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. The last C.difficile presentation (at least for a few months) JESSICA THOMPSON, PHARMD, BCPS AQ-ID INFECTIOUS DISEASES PHARMACY CLINICAL SPECIALIST RENOWN HEALTH .

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. Objectives Discuss the highlights and major differences between the 2010 and 2017 IDSA/SHEA C.difficile guidelines ◦ Slides refer to adult recommendations unless otherwise specificed .

. Diagnosis Preferred population for testing: ◦ Unexplained and new-onset ≥ 3 unformed stools in 24 hour “Clinicians can improve laboratory test relevance by only testing patients likely to have C.difficile disease” Suggestions: • Do not routinely test stool from a patient who has received a laxative in the preceding 48 hours • Develop, implement, and enforce stool rejection criteria .

. Testing In summary: Most facilities If you are unable optimize testing and/or rejection criteria do not use PCR alone for diagnosis .

. Repeat testing Test of cure: ◦ 60% of patients may remain positive Test for recurrence (i.e. recurrence of symptoms following successful treatment and diarrhea cessation): ◦ Use toxin detection, not NAAT (eg. PCR) .

. Implement antimicrobial stewardship Minimize Minimize the Restrict frequency and number of fluoroquinolones, duration of high- antibiotic agents clindamycins, and risk antibiotics prescribed cephalosporins .

. Treatment Discontinue therapy with the inciting antibiotic agent(s) as soon as possible, as this may influence the risk of recurrence Clinical Definition Recommended Treatment Initial episode, non-severe to severe Vancomycin 125 mg PO q6h x 10 days • OR May extend duration Fidaxomicin 200 mg PO BID x 10 days • to 14 days if there is Initial episode, fulminant Vancomycin 500 mg PO/NG q6h delayed treatment • (hypotension, shock, ileus, megacolon) PLUS response Metronidazole 500 mg IV q8h • especially if ileus is present If ileus also add Vancomycin 500 mg retention enema • q6h .

. Surgery No defined criteria for surgical consultation or intervention Type of surgical intervention ◦ Subtotal colectomy with preservation of rectum OR ◦ Diverting loop ileostomy with colonic lavage followed by antegrade vancomycin flushes .

. Treatment of recurrence Clinical Definition Recommended Treatment First recurrence After initial treatment course of metronidazole Vancomycin 125 mg PO q6h x 10 days • • After initial treatment course of vancomycin Vancomycin prolonged tapered and pulsed • • regimen OR Fidaxomicin 200 mg PO BID x 10 days • Second or subsequent recurrence Any one of the following: Vancomycin in a tapered and pulsed regimen • Vancomycin followed by rifaximin chaser • Fidaxomicin x 10 days • Third CDI episode: Fecal microbiota transplant • .

. Metronidazole Should only be used in the following scenarios ◦ Resource-limited settings in non-severe infections ◦ As IV for combination therapy in fulminant C.difficile Irreversible neurotoxicity associated with repeated or prolonged use ◦ Not recommended for treatment of recurrence in adults .

. Pediatric considerations Testing ◦ ≤ 2 years: Do not routinely test > 2 years: Test if prolonged or worsening diarrhea AND risk factors or relevant exposures Treatment .

. Summary Test the right patient Implement stool rejection criteria Don’t use PCR alone *if unable to implement above measures Antimicrobial stewardship No oral metronidazole *except in pediatric patients Pulse/taper vancomycin for 2 nd occurrence FMT for 3 rd occurrence .

. Questions? .