Podcast #167 - 10 Things to Remember with C. difficile Infections

Back by popular demand we have enough podcast to cover 10 important pearls about a particular topic and this one comes from a recently published BMJ article covering Clostridioides difficile (formerly known as Clostridium difficile).

You can find the full #FOAMed (Free and Open Access Medical Education) clinical review article here at the BMJ's website titled "Clostridioides difficile: diagnosis and treatments" and with the lead author of Benoit Guery.

1.  Fulminant life-threatening colitis is rare but serious.

• Shock, ileus, and megacolon occur in less than 5% of all cases.
• Mortality rate is 35-50% in this group though. 

2.  Keep recurrence in the differential.

• Recurrence in the first two months occurs in 15-25% of patients after the first episode.
• An episode of recurrence increases the likelihood of subsequent recurrence.

3.  Asymptomatic colonization does exist.

• This is present in 4-15% of healthy adults.
• It is detected by shedding of the spores.
• Colonization can either be transient or persistent.

4.  Consider the possibility of community-acquired infection.

• More than 25%    of cases are community-acquired.
• This can affect atypical patients such as those that are younger or do not have recent antibiotic use.
• The numbers may be under recognized due to lack of screening.

5.  When to test:

• Patients with diarrhea in a healthcare setting.
• Negative results for usual GI pathogens.
• Inflammatory colitis and enteral nutrition has been ruled out.

6.  Do NOT test:

• Laxatives in the past 48 hours.
• No diarrhea (defined 3 or more unformed stools in 24 hours)
• Diarrhea has also been defined as 3 or more unformed stools for at least two consecutive days.
• Patients less than a year   old (often associated with asymptomatic colonization).

7.  Only test unformed stools.

• Defined as stools taking the shape of the container or Bristol stool types 5 to 7.
• Avoids positive result of someone asymptomatically colonized.

8.  Do NOT perform test of cure after treatment.

• Spores/toxins are detectable in 7% of patients post treatment.
• Up to 56% have a positive stool culture 1-4 weeks post-treatment despite symptom resolution.

9.  Treat with vancomycin or fidaxomicin in mild and severe disease.

• Metronidazole has lower efficacy and isno longer recommended.
• If severe infection consider tigercycline as adjunct to vancomycin.

10.  If recurrent disease off fecal transplantation.

• Evidence has demonstrated great efficacy.
• Methods of performing this procedure varies.

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