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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 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 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 First recurrence After initial treatment course of metronidazole After initial treatment course of vancomycin Second or subsequent recurrence Recommended Treatment Vancomycin 125 mg PO q6h x 10 days Vancomycin prolonged tapered and pulsed regimen OR Fidaxomicin 200 mg PO BID x 10 days 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?