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ID exam 5 A
C. Diff
| Term | Definition |
|---|---|
| Tell me about C. Diff (Clostridoides difficile) | Anaerobe, Gram (+) bacilli, Spore forming, Toxin producing |
| What are the main 4 C. Diff infection (CDI) risk factors that Beck told us to remember? | Exposure to organism, Advanced Age (>65 yo), Hospitalization or long term care facility, Exposure to abx |
| Other CDI risk factors include: | Exposure to chemotherapy, GI surgery or manipulation of GI tract, Inflammatory bowel disease, Immunosuppression, Use of a proton pump inhibitor/H2 blockers |
| Whatare the "very common" abx associated with CDI? | Clindamycin; FQs; Cephalosporins (3rd and 4th gen); Ampicillin; Amoxicillin; Carbapenems |
| What are the "Somewhat common" abx associated with CDI? | PCNs, TMP-SMX, Macrolides |
| What are the "Uncommon" abx associated with CDI? | Aminoglycosides, Metronidazole, Rifampin, TCNs, Daptomycin |
| What are some s/sx of CDI? | Diarrhea âď¸, Fever, Loss of appetite, Nausea, Abdominal pain/ tenderness |
| Range of Disease: A pt that is considered a "Asymptomatic Carrier"--> | won't experience symptoms; could expose someone who is high risk; Can still test positive for C. Diff or its toxins |
| Range of Disease: A person with "mild-severe"--> | seen in majority of pts with CDI; Electrolyte imbalance (K+, Mg+, Na+, etc); Dehydration; Acute Kidney Injury |
| What is the most serious form of CDI? | Fulminant Colitis |
| Range of Disease: Tell me about Fulminant Colitis--> | Inflammation of the colon; Hypotension or shock; Ileus; MEGACOLON (diameter of the colon gets huge) |
| What does "Ileus" mean (BECK): | GI tract not functioning |
| Diagnosis/Assessment of CDI includes: | 1. Unexplained and new onset of > or = 3 unformed stools in 24h 2. Abdominal cramping, nausea/vomiting |
| When Beck states "Unexplained and new onset of > or = 3 unformed stools in 24h" she's referring to no comorbidities that can cause: | 1. diarrhea; i.e. inflammatory bowel disase 2. Ensure the pt is not taking any medication (beyond abx) that can cause the diarrhea (i.e. metformin, Laxatives, etc) |
| Unformed stools refers to: | waste that takes the shape of the container |
| (Do not memorize) What are some diagnostic tools we can use to determine CDI? | 1. Stool culture (but slow turn around time); 2. C. diff PCR (most commonly used, Quick results, tests for the toxin producing genes, may be (+) in asymptomatic carriers) 3. Antigen detection (rapid tests, testing presence of C. diff glutamate dehydrogenase (GDH), should not be used alone to diagnose CDI) 4. Enzyme immunoassays (same day tests, detects toxin A, toxin B, or both, toxins rapidly degrade in stools- may lead to false (-) if storage of samples is compromised) |
| When can Repeat testing for C. Diff occur? | Do not repeat testing within 7 days during SAME episode of diarrhea; Test of cure is not necessary |
| What is the definition of an INITIAL (FIRST TIME GETTING DIAGNOSED) episode of CDI? | New primary episode with symptoms and (+) C. diff toxin assay or PCR |
| What is the definition of a RECURRENT episode of CDI? | Episode of symptom onset (new diarrhea) and + assay result AFTER an episode of CDI in the previous 2-8 WEEKS |
| S/sx of INITIAL infection (initial episode classified as Non-Severe would have what supporting Clinical data? | WBC </= 15K cells/mL and SCr < 1.5 mg/dL |
| S/sx of INITIAL infection (initial episode classified as Severe would have what supporting Clinical data? | WBC > 15K cells/mL and SCr > 1.5 mg/dL |
| S/sx of INITIAL infection (initial episode classified as FULMINANT would have what supporting Clinical data? | Hypotension or Shock (<90/60, MAP </= 65mmHg), ileus, Megacolon |
| According to the 2021 IDSA/SHEA guidelines for Initial Treatment what is the preferred tx option for CDI initial episode? | Fidaxomicin 200 mg PO BID for 10 days |
| According to the 2021 IDSA/SHEA guidelines for Initial Treatment what is the alternative tx option for CDI initial episode? | Vancomycin 125 mg PO QID for 10 days; âď¸ IV vanco for C. diff DOES NOT EXIST |
| According to the 2021 IDSA/SHEA guidelines for Initial Treatment what is the alternative tx option for a NON-SEVERE CDI initial episode IF Fidaxomicin or Vanco is not available? | Metronidazole 500 mg PO TID for 10-14 days |
| According to the 2021 IDSA/SHEA guidelines for Recurrent Treatment what is the preferred for First recurrence? | Fidaxomicin 200 mg PO BID for 10 days OR twice daily for 5 days followed by once every other day for 20 days |
