spindle difficult

3. HTN
AF
CCF
Osteoporosis
Gout
Depression
Dementia TIA
Iron
deficiency
anemia

4. Recent Hospitalizations
 1/2014 : Pneumonia
 Augmentin
 Chlarithromycin
 24/ 3//2014: Pneumonia
 Rocephine & Doxycyciine
 Moxifloxacin
 10/4/2014 : Gastroenteritis
 Ceftriaxone
 Augmentin

5. Course in the Wards
 Gastroenteritis with Dehydration
 IV fluids
 IV Rocephine shifted to Augmentin
 AKI and Hypernatremia
 Deconditioning

6. Course in the Wards
 Gastroenteritis likely antibiotic related
 Cd toxin not detected
 Antibiotics discontinued
 Diarrhea resolved
 Delirium likely stroke disease
 Poor Oral intake
 Depression – fluoxetine, mirtazipine
 Worsening Dementia
 NGT was inserted

7. Course in the Wards
 Refeeding syndrome
 Low magnesium (0.57 )
 Low phosphate (0. 38)
 Low potassium ( 3.3)
 Pneumonia
 Iv tazocin

8. Course in the Wards
 Recurrence of diarrhea
 CD toxin : Negative
 CD PCR : Positive
 Metronidazole 500 mg per NGT 6 hourly
 Vancomycin 250mg per NGT q6hourly

10. Epidemiology

13. Clostridium Difficile
 Anerobic gram positive
spore forming, toxin
producing bacillus
 Exists in spores and
vegetative forms
 causative pathogen for
antibiotic associated
diarrhea and colitis
NAP1/B1/027 –
virulent strain

14. 

16. Clostridium difficile
Pathonegesis
FROM THE FOLLOWING ARTICLE:
Clostridium difficile infection: new developments in epidemiology and pathogenesis
Maja Rupnik, Mark H. Wilcox & Dale N. Gerding
Nature Reviews Microbiology 7, 526-536 (July 2009)

17. Risk factors
Antibiotics
Hospitalization
Advanced age
Severe illness
Gastric acid suppression
Enteral feeding
Gastroentrointestinal conditions & procedures
Obesity
Cancer chemotheray
Hematopoetic transplantation
Antidepressant

18. Antimicrobial agents that may
induce Clostridium difficile
diarrhea and colitis
Frequently
associated
Occasionally
associated
Rarely
associated
Fluoquinolones Macrolides Aminoglycosides
Clindamycin Trimethoprim Tetracyclines
Penicillins sulfonamides Chloramphenicol
Cephalosphorins Metonidazole
Vancomycin

19. Clinical Manifestations and
Diagnosis
Carrier
state
Diarrhea
and colitis
Pseudomem
branous
colitis
Recurrent
disease :
relapse vs
reinfection
Fulminant
colitis

20. Clinical Manifestations
 96% of patients with symptoms had
received antimicrobials with 14 days
before the onset of diarrhea
 Symptoms begin soon after colonization
( median time onset 2-3 days )
 Fever, cramping, abdominal discomfort
and peripheral leukocytosis are common
 Arthritis, bacteremia
 Unexplained Leukocytosis

21. Diagnosis
Presence of moderate to severe diarrhea or
ileus
And either
A stool positive for C. Difficile toxins or
toxigeneic c. Dificile
Endoscopic or histologic findings of
pseudomembranous colitis

22. Diagnostics Tests
Only stools from patient with diarrhea should be tested for
CD
• ( strong recommendation, High Quality evidence )
NAAT ( PCR are superior to toxins A & B EIA testing as a
standard diagnostic test for CDI
• (strong recommedation, moderate quality evidence )
Glutamate Dehydrogenase can be used in 2 to 3 step
screening algorithms with subsequent toxin A and B EIA
testing, but the sensitivity of such is lower than NAATS
• ( strong recommendation, moderate quality evidence )
Guidelines for diagnosis, treatment, and Prevention of clostridium difficle infections
American College of Gastroenterology
Published online 26 feb 2013
2010 UPDATE BY Society for Healthcare Epidemiology of America and infectious
diseases Society of America

23. Diagnostic testing
Repeat testing should be discourage
• Strong recommendation, moderate quality evidence
Testing for cure should not be done
• ( strong recommendation, moderate quality evidence )
Stool culture is most sensitive and essential in
epidemiologic studies
• ( good evidence to support recommendation)
Guidelines for diagnosis, treatment, and Prevention of clostridium difficle infections
American College of Gastroenterology
Published online 26 feb 2013
2010 UPDATE BY Society for Healthcare Epidemiology of America and infectious diseases Society of America

