that the C diff toxin assays may stay positive after a CDI is appropriately treated so a positive C diff stool test after an appropriate course of treatment for CDI needs to be interpreted with caution (i.e. involve the expertise of Infectious Disease)

Risk stratification and management:

-          How one treats CDI varies depending on the severity of the infection.
-          One resource I find very helpful is the Antimicrobial Stewardship Program of UHN/SHS best practices:

-          This is their summary slide on C difficile severity Criteria:




-          And here is a summary of the treatment of CDI based on severity:



-           


-          Bottom line is that metronidazole is first-line for mild-moderate disease and ORAL vancomycin is first line for severe disease. Once there is complicated/fulminant disease, ORAL vancomycin and IV metronidazole are both given and General Surgery and Infectious Diseases consultations are key.

-          Keep in mind that the vancomycin needs to be given ORALLY! It is not absorbed in the GI tract and therefore will act in the colon where the infection is; IV vancomycin isn’t going to help.

-          There are subtleties to the treatment of recurrent CDI including much interest in fecal microbial transplantation, which has evidence supporting its effectiveness and cost-effectiveness in the treatment of recurrent CDI, including RCTs (4).

References:
1.       NEJM review article: Leffler D, Lamont JT. Clostridium difficile infection.  N Engl J Med. 2015;372(16):1539. http://www.nejm.org/doi/pdf/10.1056/NEJMra1403772
2.       Freedberg et al. Receipt of antibiotics in hospitalized patients and risk for Clostridium difficile infection in subsequent patients who occupy the same bed. JAMA Intern Med. 2016;176(12):1801-1808.
3.       Antimicrobial Stewardship Program of UHN/SHS best practices: http://www.antimicrobialstewardship.com/antimicrobial-stewardship-best-practices

4.       Health Quality Ontario. Fecal Microbiota therapy for Clostridium difficile infection: A health technology assessment. Ont Health Technol Assess Ser. 2016; 16(17):1-69. 

9 comments:

  1. This comment has been removed by a blog administrator.

    ReplyDelete
  2. This comment has been removed by a blog administrator.

    ReplyDelete
  3. good work,good sharing...

    http://www.grsshoes.com/

    ReplyDelete
  4. It was during my research on HIV/Herpes that I stumbled upon the Hiv/Herpes information; information which is quite easy to find when doing a search for STD on google. I was into conspiracy at the time thought of HIV/Herpes Cured' being a conspiracy was something Ignorance though,I found pretty interesting about herbal medicine. I asked questions about the Herbal cure's on official HIV/Herpes websites and I was banned for doing so by moderators who told me that I was parroting Hiv/Herpes propaganda. This reinforced my belief that there is a cure for Hiv/Herpes Then i found a lady from germany name Achima Abelard Dr Itua Cure her Hiv so I send him a mail about my situation then talk more about it and send me his herbal medicine I drank for two weeks.And today I'm Cured no Hiv/Herpes in my life,I searched for Hiv/Herpes groups to attempt to make contact with people in order to learn more about Hiv/Herpes Herbal Cure's I believed at this time that you with the same disease this information is helpful to you and I wanted to do the best I could to spread this information in the hopes of helping other people.That Dr Itua cure Hiv,Herpes,Hepatitis,Diabetes,Copd,Fibroid,Als, And Cancer. He's a herbal doctor with a unique heart of God, Contact Emal..drituaherbalcenter@gmail.com Phone or whatsapp..+2348149277967.

    ReplyDelete
  5. I have being on blog Sites for a while now and today I felt like I should share my story because I was a victim too. I had HIV for 6 years and i never thought I would ever get a cure I had and this made it impossible for me to get married to the man I was supposed to get married to even after 2 years of relationship he broke up with me when he finds out I was HIV positive. So I got to know about Dr. Itua on Blog Site who treated someone and the person shared a story of how she got a cured and let her contact details, I contacted Dr. Itua and he actually confirmed it and I decided to give a try too and use his herbal medicine that was how my burden ended completely. My son will be 2 soon and I am grateful to God and thankful to his medicine too.Dr Itua Can As Well Cure The Following Disease… Cancer, HIV, Herpes, Hepatitis B, Liver Inflammatory,Diabetes,Fibroid, Get Your Ex Back, If you have (A just reach him on drituaherbalcenter@gmail.com Or Whatsapp Number.+2348149277967)He can also advise you on how to handle some marital's issues. He's a good man.

    ReplyDelete
  6. Dr Itua cure my HIV, I have been a ARV Consumption for 10 years. i have been in pains until i came across Dr Itua on blogs site.I emailed him about my details of my HIV and my location i explained every thing to him and he told me that there is nothing to be scared of that he will cured me, he gave me guarantee,He ask me to pay for items fees so when i'm cured I will show gratitude I did and giving testimony of his healing herbs is what I'm going to do for the rest of you out there having HIV and other disease can see the good work of Dr Itua.I received his herbal medicine through EMS Courier service who delivered to my post office within 5 working days.Dr Itua is an honest man and I appreciate him for his good work.My GrandMa called him to appreciate him and rest of my friends did too,Is a joy to me that I'm free of taking Pills and having that fat belle is a nightmare.you will understand what i'm talking about if you have same problem I was having then not now though.I'm free and healthy Big Thanks To Dr Itua Herbal Center.I have his calendar too that he recently sent me,He Cure all kind disease Like,Cancer,Weak Erection,Wart Remover,Hpv,Herpes,Fibromyalgia,Hiv,Hepatitis B,Liver/Kidney Inflamatory,Epilepsy,Infertility,Fibroid,Diabetes,Dercum,Copd ,and also Bring back Ex Lover Back..Here his Contact .drituaherbalcenter@gmail.com Or Whats_app Number +2348149277967

    ReplyDelete
  7. Thanks for sharing, nice post! Post really provice useful information!

    Công ty vận chuyển hàng nước ngoài FadoExpress hàng đầu chuyên vận chuyển, chuyển phát nhanh siêu tốc đi khắp thế giới, nổi bật là dịch vụ gửi hàng đi mỹ, gửi hàng đi úcgửi hàng đi đài loan uy tín, giá rẻ.

    ReplyDelete


  8. I actually was told otherwise, that the herpes can not be treated and that there is no way to make it go away once you have it. But I decided to do my own research and found out it is possible to fight it.. I got a lot of information about it here in forums and online,I got Dr Oduku contact on a group were a man from Cordova was sharing his testimony of how he cured him of herpes so I decided to give him a try I emailed him through odukuherbalremedies@gmail.com. he called me to know if I actually wanted the cured after which the cure was sent to me few days later I was surprised when the same doctor who told me that I was diagnosed of herpes told me that I was completely free from herpes you can reach him through his email odukuherbalremedies@gmail.com. or through his WhatsApp +2349064430408 if you are diagnosed and also wanna be free from this deadly virus because he is really gonna be of great help to you!!

    ReplyDelete
  9. Very informative, because it compresses most of the information needed and the best solution to Paralysis still remains herbal medicines.
    I became more convinced in herbal medicines because of NZE NJOKU HERBAL HOME.
    I have also contacted Nze Njoku for herbal treatment for my grandfather who had suffered paralysis caused by stroke for eight years.
    My grandfather took herbal medicines from Nze Njoku Herbal Home as he's instructed without any lifestyle change which healed him of paralysis within nine weeks.
    As I write this my grandfather is doing great on his feet and most importantly he has started his business effectively as if nothing happened to him.
    Feel free to contact them on;
    nzenjokuherbalhome@gmail.com

    ReplyDelete