| According to the 2021 IDSA/SHEA guidelines for Recurrent Treatment what is the alternative for First recurrence? | Oral Vanco taper with pulse therapy (125 mg PO QID for 10-14 days, 125 mg PO BID for 7 days, 125 mg PO daily for 7 days and then 125 mg PO daily every 2-3 days for 2-8 weeks |
| According to the 2021 IDSA/SHEA guidelines for Recurrent Treatment: If Metronidazole was used for initial tx, what is my alternative tx option for First recurrence? | Vancomycin 125 mg PO QID for 10 days |
| According to the 2021 IDSA/SHEA guidelines for Recurrent Treatment: what medication that can be used as adjunctive therapy for both First recurrence and/or Second or Subsequent recurrence? | Bezlotoxumab 10 mg /kg IV once during the administartion of standard of care abx |
| For second or subsequent recurrence of CDI what is the preferred tx? | Fidaxomicin 200 mg PO BID for 10 days OR twice daily for 5 days followed by once every other day for 20 days |
| For second or subsequent recurrence of CDI what is the alternative? | Oral Vanco taper with pulse therapy (125 mg PO QID for 10-14 days, 125 mg PO BID for 7 days, 125 mg PO daily for 7 days, and then 125 mg PO daily every 2-3 days for 2-8 weeks) |
| For second or subsequent recurrence of CDI what is the alternative? *hint (vanco is added with a new drug | Vanco 125 mg PO QID for 10 days followed by Rifaximin 400 mg PO TID for 20 days OR Fecal Microbiota Transplant |
| Rifaximine is added on because? | Not to cure but used for recurrence |
| Primary Prevention of CDI: Infection control includes: | -isolation of the pt -proper hand hygiene -contact precautions (in-hospital) |
| Primary Prevention of CDI: Antibiotic Stewardship includes: | Treat infections w/ the narrowest (but approrpriate) abx for the shortest duration as possible; De-escalate abx quickly as possible; Ensure appropriate indications for abx |
| According to the 2017 IDSA/SHEA guidelines AND 2021 ACB guidelines __ _____ ______ probiotics at the time of abx to try to prevetn C. difficile. | DO NOT RECOMMEND -mixed evidence in the literature; limitations of the studies that do show a benefit are small sample sizes and the lack of consistency of the type of probiotic strains used |
| 1 in 6 pts will develop C. Diff again w/in 2-8 weeks of their previous CDI. Continue to follow good practices to ____ first episode of C. diff | prevent |
| According to the 2021 Tariq et al systematic review/meta-analysis: _____ _________ ___________ decreases the risk of future CDI IF pt had a history of CDI but no benefit for primary prophylaxis | Oral Vancomycin prophylaxis |
| In recent years, there has been a few advances in drugs that can be used to try to prevent recurrent CDI: These include: | Bezlotoxumab; Fecal microbiota (Live JSLM); Oral Fecal microbiota |
| Bezlotoxumab: brand __________, is indicated for? | Zinplava; indication: human monoclonal antibody that binds to C. Difficile toxin B to REDUCE the recurrence of CDI in adults (> or = 18 yo) that are receiving tx abx for CDI and are at high risk of developing recurrent CDI; **Not indicated for the tx of CDI (not a cure); Caution: pts with HF đ |
| Fecal Microbiotia, Live JSLM: brand _________, is indicated for? | Rebyota; Indication: for the prevention of recurrence of CDI in adults (>/= 18 yo) following abx for the tx for recurrent CDI |
| Fecal Microbiota, Live JSLM: is NOT indicated as ______ __ ___; Administer it as a single dose rectally 24-72h after ___ ____ of tx abx for CDI | treatment of CDI; last dose |
| What allergy should we worry about when dispensing Fecal Microbiota, Live JSLM to a pt? | PEG allergy; Fecal matter is suspended in polyethylene glycol (PEG) 3350 and 0.9% NaCl solution; may not be an option for pts allergic to PEG |
| ORAL Fecal Microbiota: Brand _______, is indicated for? | Vowst; indication: for the prevention of recurrence of CDI in adults (>/= 18 yo) following abx for the tx for recurrent CDI; Similar to Live JSLM: this med is also not indicated for the tx of CDI |
| Vowst administration: | Drink 10 oz magnesium citrate the day before and at least 8 hours prior to first dose; Administer it as 4 capsules daily for 3 days on an empty stomach |
| This drug is currently being studied and waiting for Phase III studies to be published comparing this as a TREATMENT option for CDI: | Ridinilazole |
| ________ are the LEADING cause of infectious diarrhea worldwide i.e Norovirus, Rotovirus | Viruses |
| Bacteria responsible for "watery diarrhea"(w/o blood) include: | Enterotoxigenic Escherichia Coli (ETEC); Vibrio cholerae O1 |