24. Other Methodologies
Sigmoidoscopy or colonoscopy
• Detects pseudomembranous colitis in 51-55% of
CDI cases
Histopathology
Abdominal CT SCAN – facilitate diagnosis,
but not sensitive nor specific
Guidelines for diagnosis, treatment, and Prevention of clostridium difficle infections
American College of Gastroenterology
Published online 26 feb 2013
2010 UPDATE BY Society for Healthcare Epidemiology of America and infectious diseases Society of America

28. CDI Severity Scoring System
Severity criteria
Mild to moderate Diarrhea + s/s not meeting severe or
complicated criteria
Severe Disease <3g/dl + 1 of the ff:
WBC >15,000 cells/mm3, abdominal
tenderness
Severe and
Complicated disease
Any of the following attributable to CDI
Admission to ICU
Hypotension +/- vasopressors
Fever >38.5 C
Ileus or significant abdominal distention
Mental status changes
WBC >35,0000or <2,000
Recurrent CDI Recurrent within 8 weeks of completion of
therapy

29. Factors to Consider Before
Treating
AGE
Peak
White cell
count
Peak
serum
creatinine

30. Treatment
• Metronidazole 500mg TDS or 250mg QDS for 10-14
days THEN
• Vancomycin 125mg orally QDS 10-14 days. If no
response
Mild
disease
• Vancomycin500mg 4x/day + metronidazole 500mg every
8 hours IV
• If complete ileus : add rectal vancomycin
Severe
disease
• If symptoms is mild, conservative management may be
appropriate
• If antibiotics are needed, repeat treatment as in initial
episode
• Alternative : Fidaxomicin 200mg BD x 10 days
First
Relapse
UPTODATE

31. Treatment
• Tapering and pulsed vancomycin
with or without probiotics
• 125mg QDS for 7-14 days
• 125 BD x 7 days
• 125 once x 7 days
• 125mg orally every other day for 7
days
• 125mg orally every 3 days x 14 days
• Alternative : Fidaxomicin 200mg
orally BD x 10days
Second
Relapse
UPTODATE

32. Treatment
• Fidaxomicin 200mg
Orally BD x 10 days
• Alternative :
vancomycin 125mg
QDS x 14 days
followed by rifiximim
400mg BD x 14 days
Subsequent
relapse

33. Fidaxomicin
 Macrolide, bactericidal
 Narrower antimicrobial spectrum than
Metronidazole & Vancomycin
 3RCT : in non severe C. Difficile , clinical
cure rates with vacomycin were similar
 Recurrence is less often among patients
with non NAP1 strain ( 10 vs 28 % )
UPTODATE

34. Probiotics
 May be effective for prevention and
treatment
 Alteration of intestinal flora
 Antimicrobrial activity
 Intestinal barrier protection
 immunomodulation
 Administration consist only of regimens
with demonstrated efficacy
 Dosage of >10 billion CFU per day
 A cocrane review: insufficient evidence to
recommend as adjunct in treatment
UPTODATE

35. RICE WATER
Rice water and diarrhoea
The advantage of using rice water is that rice is cooked
daily in South East Asia.
WHO photograph by Dr Gramiccia In South East Asia, rice is
prepared in two ways - to produce either dry, cooked rice or,
with extra water, rice porridge. This leaves a fluid (rice water)
on top of the cooked rice grains.
Professor Wong Hock Boon, a paediatrician working in
Singapore, has been using rice water to rehydrate babies for
several years. If the babies are bottle-fed rice water is given
exclusively for the first 24 hours of treatment - breastfeeding
can continue as normal (1).
Professor Wong and his colleagues have found that many
babies who have not responded to other rehydration solutions
respond well to rice water. If diarrhoea starts again with the
re-introduction of milk, extra rice water is given with additional
rice porridge. Older babies are sometimes given rice porridge
alone.

36. Treatment
 Antimotility Agents and Opoids
 Associated with increase risk of toxic
megacolon
 IVIG
 No effective immunotherapy is currently
available
 Does not have a role as sole therapy for
RCDI
 May be helpful in patient with
hypogammaglobulimenia

37. Colectomy
 Consider in severely ill patients
 Monitoring serum lactate and White cell
may be helpful in prompting a decision
to operate

39. Fecal Microbiota
Transplantation
 Patient selection
 Severe and Recurrent C. Difficile infection
 Cure rates 81-94% in patients with
recurrent disease
 Response within 24h to 12 days
 Only method capable of providing
durable implantation of probiotics
 Route of administration :
 Colonoscopy, nasogastric, enema

40. Infection Control, & Prevention
 A hospital – based infection contol program
can help decrease the incidence of CDI
 Routine screening for C. Difficile in
hospitalized patients without diarrhea is not
recommended and asymptomatic carriers
should not be treated
 Antibiotic stewardship is recommended to
reduce the risk of CDI

