Clostridium difficile infection (cdi)
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Clostridium difficile infection (cdi) Clostridium difficile infection (cdi) Presentation Transcript

  • WHEN ANTIBIOTICS DO MORE HARM THAN GOOD
    ID Conference
    Reinalyn Cartago MD
    Jerome Ramos MD
    April 29, 2010
  • To identify risk factors for acquiring Clostridium difficile infection (CDI)
    To explain diagnosis and management of CDI in adult patients
    To compare diagnosis and management of CDI in our institution with that of the current guidelines
    To identify methods of infection prevention and control as well as environmental management of the pathogen
    OBJECTIVES
  • I. E.
    71/M
    Misamis Occidental
    presently residing in Marikina City
    GENERAL DATA
  • DIARRHEA
    CHIEF COMPLAINT
  • No known co-morbids
    Alcoholic beverage drinker
    40 pack yr smoker
    Good Functional Capacity
    PROFILE
  • HISTORY OF PRESENT ILLNESS
    3 months PTA
    • (+) odynophagia/ dysphagia
    • Self-medicated with:
    • Clarithromycin (5 doses)
    • Clindamycin (5 doses)
    • Co-trimoxazole
    unrecalled
    dose and
    duration
    • Noted resolution of
    odynophagia
    • asymptomatic and
    well
  • 2 weeks PTA
    - consult and subsequent
    admission at a local
    hospital
    - management unrecalled
    - Holoabdominal Ultrasound
    and Abdominal CT
    - transferred to PGH
    3 weeks PTA
    - LBM – 10x/day
    - undocumented fever
    • diffuse abdominal pain relieved by
    bowel movement
    - increasing abdominal girth
    - occlvomiting
    • NO hematochezia/ melena; nor
    decrease in caliber of stool
    HISTORY OF PRESENT ILLNESS
  • Holoabdominal UTZ
    liver parenchymal disease; moderate ascites; UR GB, Pancreas, spleen, kindneys and urinary bladder
    Abdominal CT Scan
    minimal ascites; fecal stasis; adynamicileus; mild to mod bilateral pleural effusion; non-focal thickening on antero-lateral abd wall
  • (+) Generalized body malaise, anorexia, undocumented weight loss
    (+) dysphagia/ odynophagia
    (-) cough/ colds; no DOB
    (-) angina chest pain; no orthopnea; no PND; no easy fatigability
    (-) no urinary changes
    (-) edema
    REVIEW OF SYSTEMS
  • Not a known hypertensive, diabetic and asthmatic
    No known allergies
    1970’s – admitted for typhoid fever
    PAST MEDICAL HISTORY
  • No known heredo-familial diseases
    No history of Cancer
    No similar illness in the family
    FAMILY HISTORY
  • Alcoholic beverage drinker
    40 pack yr smoker
    Denies illicit drug use
    PERSONAL/SOCIAL HISTORY
  • COURSE IN THE WARDS
  • Awake, weak looking, not in distress
    110/70 79 18 afebrile
    AS, PC, (-) CLAD
    ECE, CBS
    AP, DHS, normal rate, irregular rhythm, no murmurs/thrills
    Globular, soft, nontender abdomen
    DRE: (+) redundant mucosa vs mass
    FEP, PNB, (+) grade 2 bipedal edema
    ASSESSMENT:
    Diarrhea probably secondary to
    overflow secondary to PGO
    r/o Colonic New Growth
    Amoebic Colitis
    T/C PGO
    T/C CLD
    R/O Typhoid Fever
    ADMISSION
    NPO
    Metronidazole 500mg IV q6
    Lansoprazole 30mg/tab, 1 tab SL
  • (07/23/08)
