Natasha Press, MD, FRCPC (biography and disclosures)
What I did before
Clostridium difficile infection (CDI) can range from asymptomatic carriage, to mild or moderate diarrhea, to fulminant and sometimes fatal pseudomembranous colitis. Risk factors for CDI include antibiotic use, duration of hospitalization, and age >65. In the past few years, a hypervirulent strain of C. difficile, called NAP-1, has caused hospital outbreaks that have been unusually severe and recurrent.
What changed my practice
Clinical practice guidelines, published in 2010, by the Infectious Diseases Society of America, provide treatment recommendations for initial and recurrent episodes of C. difficile. The guidelines are available free online at www.idsociety.org. They help to clarify when to use oral vancomycin versus oral metronidazole, and how to treat recurrences, which occur in 20% of patients.
What I do now
The guidelines have changed my practice in 6 ways:
- In the hospital, when a patient has a high white blood count, I order a stool test for C. difficile. Most patients with CDI will have diarrhea, and may have abdominal discomfort or fever, but some patients will present with leucocytosis, which prompts me to consider CDI, in addition to other causes.
- If a patient has severe CDI, I prescribe oral vancomycin 125 mg po qid x 14 days. Severe CDI is defined as a WBC>15 or creatinine >1.5x above baseline. (“Severe” can also include older patients, particularly if they are febrile or have a low albumin). For patients with mild to moderate CDI (normal WBC and creatinine), I prescribe metronidazole 500 mg po tid x 14 days. When I see patients in my office, and I’m not sure if their CDI is severe or not, I will send them for bloodwork to determine their WBC and creatinine.
- If a patient has a recurrence of CDI after I’ve treated them, I again consider whether or not it’s severe. If it’s severe, I prescribe oral vancomycin just like I did for their initial episode. Sometimes patients who’ve initiated treatment for CDI in hospital, follow-up with their family doctor after discharge. Once the patient has completed treatment, no further investigations are required. However, if their diarrhea recurs, then they should be re-tested for C. difficile. Different labs do different types of testing for C. difficile, but all the tests detect the toxin-producing C. difficile, so you don’t have to specify which type of test you want. If patients have a second recurrence, they can receive a longer course of vancomycin as described in the guidelines. For the longer course, the vancomycin dose is tapered, then pulsed. At this point, family physicians may decide to refer the patient to a specialist (infectious diseases or gastroenterology).
- If a patient is very sick with CDI, and has hypotension or ileus or toxic megacolon, I ask for a surgical consult, and order a higher dose of oral vancomycin (500mg po qid) and add IV metronidazole 500 mg q8h. In very sick patients, colectomy may be necessary and can be life-saving.
- In terms of vancomycin, I only give it orally. I never give it IV because IV doesn’t work to treat CDI.
- Probiotics require further study, and are not recommended as standard-of-care. They may be considered as an adjunct to CDI treatment in patients with recurrent disease that is not severe, as long as there are no significant comorbidities.
One more thing for patients in British Columbia: Oral vancomycin is very expensive. Filling out a special authority form for Pharmacare allows eligible patients to qualify for coverage. These forms are available online at www.health.gov.bc.ca/exforms/pharmacare/5328fil.pdf.
Once the CDI treatment is completed, if the patient feels well, I do not re-test them for C. difficile, and I do not test their family members for asymptomatic carriage. The reason is that patients may continue to have C. difficile in their stool, but as long as it’s not causing them symptoms, treatment is not necessary.
To prevent recurrence of CDI, I tell patients to avoid antibiotics unless absolutely necessary. They should also avoid anti-secretory therapy (PPIs) if possible (see Dr. Ted Steiner’s post, thischangedmypractice.com/ppis-and-c-difficile-infection July 4, 2011).
Reference
Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Stuart H. Cohen, Dale N. Gerding, Studart Johnson et al. Infection Control and Hospital Epidemiology, Vol. 31, No. 5 (May 2010), pp. 431-455. http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/cdiff2010a.pdf
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Thank you, very concise and informative. Appreciate severity based on WCC and creatinine.
vanco vs metro depends on severity….good lesion
Good to review CDI guidelines
well written piece but disagree on two things:
you imply that you are ordering c. diff on patients with high white counts. do you mean even if they don’t have diarrhea. our lab won’t even analyze stool for c diff unless it is loose.
you don’t mention stool transplants. surely this is a safer and better approach than a total colectomy!
Is it cost effective to use vancomycin as the first line Rx ? Any evidence on this ?
Nice summary of management of this increasingly common infection. I do find that the WBC does seem to correlate with severity quite well.
is there a role for feacal transplant?
I have repeatedly been told by the lab at my hospital that there is no point in retesting for C Diff for at least three or four months after an infection, because the test remains positive regardless of current infective status. Retesting may on occasion convince you to look for another cause of the diarrhoea but my understanding is that it is utterly unreliable as confirmation of a recurrent infection..
The rest of the article made very good sense and was a useful overview.
Good, brief summary, useful for point of care treatment. Presentation style easy to read and assimilate
I agree and is my approach
Good summary. I am unsure if it will work out well in the community setting. How many family physicians will prescribe Vanco? Will surgeons accept emergent consults from community physicians without going through emergency physicians to screen severity?
Further to the astounding initial evidence about the prevention of recurrences of CDI with fecal transplant, it alarms me that so little has been studied in the direction of colon flora restoration with less risky means–eg. Probiotic enemas, for instance.
It is interesting to note the pathological transformation of CD from commensalism in the 1930’s to toxin producing scourge. Our study of the microbiota is sadly late on the scene, like documenting forest growth after a fire (antibiotic use). One wonders whether the Canadian Nobel discovery of bacteriophages will ever be of use as a specific therapy in infectious diseases.
Thanks for your comments. I’d like to clarify a few of the issues that were raised:
1. My article was written prior to the recent randomized control trial showing that fecal microbiota transplant outperformed 14 days of oral vancomycin [1]. Although it is recognized that stool transplant is valuable in treating recurrent CDI, it is still not available in many centers. Until it becomes more widely available, many health care providers will continue to rely on longer tapering courses of vancomycin.
2. The comment about labs not testing formed stool is correct. As well, the comment about not doing a test of cure (repeating the test after treating the patient) is also correct.
3. A elevated WBC in a hospitalized patient may be a clue that they have CDI. The differential for leukocytosis, however, has to be considered in the specific clinical context.
4. Sick patients should be sent to the ER. Patients with complicated CDI (hypotension, toxic megacolon, ileus), require hospitalization. If fluids and treatment aren’t helping, surgery is consulted.
5. The probiotics trials have been inconsistent with poor methodology, so it’s difficult to make recommendations based on them. However, there is currently a human microbiome project underway, which should shed some light on the role of “good” bacteria in human health and disease [2].
References:
1. Van Hood, E. et al. Duodenal Infusion of Donor Feces for Recurrent Clostridium difficile. N. Engl. J. Med. 2013;368:407-415.
2. http://commonfund.nih.gov/hmp/
nothing new here
I agree with many of the correspondents. The future seems to be hopeful for widespread stool transplants even if the practice smacks of a return to leeches!!
Very useful.
Interesting, however I only use Vancomycin as a second line treatment for CDI
Certainly interesting watching the evolution/revolution in treating c.diff and certainly the results are slowly getting much better.
Thankyou for concise and good information. What does clostridium disesease symtoms are?
I have found Flagyl does not work in most people.. stick to Vancomycin. If a person does not clear up on Vancomycin, immediately do a FMT
Thoughts on Dificid?