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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

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

Most facilities

In summary: If you are unable

• ptimize 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

• Fidaxomicin 200 mg PO BID x 10 days

Initial episode, fulminant (hypotension, shock, ileus, megacolon)

• Vancomycin 500 mg PO/NG q6h

PLUS

• Metronidazole 500 mg IV q8h

especially if ileus is present If ileus also add

• Vancomycin 500 mg retention enema

q6h May extend duration to 14 days if there is delayed treatment response

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
• After initial treatment course of vancomycin
• Vancomycin 125 mg PO q6h x 10 days
• 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 2nd occurrence FMT for 3rd occurrence

Questions?