Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

Abstract

Clostridium diffi cile infection (CDI) is a leading cause of hospital-associated gastrointestinal illness and places a high burden on our health-care system. Patients with CDI typically have extended lengths-of-stay in hospitals, and CDI is a frequent cause of large hospital outbreaks of disease. This guideline provides recommendations for the diagnosis and management of patients with CDI as well as for the prevention and control of outbreaks while supplementing previously published guidelines. New molecular diagnostic stool tests will likely replace current enzyme immunoassay tests. We suggest treatment of patients be stratifi ed depending on whether they have mild-to-moderate, severe, or complicated disease. Therapy with metronidazole remains the choice for mildto-moderate disease but may not be adequate for patients with severe or complicated disease. We propose a classifi cation of disease severity to guide therapy that is useful for clinicians. We review current treatment options for patients with recurrent CDI and recommendations for the control and prevention of outbreaks of CDI. Am J Gastroenterol 2013; 108:478-498; doi: 10.1038/ajg.2013 12. In patients in whom oral antibiotics cannot reach a segment of the colon, such as with Hartman's pouch, ileostomy, or colon diversion, vancomycin therapy delivered via enema should be added to treatments above until the patient improves. (Conditional recommendation, low-quality evidence)13. The use of anti-peristaltic agents to control diarrhea from confi rmed or suspected CDI should be limited or avoided, as they may obscure symptoms and precipitate complicated disease. Use of anti-peristaltic agents in the setting of CDI must always be accompanied by medical therapy for CDI. (Strong recommendation, low-quality evidence) Management of severe and complicated CDI14. Supportive care should be delivered to all patients and includes intravenous fl uid resuscitation, electrolyte replacement, and pharmacological venous thromboembolism prophylaxis. Furthermore, in the absence of ileus or signifi cant abdominal distention, oral or enteral feeding should be continued. 17. Vancomycin delivered orally (500 mg four times per day) and per rectum (500 mg in a volume of 500 ml four times a day) plus intravenous metronidazole (500 mg three times a day) is the treatment of choice for patients with complicated CDI with ileus or toxic colon and / or signifi cant abdominal distention. (Strong recommendation, low-quality evidence)18. Surgical consult should be obtained in all patients with complicated CDI. Surgical therapy should be considered in patients with any one of the following attributed to CDI: hypotension requiring vasopressor therapy; clinical signs of sepsis and organ dysfunction (renal and pulmonary); mental status changes; white blood cell count ≥ 50,000 cells / μ l, lactate ≥ 5 mmol / l; or failure to improve on medical therapy after 5 days. (Strong recommendation, moderate-quality evidence) Management of recurrent CDI (RCDI)19. The fi rst recurrence of CDI can be treated ...

Clinical and demographic profile and risk factors for Clostridium difficile infection

“…1,[6][7][8][9][10][11][12][13][14][15]9). A pesar de los datos encontrados por estos investigadores, la muestra solo incluía 22 casos y 44 controles, y se plantearon reparos sobre la sensibilidad de la prueba diagnóstica utilizada para la detección de la toxina.…”

“…La enfermedad asociada a C. difficile se define como un cuadro de diarrea de inicio agudo y de causa no aparente en pacientes con presencia confirmada de C. difficile toxigénico o de su toxina (7). Los síntomas mas frecuentes son la diarrea, el dolor abdominal, la distensión abdominal y la fiebre.…”

“…Son múltiples los factores de riesgo, pero los más importantes son el uso previo de antibióticos (8,9) y la exposición al germen (7). Además, se han reconocido otros factores asociados, como la edad mayor de 65 años (8), el tiempo de hospitalización (10,11), la estancia previa en la unidad de cuidados intensivos (12), la gravedad de la condición de salud, la hipoalbuminemia (<2,5 g/dl) (11), el uso previo de quimioterapia, la manipulación del tubo digestivo (incluido el paso de sondas de nutrición) (13) y el uso de medicamentos que suprimen el ácido gástrico (bloqueadores de la histamina 2 o inhibidores de la bomba de protones) (12,14,15 Entre las complicaciones de la infección por C. difficile están la alteración electrolítica, el megacolon tóxico, la perforación intestinal con peritonitis y el choque séptico, las cuales pueden llevar a la muerte (14).…”

Cirrhosis and C. difficile: A Deadly Duo?

“…While this recommendation is interesting, it contradicts important points documented in two current published guidelines, that is, (1) test-only diarrheal stools and (2) do not treat C. difficile carriers [3,4]. We shall now discuss these points in more detail.…”

“…This latter point may be particularly challenging in patients with cirrhosis receiving lactulose for hepatic encephalopathy as this medication is often associated with loose stools; however, this judgment must be left up to the inpatient care team at the time of admission. We recommend close vigilance for the development of CDI symptoms and encourage hospital laboratories to consider polymerase chain reaction (PCR) testing as a rapid means of diagnosis, even though stool culture is the currently accepted reference test [4]. We appreciate the extensive analysis performed by Saab et al, particularly the raising of this important issue as a catalyst for future discussion and research.…”