UPTODATE

American College of Gastroenterology

210 Update by Society for Healthcare Epidemiology of America (SHEA ) and the Infectious Diseases Society of America

Center for Infectious Disease CGH Guidelines

L.S.W /96/ FEMALEADL DEPENDENT/ DUALLY

INCONTINENTSPICE

FEVER AND DIARRHEA

The Patient HTN AF CCF Osteoporosis TIA Dementia Depression Iron deficiency

anemia Gout

Recurrent admission for UTI,

Gout attacks 1/2014 : Pneumonia

-Augmentin Chlarithromycin

3/24/2014: Pneumonia Rocephine & Doxycyciine Moxifloxacin

10/4/2014 : Gastroenteritis Ceftriaxone Augmentin

Course in the Wards

Gastroenteritis with DehydrationIV fluidsIV Rocephine shifted to Augmentin

AKI and Hypernatremia

Deconditioning

Course in the Wards Gastroenteritis likely antibiotic related

Cd toxin not detectedAntibiotics discontinuedDiarrhea resolved

Delirium likely stroke disease

Poor Oral intake DepressionWorsening DementiaNGT was inserted

Course in the Wards

Recurrence of diarrheaCD toxin : CD PCR : Positive

Metronidazole 500 mg per NGT 6 hourly Vancomycin 250mg per NGT q6hourly

Epidemiology

Clostridium Difficile Anerobic gram positive

spore forming, toxin producing bacillus

Exists in spores and vegetative forms

causative pathogen for antibiotic associated diarrhea and colitis

NAP1/B1/027 – virulent strain

How C. Difficile Spreads

Few days later, persistence of diarrhea, retested for CD, which turns out to be positive. Was given proper antiobitiotics, with resolution of diarrhea

At Rehab facility – with no strict contact precaution. L.S.W. developed diarrhea, CD toxin was not tested at that time. health care worker attends to her, infects another patient

1 ½ month later : admitted to Pneumonia, given another course of antibiotics. A health care worker forgetting to wash hands /wear gloves after attending to a C. D. Infected

patient next to her bed, infecting patient

L.S.W . 96/female, went to doctor, diagnosed with Pneumonia, given antibiotics that put her at risk of developing antibiotic related diarrhea

Clostridium difficile Pathonegesis

FROM THE FOLLOWING ARTICLE:Clostridium difficile infection: new developments in epidemiology and pathogenesis

Maja Rupnik, Mark H. Wilcox & Dale N. GerdingNature Reviews Microbiology 7, 526-536 (July 2009)

Risk factorsAntibiotics

Hospitalization

Advanced age

Severe illness

Gastric acid suppression

Enteral feeding

Gastroentrointestinal conditions & procedures

Obesity

Cancer chemotheray

Hematopoetic transplantation

Antidepressant

Factors contributing to the development of Clostridium difficile colonization and diarrhea [adapted, with permission, from Johnson S, Gerding DN. Clostridium difficile-associated

diarrhea. Clin Infect Dis 1998;26:1027-36, published by the University of Chicago Press, Infectious Diseases Society of America; 1998]. Photo: Lianne Friesen and Nicholas Woolridge

Antimicrobial agents that may induce Clostridium difficile diarrhea and colitis

Frequently associate

Occasionally associated

Rarely associated

Fluoquinolones Macrolides Aminoglycosides

Clindamycin Trimethoprim Tetracyclines

Penicillins sulfonamides Chloramphenicol

Cephalosphorins Metonidazole

Vancomycin

Clinical Manifestations and Diagnosis

Carrier state

Diarrhea and colitis

Pseudomembranous colitis

Recurrent disease :

relapse vs reinfection

Fulminant colitis

Clinical Manifestations

96% of patients with symptoms had received antimicrobials with 14 days before the onset of diarrhea

Symptoms begin soon after colonization ( median time onset 2-3 days )

Fever, cramping, abdominal discomfort and peripheral leukocytosis are common

Arthritis, bacteremia Unexplained Leukocytosis

Diagnosis

Presence of moderate to severe diarrhea or ileus

And either

A stool positive for C. Difficile toxins or toxigeneic c. Dificile

Endoscopic or histologic findings of pseudomembranous colitis

Diagnostics Tests

Only stools from patient with diarrhea should be tested for CD

• ( strong recommendation, High Quality evidence )

NAAT ( PCR are superior to toxins A & B EIA testing as a standard diagnostic test for CDI

• (strong recommedation, moderate quality evidence )

Glutamate Dehydrogenase can be used in 2 to 3 step screening algorithms with subsequent toxin A and B EIA testing, but the sensitivity of such is lower than NAATS

• ( strong recommendation, moderate quality evidence )

Diagnostic testing

Repeat testing should be discourage

• Strong recommendation, moderate quality evidence

Testing for cure should not be done

• ( strong recommendation, moderate quality evidence )

Stool culture is most sensitive and essential in epidemiologic studies • ( good evidence to support recommendation)

Other Methodologies

Sigmoidoscopy or colonoscopy

• Detects pseudomembranous colitis in 51-55% of CDI cases

Histopathology

Abdominal CT SCAN – facilitate diagnosis, but not sensitive nor specific

MANAGEMENT OF MILD, MODERATE,

SEVERE CDI

CDI Severity Scoring System

Severity criteria

Mild to moderate Diarrhea + s/s not meeting severe or complicated criteria

Severe Disease <3g/dl + 1 of the ff:WBC >15,000 cells/mm3, abdominal tenderness

Severe and Complicated disease

Any of the following attributable to CDIAdmission to ICUHypotension +/- vasopressorsFever >38.5 CIleus or significant abdominal distentionMental status chnages WBC >35,0000or <2,000

Recurrent CDI Recurrent within 8 weeks of completion of therapy

Factors to Consider Before Treating

AGE

Peak White cell

count

Peak serum

creatinine

Treatment

•Metronidazole 500mg TDS or 250mg QDS for 10-14 days

•Vancomycin 125mg orally QDS 10-14 days.

