Clostridium difficile infection (cdi)

58,478 views
58,301 views

Published on

Published in: Health & Medicine
2 Comments
1 Like
Statistics
Notes
No Downloads
Views
Total views
58,478
On SlideShare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
92
Comments
2
Likes
1
Embeds 0
No embeds

No notes for slide

Clostridium difficile infection (cdi)

  1. 1. WHEN ANTIBIOTICS DO MORE HARM THAN GOOD<br />ID Conference<br />Reinalyn Cartago MD<br />Jerome Ramos MD<br />April 29, 2010<br />
  2. 2. To identify risk factors for acquiring Clostridium difficile infection (CDI)<br />To explain diagnosis and management of CDI in adult patients<br />To compare diagnosis and management of CDI in our institution with that of the current guidelines<br />To identify methods of infection prevention and control as well as environmental management of the pathogen<br />OBJECTIVES<br />
  3. 3. I. E.<br />71/M<br />Misamis Occidental<br />presently residing in Marikina City<br />GENERAL DATA<br />
  4. 4. DIARRHEA<br />CHIEF COMPLAINT<br />
  5. 5. No known co-morbids<br />Alcoholic beverage drinker<br />40 pack yr smoker<br />Good Functional Capacity<br />PROFILE<br />
  6. 6. HISTORY OF PRESENT ILLNESS<br />3 months PTA<br /><ul><li>(+) odynophagia/ dysphagia
  7. 7. Self-medicated with:
  8. 8. Clarithromycin (5 doses)
  9. 9. Clindamycin (5 doses)
  10. 10. Co-trimoxazole</li></ul> unrecalled <br /> dose and <br /> duration <br /><ul><li>Noted resolution of </li></ul>odynophagia<br /><ul><li> asymptomatic and </li></ul> well <br />
  11. 11. 2 weeks PTA<br />- consult and subsequent <br />admission at a local<br />hospital<br /> - management unrecalled<br />- Holoabdominal Ultrasound <br />and Abdominal CT <br /> - transferred to PGH<br />3 weeks PTA<br />- LBM – 10x/day<br />- undocumented fever<br /><ul><li> diffuse abdominal pain relieved by </li></ul> bowel movement<br />- increasing abdominal girth<br />- occlvomiting<br /><ul><li> NO hematochezia/ melena; nor </li></ul> decrease in caliber of stool<br />HISTORY OF PRESENT ILLNESS<br />
  12. 12. Holoabdominal UTZ<br />liver parenchymal disease; moderate ascites; UR GB, Pancreas, spleen, kindneys and urinary bladder<br />Abdominal CT Scan<br />minimal ascites; fecal stasis; adynamicileus; mild to mod bilateral pleural effusion; non-focal thickening on antero-lateral abd wall <br />
  13. 13. (+) Generalized body malaise, anorexia, undocumented weight loss<br />(+) dysphagia/ odynophagia<br />(-) cough/ colds; no DOB<br />(-) angina chest pain; no orthopnea; no PND; no easy fatigability<br />(-) no urinary changes<br />(-) edema<br />REVIEW OF SYSTEMS<br />
  14. 14. Not a known hypertensive, diabetic and asthmatic<br />No known allergies<br />1970’s – admitted for typhoid fever<br />PAST MEDICAL HISTORY<br />
  15. 15. No known heredo-familial diseases<br />No history of Cancer<br />No similar illness in the family<br />FAMILY HISTORY<br />
  16. 16. Alcoholic beverage drinker<br />40 pack yr smoker<br />Denies illicit drug use<br />PERSONAL/SOCIAL HISTORY<br />
  17. 17. COURSE IN THE WARDS<br />
  18. 18. Awake, weak looking, not in distress<br />110/70 79 18 afebrile<br />AS, PC, (-) CLAD<br />ECE, CBS<br />AP, DHS, normal rate, irregular rhythm, no murmurs/thrills<br />Globular, soft, nontender abdomen<br />DRE: (+) redundant mucosa vs mass<br />FEP, PNB, (+) grade 2 bipedal edema<br />ASSESSMENT:<br />Diarrhea probably secondary to <br />overflow secondary to PGO<br />r/o Colonic New Growth<br />Amoebic Colitis<br />T/C PGO<br />T/C CLD<br />R/O Typhoid Fever <br />ADMISSION<br />NPO <br />Metronidazole 500mg IV q6 <br />Lansoprazole 30mg/tab, 1 tab SL<br />
