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C Diff

This document provides guidelines for treating Clostridium difficile colitis in adults. It outlines testing protocols for diagnosing C. difficile and recommends specific antibiotic treatments based on factors like disease severity, number of recurrences, and presence of complications. For initial or mild cases, metronidazole is recommended, while vancomycin is preferred for severe cases, recurrences, or if complications are present. It also provides tapering schedules for long-term vancomycin treatment and notes the importance of consulting infectious disease specialists for complex or recurrent cases.

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129 views2 pages

C Diff

This document provides guidelines for treating Clostridium difficile colitis in adults. It outlines testing protocols for diagnosing C. difficile and recommends specific antibiotic treatments based on factors like disease severity, number of recurrences, and presence of complications. For initial or mild cases, metronidazole is recommended, while vancomycin is preferred for severe cases, recurrences, or if complications are present. It also provides tapering schedules for long-term vancomycin treatment and notes the importance of consulting infectious disease specialists for complex or recurrent cases.

Uploaded by

theseus5
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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GUIDELINES FOR TREATMENT OF CLOSTRIDIUM DIFFICILE COLITIS IN ADULTS

Clostridium difficile Assay Results Antigen Result1


Negative Positive Positive

EIA Toxin Result2


Negative Positive Negative

PCR Result3
Not necessary Not necessary Positive Negative Positive Negative

Interpretation
No C. difficile present. Toxigenic C. difficile present. Toxigenic C. difficile present. Non-toxigenic C. difficile present. Treatment not required. Toxigenic C. difficile present. No C. difficile present.

Negative
1. 2. 3.

Positive

The negative predictive value of this test for ruling-out C. difficile-associated diarrhea approaches 99% C. difficile toxin assay is not a test of cure, and may be positive for up to 30 days after treatment. Re-testing is not recommended PCR testing is automatically performed if the antigen and EIA toxin results are discordant

Treatment of Clostridium difficile colitis


For all patients: - Discontinue/change antibiotics if possible. - Avoid PPI/H2 blockers without an appropriate indication. - Implement infection control measures: http://www.med.umich.edu/i/policies/ice/ICM_dx/pdf/cdif.pdf

Clinical Setting
Mild - Moderate Disease (WBC 15,000 and SrCr < 1.5 times premorbid level)

Initial Episode1
Metronidazole 500mg PO tid x 10-14 days

First Recurrence1,2
Metronidazole 500mg PO tid x 10-14 days

Second Recurrence1,5,6
Vancomycin 125 mg PO qid x 1014 days then taper7 over 4-6 weeks. Consider Infectious Diseases consultation Vancomycin 125mg PO qid x 1014 days then taper7 over 4-6 weeks. Consider Infectious Diseases consultation Repeat primary therapy then taper7 vancomycin over 4-6 weeks. Surgical consultation Consider Infectious Diseases consultation

Severe Disease (WBC>15,000 or SrCr 1.5 times premorbid level)

Vancomycin 125mg PO qid x 10-14 days

Vancomycin 125mg PO qid x 10-14 days Consider Infectious Diseases consultation Repeat primary therapy

Severe Disease with Complications (Hypotension or shock, ileus, megacolon)

Metronidazole 500mg IV3,4 every 8 hours plus vancomycin 500mg PO qid If ileus, vancomycin by enema every 8 hrs4 Surgical consultation for possible colectomy

Surgical consultation Consider Infectious Diseases consultation

1. 2. 3. 4. 5. 6.

Failure is defined as no improvement or worsening symptoms after 48-96 hours of primary therapy. If no resolution after 14 days of treatment, look for alternative explanations diagnoses, continue C. difficile treatment doses until resolution, and consider infectious diseases consultation. C.difficile colitis recurrence is defined as relapse within 4 weeks of finishing primary therapy. Parenteral administration of metronidazole has poor intraluminal penetration. Parenteral vancomycin has no significant luminal accumulation and should not be used for C. difficile treatment. Intracolonic vancomycin 500 mg in 1,000 mL of normal saline every 8 hours given as retention enema using the following procedure: 18inch Foley catheter with a 30-ml balloon inserted into rectum, balloon inflated, vancomycin instilled, catheter clamped for 60 minutes, deflate and remove. Avoid multiple or prolonged courses of metronidazole in recurrent disease due to the risk for cumulative neurotoxicity. Alternative and/or adjunctive agents: a. Rifaximin, nitazoxanide, fidaxomicin (requires ID approval), IVIG (requires approval) and stool transplants (may be available at outside institutions) may be effective in specific patient populations. Consider infectious diseases consultation for appropriate alternative agents in a given patient. b. The role of probiotics in prevention and treatment of C. difficile colitis is unclear. Avoid the use of probiotics in immunocompromised patients (transplant recipients, unintact gut mucosa, neutropenic patients, HIV/AIDS patients, etc) and patients with severe C. difficile colitis. c. Cholestyramine binds PO vancomycin and may decrease its efficacy. Avoid concomitant use.

Patients on tapered doses of PO vancomycin should continue to be monitored for signs and symptoms of C. difficile disease. Tapers should begin after the treatment course is completed. Example of PO vancomycin taper: 125mg PO BID x 7 days, then 125mg PO daily x 7 days, then 125mg PO every other day x 7 days, and 125mg PO every 2-3 days x 2-8 weeks Last Updated: October 2011; Approved by: UMHS P & T Committee (November 2011) Reference: http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/cdiff2010a.pdf

7.

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