41. Infection Control and
Prevention
 Gloves and gowns upon entry to a room
 Emphasize compliance with practice of
hand hygiene
 Hand wash with soap and water after
caring for or contacting patient with CDI
 Accommodate patients with CDI in
private room with contact precaution

42. Environmental Cleaning and
Disinfection
 Identification and removal of environmental
sources of C. Dificille including
 replacement of electronic rectal thermometers
with disposable, can reduce the incidence of CDI
 Use chlorine-containing cleaning agents or
other sporicidal agents
 to address environmental contamination in area
 associated with increased rates CDI

43. Prognosis
 Mild disease, may recover without
specific therapy
 Debilitating and can last for several
weeks
 20-27% treated for first episode ,
relapse after successful completing the
antibiotics , 3days -3week after
treatment
 65%- relapse rate with patient with 2 or
more relapses

44. Prognosis
 Adverse outcomes
 Treatment failure
 Severe or complicated infection
 Sepsis
 Need for admission to ICU
 Need for colectomy
 Increase length of hospital stay
 Need for hospitalization for community acquired
CDI
 Mortality 4.2-6.9%

48. Sources
 UPTODATE
 American College of Gastroenterology
 2010 Update by Society for Healthcare
Epidemiology of America (SHEA ) and the
Infectious Diseases Society of America
 Center for Infectious Disease
 CGH Guidelines
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2224300/figure/f1/
 https://www.nuh.nhs.uk/media/1069241/new_cdiff_testing_and_reporting.pd
f

49. Proposed algorithm for detection of C. difficile in fecal specimens submitted for C. difficile testing. Tests used are C.DIFF
CHEK-60 for C. difficile specific antigen (glutamate dehydrogenase) and TOX A/B QUIK CHEK for toxin A/B (both
TechLab/Wampole). The percentage values refer to the total numbers of stool specimens analyzed (n = 1,468). Results for
nine specimens (0.6%) which did not fit into the described categories are not included. J Clin Microbiol. Jan 2008; 46(1):
328–330

51. Differential Diagnosis
 Osmotic diarrhea

 Antibiotics alter colonic microflora
 Impaired carbohydrate fermentation
 Increased osmotic concentration in
colonic lumen

52. Prevention strategies
 Early detection and isolation
 Rapid implementation of contact precautions
 Vigilant screening for new onset diarrhea in
patients at risk and rapid and accurate
testing
 Contact precaution

53. Prevention and strategies
 Hand Hygiene
 Healthcare personel should hand wash
hands with soap and water
 Alcohol based hand rub does NOT eradicate
C. Difficile spores
 Adherance to gloves is also important

55. Figure 1 Treatment algorithm for recurrent Clostridium difficile infection
Permission obtained from Nature Publishing Group ©
Surawicz, C. M. Nat. Clin. Pract. Gastroenterol. Hepatol. 1, 32–38 (2004)
Surawicz, C. M. & Alexander, J. (2011) Treatment of refractory and recurrent Clostridium difficile infection
Nat. Rev. Gastroenterol. Hepatol. doi:10.1038/nrgastro.2011.59

56. Factors contributing to the development of Clostridium difficile colonization and
diarrhea [adapted, with permission, from Johnson S, Gerding DN. Clostridium difficile-associated
diarrhea. Clin Infect Dis 1998;26:1027-36, published by the University of Chicago Press, Infectious
Diseases Society of America; 1998]. Photo: Lianne Friesen and Nicholas Woolridge

57. How C. Difficile Spreads
L.S.W . 96/female, went to doctor, diagnosed with Pneumonia, given antibiotics that put
her at risk of developing antibiotic related diarrhea
1 ½ month later : admitted to Pneumonia, given another course of antibiotics. A health
care worker forgetting to wash hands /wear gloves after attending to a C. D. Infected
patient next to her bed, infecting patient
At Rehab facility – with no strict contact precaution. L.S.W. developed diarrhea, CD toxin
was not tested at that time. health care worker attends to her, infects another patient
Few days later, persistence of diarrhea, retested for CD, which turns out to be positive.
Was given proper antiobitiotics, with resolution of diarrhea

58. Recurrent Disease
 Complete abatement of CDI symptoms
while on appropriate treatment
 Followed by subsequent reappearance
of diarrhea and other symptoms after
treatment has been stopped
 Risks factors : > 65 years old, severe
underlying medical condition, need
forongoing therapy with concomitant
antiobiotics during treatment with CDI
 Pathophysiology :not fully understood

59. FIGURE 1 | Treatment algorithm for recurrent Clostridium
difficile infection
 FROM THE FOLLOWING ARTICLE:
 Treatment of refractory and recurrent Clostridium difficile infection
 Christina M. Surawicz & Jacob Alexander
 Nature Reviews Gastroenterology & Hepatology 8, 330-339 (June 2011)