  19. 19. (07/23/08) <br />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<br />BUN 6.34 crea 123 alkphos 109 ast 60 alt 53 Na 133 K 4.9 Cl 101<br />PT 12.1/ 17.6/ 0.48/ 1.70<br />Fecalysis : Brown/ watery/mucoid/ 0-2 RBC/ 38-40 WBC; no ova or parasites; (+) occult blood<br />LABS<br />
  20. 20. D1 D2 D3 D4 D5 D6 D7 D8 D9<br />(+) Loose watery stools – 4 episodes per day; <br />Non-bloody<br />Afebrile<br />Started OF feeding<br />Ciprofloxacin 200mg IV q12h<br />Cleared for Colonoscopy<br />
  21. 21. (07/24/08) DAY 1<br />BUN 6.38 crea 101 Ca 1.79 Mg 0.83 K 4.7<br />Anti HBc total – NR; Anti HCV – NR<br />Salmonella IgG – R; IgM – NR<br />Stool CS - No enteric pathogen isolated<br />Holoab UTZ - N<br />(07/25/08) DAY 2<br />HgbA1c 6.5 Alb 18<br />Urinalysis - Y/ Clear/ 1.020/ 6.0/ (-) sugar and protein/ (-) RBC and WBC/ (-) cast and crystals/ (-) EC<br />LABS<br />
  22. 22. D1 D2 D3 D4 D5 D6 D7 D8 D9<br />DAY 4<br /><ul><li> Severe abdominal pain
  23. 23. NGT opened to drain
  24. 24. with relief of abdominal pain
  25. 25. 200cc residuals; minimal coffee ground
  26. 26. Omeprazole 40 mg IV q12
  27. 27. Rebamipide 100mg/tab, 1 tab TID</li></ul>DAY 5<br /><ul><li> 9 episodes of loose watery stools
  28. 28. EGD, Colonoscopy
  29. 29. Blood CS</li></li></ul><li>LABS<br />Blood CS x 1 (07/27/08) DAY 4<br />Staphylococcus haemolyticus after 18.9 h of incubation<br />S: Vancomycin<br />Biopsy (07/28/10) DAY 5<br />Duodenum – tubulovillous adenoma<br />Acute on chronic colitis<br />(07/28/08) <br />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<br />Alb 17 Ca 1.76 Mg 0.90 Na 132 K 3.6<br />
  30. 30. D1 D2 D3 D4 D5 D6 D7 D8 D9<br />COLONOSCOPY<br />Nodular mucosa with yellowish exudates from rectum to cecum, more severe on the left side<br />CLINICAL IMPRESSION: Pseudomembranous Colitis; Internal Hemorrhoids<br />DAY 5<br /><ul><li>Meds revised:
  31. 31. Start Vancomycin 500 mg IV </li></ul> q12h as continuous IV Infusion <br /> to run for 1 h<br /><ul><li>Metronidazole IV continued
  32. 32. Discontinued Ciprofloxacin
  33. 33. Esomeprazole 40mg/tab q12h</li></ul>EGD <br />hiatal hernia; reflux esophagitis; gastroduodenitis; duodenal polyps<br />
  34. 34.
  35. 35. D1 D2 D3 D4 D5 D6 D7 D8….D17<br /><ul><li>07/30/08</li></ul>crea 101 BUN 3.49 Na 143 K 3.0<br /><ul><li>08/02/08 </li></ul>crea 90 Mg 0.77 K 3.6<br /><ul><li> 08/03/08</li></ul> Alb 18 Ca 1.79 Na 139<br />WBC 6.77/ HGb 117/ HCT 0.36/<br />neut 0.630/ lymph 0.230/ <br /> mono 0.100/ eos 0.030/ baso 0.010<br /><ul><li>08/04/08 </li></ul>Phos 0.81<br /><ul><li>Noted improvement on bowel movement
  36. 36. stools occurring once a day, formed
  37. 37. abdominal pain completely resolved
  38. 38. DAT well-tolerated</li></ul>DAY 10<br />- Metronidazole IV shifted to 500mg/tab, 1 tab q6<br /><ul><li>Completed 10 days of Vancomycin IV </li></ul>- eventually discharged improved and well<br />
  39. 39. SUMMARY OF COURSE<br />HOSPITAL DAY<br />Metronidazole 500mg IV q6h<br />Metronidazole 500mg /tab , 1 tab q6h<br />Ciprofloxacin<br />200 mg IV q12h<br />Vancomycin 500mg IV q12h<br />BM x 9<br />BM x 1<br />Resolution of LBM<br />LBM x 4<br />WBC<br />21.1<br />WBC<br />7.57<br />WBC<br />6.77<br />
  40. 40. TAKE HOME MEDS:<br />Esomeprazole 40 mg/tab, BID<br />Rebamipide 100 mg/tab, TID x 2 wks<br />Metronidazole 500 mg/tab, TID x 2 <br /> more days<br />Mebeverine tab, TID x 1 week<br />
  41. 41. FINAL DIAGNOSIS<br />PSEUDOMEMBRANOUS COLITIS<br />