    WBC 21.10/ RBC 4.69/ HGb 143/ HCT 0.423/ Platelets 355/ neut 0.887/ lymph 0.043/ mono 0.064/ eos 0/ baso 0.006
    BUN 6.34 crea 123 alkphos 109 ast 60 alt 53 Na 133 K 4.9 Cl 101
    PT 12.1/ 17.6/ 0.48/ 1.70
    Fecalysis : Brown/ watery/mucoid/ 0-2 RBC/ 38-40 WBC; no ova or parasites; (+) occult blood
    LABS
  • D1 D2 D3 D4 D5 D6 D7 D8 D9
    (+) Loose watery stools – 4 episodes per day;
    Non-bloody
    Afebrile
    Started OF feeding
    Ciprofloxacin 200mg IV q12h
    Cleared for Colonoscopy
  • (07/24/08) DAY 1
    BUN 6.38 crea 101 Ca 1.79 Mg 0.83 K 4.7
    Anti HBc total – NR; Anti HCV – NR
    Salmonella IgG – R; IgM – NR
    Stool CS - No enteric pathogen isolated
    Holoab UTZ - N
    (07/25/08) DAY 2
    HgbA1c 6.5 Alb 18
    Urinalysis - Y/ Clear/ 1.020/ 6.0/ (-) sugar and protein/ (-) RBC and WBC/ (-) cast and crystals/ (-) EC
    LABS
  • D1 D2 D3 D4 D5 D6 D7 D8 D9
    DAY 4
    • Severe abdominal pain
    • NGT opened to drain
    • with relief of abdominal pain
    • 200cc residuals; minimal coffee ground
    • Omeprazole 40 mg IV q12
    • Rebamipide 100mg/tab, 1 tab TID
    DAY 5
    • 9 episodes of loose watery stools
    • EGD, Colonoscopy
    • Blood CS
  • LABS
    Blood CS x 1 (07/27/08) DAY 4
    Staphylococcus haemolyticus after 18.9 h of incubation
    S: Vancomycin
    Biopsy (07/28/10) DAY 5
    Duodenum – tubulovillous adenoma
    Acute on chronic colitis
    (07/28/08)
    WBC 7.57/ RBC 4.67/ HGb 138/ HCT 0.42/neut 0.760/ lymph 0.120/ mono 0.100/ eos 0.010/ baso 0.010
    Alb 17 Ca 1.76 Mg 0.90 Na 132 K 3.6
  • D1 D2 D3 D4 D5 D6 D7 D8 D9
    COLONOSCOPY
    Nodular mucosa with yellowish exudates from rectum to cecum, more severe on the left side
    CLINICAL IMPRESSION: Pseudomembranous Colitis; Internal Hemorrhoids
    DAY 5
    • Meds revised:
    • Start Vancomycin 500 mg IV
    q12h as continuous IV Infusion
    to run for 1 h
    • Metronidazole IV continued
    • Discontinued Ciprofloxacin
    • Esomeprazole 40mg/tab q12h
    EGD
    hiatal hernia; reflux esophagitis; gastroduodenitis; duodenal polyps
  • D1 D2 D3 D4 D5 D6 D7 D8….D17
    • 07/30/08
    crea 101 BUN 3.49 Na 143 K 3.0
    • 08/02/08
    crea 90 Mg 0.77 K 3.6
    • 08/03/08
    Alb 18 Ca 1.79 Na 139
    WBC 6.77/ HGb 117/ HCT 0.36/
    neut 0.630/ lymph 0.230/
    mono 0.100/ eos 0.030/ baso 0.010
    • 08/04/08
    Phos 0.81
    • Noted improvement on bowel movement
    • stools occurring once a day, formed
    • abdominal pain completely resolved
    • DAT well-tolerated
    DAY 10
    - Metronidazole IV shifted to 500mg/tab, 1 tab q6
    • Completed 10 days of Vancomycin IV
    - eventually discharged improved and well
  • SUMMARY OF COURSE
    HOSPITAL DAY
    Metronidazole 500mg IV q6h
    Metronidazole 500mg /tab , 1 tab q6h
    Ciprofloxacin
    200 mg IV q12h
    Vancomycin 500mg IV q12h
    BM x 9
    BM x 1
    Resolution of LBM
    LBM x 4
    WBC
    21.1
    WBC
    7.57
    WBC
    6.77
  • TAKE HOME MEDS:
    Esomeprazole 40 mg/tab, BID
    Rebamipide 100 mg/tab, TID x 2 wks
    Metronidazole 500 mg/tab, TID x 2
    more days
    Mebeverine tab, TID x 1 week
  • FINAL DIAGNOSIS
    PSEUDOMEMBRANOUS COLITIS
  • What are possible causes of chronic diarrhea in an elderly patient with questionable history of prolonged antibiotic use?