Mild disease

•Vancomycin500mg 4x/day + metronidazole 500mg every 8 hours IV

•If complete ileus : add rectal vancomycin

Severe disease

•If symptoms is mild, conservative management may be appropriate

•If antibiotics are needed, repeat treatment as in initial episode

•Alternative : Fidaxomicin 200mg BD x 10 days

First Relapse

Treatment•Tapering and pulsed

vancomycin with or without probiotics

•125mg QDS for 7-14 days•125 TDS x 7 days•125 once x 7 days•125mg orally every other

day for 7 days•125mg orally every 3 days

x 14 days•Alternative : Fidaxomicin

200mg orally BD x 10days

Second Relapse

Treatment•Fidaxomicin

200mg Orally BD x 10 days

•Alternative : vancomycin 125mg QDS x 14 days followede by rifiximim 400mg BD x 14 days

Subsequent relapse

Fidoximicin

Macrolide, bactericidal Narrower antimicrobial spectrum than

Metronidazole & vancomycin 3RCT : in non severe C. Difficile ,

clinical cure rates with vacomycin were similar

Recurrence is less often among patients with non NAP1 strain ( 10 vs 28 % )

Probiotics May be effective for prevention and treatment

Alteration of intestinal floraAntimicrobrial activityIntestinal barrier protectionimmunomodulation

Administration consist only of regimens with demonstrated efficacy

Dosage of >10 billion CFU per day A cocrane review: insufficient evidence to

recommend as adjunct in treatment

RICE WATERThe advantage of using rice water is that rice is cooked daily in South East Asia.

WHO photograph by Dr Gramiccia In South East Asia, rice is prepared in two ways - to produce either dry, cooked rice or, with extra water, rice porridge. This leaves a fluid (rice water) on top of the cooked rice grains.

Professor Wong Hock Boon, a paediatrician working in Singapore, has been using rice water to rehydrate babies for several years. If the babies are bottle-fed rice water is given exclusively for the first 24 hours of treatment - breastfeeding can continue as normal (1).

Professor Wong and his colleagues have found that many babies who have not responded to other rehydration solutions respond well to rice water. If diarrhoea starts again with the re-introduction of milk, extra rice water is given with additional rice porridge. Older babies are sometimes given rice porridge alone.

Rice water and diarrhoea

Treatment

Antimotility Agents and OpoidsAssociated with increase risk of toxic

megacolon IVIG

No effective immunotherapy is currently available

Does not a tole a s sole therapy for RCDIMay be helpful in patient with

hypogammaglobulimenia

Colectomy

Consider in severely ill patients

Monitoring serum lactate and White cell may be helpful in prompting a decision to operate

FECAL MICROBIOTA TRANSPLANTATION IN

THE TREATMENT OF RECURRENT CDI

Fecal Microbiota Transplantation

Patient selectionSevere and Recurrent C. Difficile infection

Cure rates 81-94% in patients with recurrent disease

Response within 24h to 12 days Only method capable of providing

durable implantation of probiotics Route of administration :

Colonoscopy, nasogastric, enema

Prognosis

Mild disease, may recover without specific therapy

Debilitating and can last for several weeks 20-27% treated for first episode , relapse

after successful completing the antibiotics , 3days -3week after treatment

65%- relapse rate with patient with 2 or more relapses

Infection Control, & Prevention

A hospital – based infection contol program can help decrease the incidence of CDI

Routine screening for C. Difficile in hospitalized patients without diarrhea is not recommended and asymptomatic carriers should not be treated

Antibiotic stewardship is recommended to reduce the risk of CDI

Infection Control and Prevention

Gloves and gowns upon entry to a room Emphasize compliance with practice of

hand hygiene Hand wash with soap and water after

caring for or contacting patient with CDI Accommodate patients with CDI in

private room with contact precaution

Environmental Cleaning and Disinfection

Identification and removal of environmental sources of C. Dificille including replacement of electronic rectal thermometers

with disposable, can reduce the incidence of CDI

Use chlorine-containing cleaning agents or other sporicidal agents to address environmental contamination in area associated with increased rates CDI

Prognosis Adverse outcomes

Treatment failureSevere or severe complicated infectionSepsisNeed for admission to ICUNeed for colectomyIncrease length of hospital stay Need for hospitalization for community acquired

CDIMortality 4.2-6.9%

THANK

YOU

Differential Diagnosis

Osmotic diarrhea Antibiotics alter colonic microflora

Impaired carbohydrate fermentation

Increased osmotic concentration in colonic lumen

Prevention strategies

Early detection and isolationRapid implementation of contact precautionsVigilant screening for new onset diarrhea in

patients at risk and rapid and accurate testing

Contact precaution

Prevention and strategies Hand Hygiene

Healthcare personel should hand wash hands with soap and water

Alcohol based hand rub does NOT eradicate C. Difficile spores

Adherance to gloves is also important