  42. 42. What are possible causes of chronic diarrhea in an elderly patient with questionable history of prolonged antibiotic use?<br />ISSUES<br />
  43. 43. For patients with CDI, is there a need to do toxin assay if colonoscopy already reveals pseudomembranes?<br />Is it prudent to treat patients as CDI based on clinical grounds only?<br />ISSUES<br />
  44. 44. Is there a need to give both Metronidazole and Vancomycin in our patient?<br /> What is the appropriate route and duration of treatment of CDI<br />ISSUES<br />
  45. 45. DISCUSSION<br />
  46. 46. 20% - 30% of antibiotic associated diarrhea<br />Few surveillance data in US<br />3.4 – 8.4 per 1,000 admissions in Canada<br />Clinical Practice Guidelines for Clostridium difficileInfection in Adults: 2010 Update by the Society for Healthcare<br />Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)<br />EPIDEMIOLOGY<br />
  47. 47. Atlanta GA--rates of Clostridium difficile infections (CDI) surpassed infection rates for methicillin-resistant Staphylococcus aureus (MRSA) in South East US Hospitals<br />Becky Miller, MD, Duke Infection Control Outreach Network, Duke University, 2009.<br />EPIDEMIOLOGY<br />
  48. 48. “CDAD should probably not be the first consideration when a patient in the ICUs of UP-PGH (2004) develops Nosocomial Diarrhea”<br />“…at least 2 specimens should be sent for C. difficile testing if the suspicion for CDAD is strong”<br />Gutierrez MD., UP-PGH, 2004<br />EPIDEMIOLOGY<br />
  49. 49. Exposure to antimicrobial agents<br />Clindamycin, Ampicillin, Cephalosporins, Fluoroquinolones<br />Advanced Age<br />Greater severity of underlying illness <br />Duration of Hospitalization<br />Gastric Surgery<br />Use of rectal thermometers<br />Enteral tube feeding<br />Antacids, PPI<br />RISK FACTORS<br />
  50. 50. PATHOGENESIS<br />
  51. 51. What are possible causes of chronic diarrhea in an elderly patient with questionable history of prolonged antibiotic use?<br />ANSWERS TO ISSUES<br />
  52. 52. For patients with CDI, is there a need to do toxin assay if colonoscopy already reveals pseudomembranes?<br />Is it prudent to treat patients as CDI based on clinical grounds only?<br />ANSWERS TO ISSUES<br />
  53. 53. Is there a need to give both Metronidazole and Vancomycin in our patient?<br /> What is the appropriate route and duration of treatment of CDI<br />ANSWERS TO ISSUES<br />
  54. 54. THANK YOU!!!<br />
  55. 55. 6% rate of resistance to metronidazoleamong 78 isolates of C. difficile<br />Peláezet al.,38th ICAAC<br />In 1997, high-level metronidazoleresistance demonstrated in C. difficile isolates obtained from horses<br />S. S. Jang, et al. 35th Annual Meeting of Infectious Diseases Society of America 1997, Clin. Infect. Dis. 25(Suppl. 2):S266–S267, 1997]<br />Highest rate of metronidazole resistance was observed in HIV-infected patients<br />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<br />METRONIDAZOLE RESISTANCE<br />
  56. 56. “…clinical isolates of Clostridium difficile with resistance to metronidazole is 6.3%.”<br />not due to the presence of nimgenes<br />resistance to metronidazole in toxigenic C. difficile isolates is heterogeneous<br />prolonged exposure to metronidazole can select for in vitro resistance<br />routine performance of the disk diffusion method (5-microg metronidazole disk)<br />J Clin Microbiol. 2008 Sep;46(9):3028-32. Epub 2008 Jul 23<br />METRONIDAZOLE RESISTANCE<br />
  57. 57. Oral rifaximin (Xifaxan®; Salix Pharmaceuticals, Inc, Morrisville, NC) 1200 mg/d for 14 days <br />Gut-selective, non-systemic antibiotic<br />METRONIDAZOLE RESISTANCE<br />

×