    ISSUES
  • For patients with CDI, is there a need to do toxin assay if colonoscopy already reveals pseudomembranes?
    Is it prudent to treat patients as CDI based on clinical grounds only?
    ISSUES
  • Is there a need to give both Metronidazole and Vancomycin in our patient?
    What is the appropriate route and duration of treatment of CDI
    ISSUES
  • DISCUSSION
  • 20% - 30% of antibiotic associated diarrhea
    Few surveillance data in US
    3.4 – 8.4 per 1,000 admissions in Canada
    Clinical Practice Guidelines for Clostridium difficileInfection in Adults: 2010 Update by the Society for Healthcare
    Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)
    EPIDEMIOLOGY
  • Atlanta GA--rates of Clostridium difficile infections (CDI) surpassed infection rates for methicillin-resistant Staphylococcus aureus (MRSA) in South East US Hospitals
    Becky Miller, MD, Duke Infection Control Outreach Network, Duke University, 2009.
    EPIDEMIOLOGY
  • “CDAD should probably not be the first consideration when a patient in the ICUs of UP-PGH (2004) develops Nosocomial Diarrhea”
    “…at least 2 specimens should be sent for C. difficile testing if the suspicion for CDAD is strong”
    Gutierrez MD., UP-PGH, 2004
    EPIDEMIOLOGY
  • Exposure to antimicrobial agents
    Clindamycin, Ampicillin, Cephalosporins, Fluoroquinolones
    Advanced Age
    Greater severity of underlying illness
    Duration of Hospitalization
    Gastric Surgery
    Use of rectal thermometers
    Enteral tube feeding
    Antacids, PPI
    RISK FACTORS
  • PATHOGENESIS
  • What are possible causes of chronic diarrhea in an elderly patient with questionable history of prolonged antibiotic use?
    ANSWERS TO ISSUES
  • For patients with CDI, is there a need to do toxin assay if colonoscopy already reveals pseudomembranes?
    Is it prudent to treat patients as CDI based on clinical grounds only?
    ANSWERS TO ISSUES
  • Is there a need to give both Metronidazole and Vancomycin in our patient?
    What is the appropriate route and duration of treatment of CDI
    ANSWERS TO ISSUES
  • THANK YOU!!!
  • 6% rate of resistance to metronidazoleamong 78 isolates of C. difficile
    Peláezet al.,38th ICAAC
    In 1997, high-level metronidazoleresistance demonstrated in C. difficile isolates obtained from horses
    S. S. Jang, et al. 35th Annual Meeting of Infectious Diseases Society of America 1997, Clin. Infect. Dis. 25(Suppl. 2):S266–S267, 1997]
    Highest rate of metronidazole resistance was observed in HIV-infected patients
    T. Peláez, L. Alcalá, R. Alonso,* M. Rodríguez-Créixems, J. M. García-Lechuz, and E. Bouza, ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, June 2002, p. 1647–1650
    METRONIDAZOLE RESISTANCE
  • “…clinical isolates of Clostridium difficile with resistance to metronidazole is 6.3%.”
    not due to the presence of nimgenes
    resistance to metronidazole in toxigenic C. difficile isolates is heterogeneous
    prolonged exposure to metronidazole can select for in vitro resistance
    routine performance of the disk diffusion method (5-microg metronidazole disk)
    J Clin Microbiol. 2008 Sep;46(9):3028-32. Epub 2008 Jul 23
    METRONIDAZOLE RESISTANCE
  • Oral rifaximin (Xifaxan®; Salix Pharmaceuticals, Inc, Morrisville, NC) 1200 mg/d for 14 days
    Gut-selective, non-systemic antibiotic
    METRONIDAZOLE RESISTANCE