PEERA HEMARAJATA, M.D., PH.D., D(ABMM)

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Quick Update: 2017 C. difficile Guidelines Summary

February 16, 2018

Leading photo: Kim JE et al. World J Gastroenterol 2014; 20(35): 12687-12690

 

Summary of new 2017 C. diff guidelines from IDSA!!!

 

https://academic.oup.com/cid/advance-article/doi/10.1093/cid/cix1085/4855916

  • Testing

    • ONLY test patients with unexplained, new-onset ≥3 unformed stools in 24 hours (although still not well supported)

    • IF, and only if, there are no test eligibility criteria in place for patient stool submission, toxin testing should be part of diagnostics (with or without NAAT, before or after NAAT) (this is also not super well supported)

    • DO NOT repeat testing (regardless of positive or negative) within 7 days and DO NOT test asymptomatic patients except for epi purposes (these are very well supported)

      • What you can say to physicians

        • NAAT has suboptimal specificity: multiple repeat testing runs a high risk of false-positive

          • But sensitivity is exceptional: single tests have very high negative predictive value (typically >99%) for CDI

        • Diagnostic yield of repeat testing within 7 day period (with either toxin EIA or NAAT) is approximately 2%!!!

        • ALSO: repeat testing to establish cure has NO value since >60% of patients may remain C. difficile positive even after successful treatment

    • No reliable biomarkers yet to help diagnose CDI (lactoferrin, calprotectin)

    • Testing in kids: careful! Infants and toddlers can be colonized

      • <= 12 mon: should NOT test even if they have (simple) diarrhea

        • Besides high colonization rate in this age group (up to 40%), some even have detectable toxin production!

        • Could maybe test if apparent pseudomembranous colitis or toxic megacolon, or if other causes of  diarrhea are ruled out

      • 1-2yo: should NOT test routinely, unless other causes have been rule out

      • >= 2yo: test in cases with prolonged or worsening diarrhea and risk factors (IBD, IC) or recent exposure to healthcare or antibiotics

  • Infection prevention

    • CDI patients should have dedicated private rooms/restrooms, and prioritize patients with incontinence to get their own rooms

    • If need to cohort, group people with same co-infecting organisms (MRSA, VRE, etc)

    • MUST use contact precautions

      • Soap and water better than alcohol rub (not super well supported) before and after, especially if poop gets on your hands or after working in areas that are likely contaminated

      • Even patients should wash hands often to reduce spore burden

      • Use disposables or make sure things are disinfected

    • If test result not available the same day, should start CP in the meantime (this is pretty well supported)

    • May stop at 48 hrs after diarrhea resolves if CDI rates not high, but IF high despite IP measures then should continue until D/C

    • If during endemic outbreak or repeated infections in same room, should consider daily and/or terminal cleaning with sporicidal agents

      • Fancy machines don’t have evidence that shows they’re better

    • Asymptomatic carriers: no evidence to support screening or initiate CP

    • Stewardship: limit use of fluoroquinolones, clindamycin, and cephalosporins (pretty well supported)

  • Treatment (adults)

    • No rec for probiotics for prevention

    • Stop inciting drugs as soon as possible

    • If delay in results is expected, just start treating empirically

    • VAN or fidaxomicin PO (well-supported)

      • Metronidazole PO now second-line

    • Fulminant CDI (hypotension or shock, ileus, or megacolon)

      • VAN PO or PR plus metronidazole IV

      • Surgery: subtotal colectomy is best

    • Recurrent CDI

      • 1st recurrence: pulsed and tapered VAN or fidaxomycin

      • After 1st: pulsed and tapered VAN, VAN then rifaximin, or fidaxomycin

      • Failed Rx: fecal microbiota transplantation (good evidence!)

  • Treatment (peds)

    • VAN or metronidazole, but if severe or recurrent VAN is better

    • Failed Rx: fecal microbiota too (evidence not as strong as adults)

 

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