Clostridioides difficile

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Clostridioides difficile / (Redirected from Clostridium difficile)

Background

Microbiology

  • Spore-forming, anaerobic, Gram-positive bacillus

Risk factors

Pathophysiology

  • Two toxins
    • Toxin A (enterotoxin) causes intestinal secretion and mucosal damage
    • Toxin B (cytotoxin) is a virulence factor
  • Virulence depends on strain (e.g. NAP1 quite virulent with high risk of severe disease and relapse)
  • Spores can persist in GI tract up to 2 to 8 weeks despite treatment

Clinical Manifestations

Severity

Severity Definitionloo2018as
Mild WBC ≤15 AND creatinine ≤1.5 x baseline
Severe, uncomplicated WBC >15 OR creatinine >1.5 x baseline OR hypoalbuminemia
Severe, complicated Hypotension OR shock OR ileus OR megacolon

Children

  • Asymptomatic carriage is common in infants (37% at 1 month, decreasing to adult levels of 3-5% by 3 years) pediatrics2012cl
    • Thought to be related to a lack of the binding target of C. difficile toxin
  • Clinical disease is rare before 12 to 24 months of age

Management

Severity First-lineloo2018as Alternatives
Initial episode
Mild to moderate Vancomycin 125 mg po QID for 10-14 days Fidaxomicin 200 mg po BID for 10 days
Metronidazole 500 mg po TID for 10-14 days
Severe, uncomplicated Vancomycin 125 mg po QID for 10-14 days
Fidaxomicin 200 mg po BID for 10 days
Severe, complicated Vancomycin 125-500 mg po QID for 10-14 days plus metronidazole 500 mg IV q8h Fidaxomicin 200 mg po BID for 10 days plus metronidazole 500 mg IV q8h
Consider rectal vancomycin if ileus
Recurrent episode
First recurrence, mild to moderate Vancomycin 125 mg po QID for 14 days Fidaxomicin 200 mg po BID for 10 days
First recurrence, severe, uncomplicated Vancomycin 125 mg po QID for 14 days
Fidaxomicin 200 mg po BID for 10 days
Second or subsequent recurrence Vancomycin as prolonged tapered or pulsed regimen Consider fecal microbiota tranplantation after vancomycin
  • For rectal vancomycin, add 500 mg to 100 mL normal saline and give as retention enema every 6 hours
  • A sample vancomycin taper: 125 mg po QID for 14 days, then 125 mg po TID for 7 days, then 125 mg po BID for 7 days, then 125 mg po daily for 7 days, then 125 mg po q2-3d for 2 to 8 weeks

High Dose Vancomycin

  • No clear data supporting high-dose vancomycin, even in severe CDADbader2020re

Prevention

Probiotics

  • Insufficient evidence to recommend for or against

Primary Prophylaxis

  • Prophylaxis with oral vancomycin 125 mg PO daily continued until 5 days after end of systemic antimicrobials may be beneficial in preventing CDAD in high-risk patientsjohnson2019ef
    • Included patients with age≥70 years or who were hospitalized in the past 90 days

Secondary Prophylaxis

  • Oral vancomycin is occasionally used as secondary prophylaxis after a recent (within 3 to 12 months) episode of CDAD
  • Per the IDSA guidelines, there is insufficient evidence to recommend for or against

Further Reading