Clostridioides difficile
From IDWiki
Background
Microbiology
- Spore-forming, anaerobic, Gram-positive bacillus
Risk factors
- Antibiotic exposure, typically broad-spectrum antibiotics especially those with anaerobic coverage1
- Clindamycin
- Fluoroquinolones (especially with NAP1 strain)
- Cephalosporins
- Monobactams
- Carbapenems
- PPI use
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
- Profuse watery diarrhea
Severity
| Severity | Definition2 |
|---|---|
| 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) 3
- 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-line2 | 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
Further Reading
- AMMI treatment practice guidelines for Clostridium difficile infection 2018
- Clostridioides difficile: diagnosis and treatments. BMJ. 2019;366:l4609. doi: 10.1136/bmj.l46091
References
- ^ Kevin A. Brown, Nagham Khanafer, Nick Daneman, David N. Fisman. Meta-Analysis of Antibiotics and the Risk of Community-Associated Clostridium difficile Infection. Antimicrobial Agents and Chemotherapy. 2013;57(5):2326-2332. doi:10.1128/aac.02176-12.
- a b Vivian G Loo, Ian Davis, John Embil, Gerald A Evans, Susy Hota, Christine Lee, Todd C Lee, Yves Longtin, Thomas Louie, Paul Moayyedi, Susan Poutanen, Andrew E Simor, Theodore Steiner, Nisha Thampi, Louis Valiquette. Association of Medical Microbiology and Infectious Disease Canada treatment practice guidelines for Clostridium difficile infection. Official Journal of the Association of Medical Microbiology and Infectious Disease Canada. 2018;3(2):71-92. doi:10.3138/jammi.2018.02.13.
- ^ Clostridium difficile Infection in Infants and Children. Pediatrics. 2012;131(1):196-200. doi:10.1542/peds.2012-2992.
