Disclosure None C. Difficile Infections Hueylan Chern MD - - PowerPoint PPT Presentation

3/8/2014 1

• C. Difficile Infections

Hueylan Chern MD Assistant Professor of Surgery UCSF

Disclosure

• None

Outline

• Pathogenesis
• Epidemiology
• Clinical presentation
• Diagnosis
• Medical management
• Surgical options

Pathogenesis

• Anaerobic, Gram-positive, spore forming rod
• Toxin damaging to the colonic mucosa
• Toxins A and B cause marked systemic

inflammatory response

3/8/2014 2

Epidemiology

• Increasing incidence, morbidity and mortality
• NAP1/B1/027 hypervirulent strain
• Incidence rates up to 9.5 cases per 10k patient-

days from 3.8 in Canada

• Up to 1096.5 discharges per 100k from 463.1 in

Michigan

Cohen et al; Infect Control Hosp Epidemiol 2010;31(5):431–45511 VerLee et al; Public Health Rep 2012;127(1):62–71

Risk Factors

• Strongest risk factor

– antimicrobial exposure – up to 98% patients having at least one dose of antibiotics in the preceding 2 weeks

• Wide range of antibiotics implicated in CDI
• Elderly, PPIs , immunosuppressed, IBD

patients

Clinical presentation

• Watery diarrhea, non bloody
• Ileus, distension, fever, tachycardia, sepsis,

shock

Diagnosis

• Lab confirmation of C difficile toxin
• Leukocytosis, hypoalbuminemia (protein-

losing enteropathy)

• Abdominal Xray to evaluate for colonic

distention, free air

• CT can show colonic thickening, stranding,

ascites

3/8/2014 3

Medical Management

• Inciting antibiotics should be stopped if possible
• Antidiarrheal medications should be discontinued
• Oral metronidazole 10-14 days for mild case is first-line
• Consider low dose vanco for more severe infection
• High dose PO Vancomycin AND IV metronidazole for

complicated CDI (shock, megacolon, ICU admission)

• Rectal Vancomycin enema helpful in cases of severe

ileus

Medical Management

• Fidaxomicin similar in efficacy to vanco in

initial clinical cure and more effective in preventing recurrence; but expensive

Louie et al. N Engl J Med 2011;364(5):422–31.

94% 10 weeks after transplant vs 23% and 31% response rate

Operative Management

• Acute surgical abdomen requires emergency

surgery

• Deciding when to intervene is more difficult
• Mortality in patients after colectomy as high

as 34 to 57%

• Predictors of mortality: multiorgan failure

3/8/2014 4

Operative Management

• Subtotal colectomy with end ileostomy

– How to manage Rectal stump

Operative Management

• Diverting loop ileostomy and colonic lavage

– Followed by antegrade vancomycin enemas and iv metronidazole – 93% colon preserve, 19% mortality

Neal et al. Ann Surg 2011;254 (3):423–427

Summary

• Clostridium Difficile infection is increasing in

prevalence and severity

• Antibiotic exposure is the strongest risk factor
• Metronidazole and Vancomycin are the main

medical treatment

• Surgery should be considered for complicated

infection or fulminant disease

• Subtotal colectomy with end ileostomy