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The last C.difficile presentation(at least for a few months)

J E S S I C A T H O M P S O N , P H A R M D, B C P S AQ - I D

I N F E C T I O U S D I S E A S E S P H A R M A C Y C L I N I C A L S P E C I A L I S T

R E N O W N H E A LT H

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

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DiagnosisPreferred 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

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Testing

Most facilities

In summary:

If you are unable optimize testing and/or rejection criteria do not use PCR alone for diagnosis

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Repeat testingTest 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)

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Implement antimicrobial stewardship

Minimize Minimize the Restrictfrequency and number of fluoroquinolones,

duration of high- antibiotic agents clindamycins, and risk antibiotics prescribed cephalosporins

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TreatmentDiscontinue 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 daysOR• Fidaxomicin 200 mg PO BID x 10 days

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

• Vancomycin 500 mg PO/NG q6hPLUS • Metronidazole 500 mg IV q8h

especially if ileus is presentIf ileus also add• Vancomycin 500 mg retention enema

q6h

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

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SurgeryNo defined criteria for surgical consultation or interventionType of surgical intervention◦ Subtotal colectomy with preservation of rectum

OR◦ Diverting loop ileostomy with colonic lavage followed by antegrade

vancomycin flushes

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Treatment of recurrenceClinical 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 daysThird CDI episode: • Fecal microbiota transplant

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MetronidazoleShould 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

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Pediatric considerationsTesting◦ ≤ 2 years: Do not routinely test

> 2 years: Test if prolonged or worsening diarrhea AND risk factors or relevant exposures

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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

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Questions?

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