| Bacteria responsible for "Dystenteric (bloody) diarrhea" include: *high risk pts | Campylobacter species; Shigella species; Salmonella nontyphoidal; Yersinia species |
| Bacteria responsible for "Traveler's Diarrhea" include: | ETEC |
| What complications can arise from Non-C. Diff infectious diarrhea? | Dehydration; Electrolyte imbalances; Bacteremia (more common with pathogens that cause dysenteric diarrhea) |
| Tx options for complications from non-C. Diff infectious diarrhea include (hint: not drugs) | Give fluids orally or IV (for more severe dehydration or unable to tolerate PO) to correct; avoid fluids containing high sugar (bacteria love sugar) |
| Renal reminder: Every 10 mEq of K+ will increase serum K+ by ______ | 0.1 *be more conservative in pts with renal dysfunction |
| Na+ can be given by some of the _____ replacement solutions | oral (ORS) |
| Who should be considered for Empiric abx tx? | Severe case of diarrhea; Moderate-Severe cases of Traveler's disease; Most cases of febrile dysenteric diarrhea; Culture-proven bacteria diarrhea |
| Tx of specific pathogens: in Water Diarrhea, the offending pathogen is Enterotoxigenic Eschericheria coli (ETEC): tx options for adults are: | Preferred: Ciprofloxacin Alternative: Rifaximin Alternative: Azithromycin |
| Tx of specific pathogens: in Water Diarrhea, the offending pathogen is Enterotoxigenic Eschericheria coli (ETEC): tx options for children are: | Azithromycin OR Ceftriaxone *Doxycycline--> (not preferred in children) |
| Tx of specific pathogens: in Water Diarrhea, the offending pathogen is Vibrio cholerae: tx options for adults are: | Preferred: Doxycylcine Alternative: Azithromycin Alternative: Ciprofloxacin |
| Tx of specific pathogens: in Water Diarrhea, the offending pathogen is Vibrio cholerae: tx options for children are: | Erythromycin OR Azithromycin |
| Tx of specific pathogens: in Dysenteric Diarrhea, the offending pathogen is Campylobacter species: tx options for adults are: | Preferred: Azithromycin Alternative: Ciprofloxacin |
| Tx of specific pathogens: in Dysenteric Diarrhea, the offending pathogen is Campylobacter species: tx options for children are: | Erythromycin OR Azithromycin |
| Tx of specific pathogens: in Dysenteric Diarrhea, the offending pathogen is Shigella species: tx options for adults are: | Preferred: Ciprofloxacin or Ceftriaxone Alternative: Ampicillin OR Azithromycin OR TMP-SMX |
| Tx of specific pathogens: in Dysenteric Diarrhea, the offending pathogen is Shigella species: tx options for children are: | Ceftriaxone OR Azithromycin |
| Tx of specific pathogens: in Dysenteric Diarrhea, the offending pathogen is Salmonella nontyphoidal: tx options for adults are: | Preferred Azithromycin OR Ceftriaxone OR Ciprofloxacin Alternative: Ampicillin or TMP-SMX |
| Tx of specific pathogens: in Dysenteric Diarrhea, the offending pathogen is Salmonella nontyphoidal: tx options for children are: | Ceftriaxone OR Azithromycin |
| Tx of specific pathogens: in Dysenteric Diarrhea, the offending pathogen is Yersinia species: tx options for adults are: | Preferred: TMP-SMX Alternative: Cefotaxime IV or Ciprofloxacin |
| Tx of specific pathogens: in Dysenteric Diarrhea, the offending pathogen is Yersinia species: tx options for children are: | Ceftriaxone OR Azithromycin |
| This type of diarrhea has no recommendation of prophylaxis for adults. Which type of non-C. diff infectious diarrhea am I? | Traveler's Diarrhea |
| Treatment for Traveler's Diarrhea include: | Azithromycin OR Ciprofloxacin OR Levofloxacin OR Ofloxacin Or Rifamycin SV OR Rifaximin 200 |
| What supportive care can pts take or can be considered once a pt is adequately hydrated? | Antimotility, antinausea, or antiematic |
| This drug should not be used in children < 18 yo with acute diarrhea | Loperamide |
| Loperamide may be used in __________ pt with acute watery diarrhea but AVOID if concern for toxic MEGACOLON or dysenteric diarrhea with fever | immunocompetent |
| Why can't Loperamide (anti-motility drug) be used in pts with suspected dysenteric diarrhea? | These drugs make your GI tract stop pulsing. Dysenteric causing pathogens produce toxins and while on these drugs will make your GI tract hold onto those toxins and you need to get those toxins out. So if blood in the diarrhea--> Anti-motility drugs are not an option |
| Prevention options for non-C. diff infectious diarrhea pathogens include? | washing your hands; If you have diarrhea, avoid swimming or water activities; If traveling, careful of foods/vendors; Infants--> have them get the rotavirus vaccine |
Created by:
Xander635
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