Clostridioides Difficile Infection (CDI)
A Comprehensive Summary with Quick Facts for Your Practice
- Anaerobic, gram-positive, rod-shaped bacterium with spore formation
- Spores have tolerance to heat, desiccation and many disinfectants.
- Two exotoxins: toxin A (“enterotoxin”) and toxin B (“cytotoxin”)
- Careful: the hypervirulent strain: NAP-1,ribotype 027, III has increased expression of toxins A and B.
- Main risk factors: previous antibiotic therapy, hospitalization, age > 65 years
- Other risk factors: multimorbidity, female, H2 and PPI therapy, immunosuppression
Definition of infection: symptoms plus evidence of toxins A and B
- Watery diarrhea or toxic megacolon (occasional no diarrhea in paralytic ileus!)
- Blood in stool (rare), abdominal pain (22%), fever (28%), peritonitis/ascites
- Leukocytosis (>15,000/µl (50%), hypoalbuminemia, creatinine increase ≥1.5 times, lactate increase
Diagnostics (Attention: only perform diagnostics on patients with clinical symptoms of CDI!)
- antibiotics in the last 60 days; risk groups, regardless of whether they are hospitalized, and any diarrhea lasting more than three days without other known pathogens
- Stool samples
- EIA test (quick but only 80% sensitive).
- GDH, if positive then toxin, then PCR.
- Imporant: fresh stools, max. 2 hours transport time (toxin breaks down at room temperature, no rectal swabs!). Culture rarely helpful (too high TAT, turn-around time)
- Cytotoxicity test (cell culture-based method): highly sensitive and specific for toxin B
- In the absence of toxin detection DO a sigmoidoscopy: pseudomembranes = pathognomonic)
- Check-ups: only if symptoms re-appear after successful therapy, not if there are no symptoms after therapy
Classification of severity (risk stratification according to Zar, Clin Infect Dis 2007) (severe course > 2 points!)
- 1 point: > 60 years, temperature > 38.5 C, albumin < 2.5 mg/dl, leukocytes > 15,000/µl
- 2 points: endoscopic evidence of pseudomembranes, stay on ICU
Hygienic measures and therapy:
- Isolation (single room): Patient with severe diarrhea, poor compliance.
- Isolation measures should be maintained for a period of 48 hours after diarrhea has resolved.
- Disposable protective gown and hand hygiene: washing hands, then disinfection if gloves were worn: disinfection alone is sufficient, mouth and nose protection only if aerosol formation and splashing
- Adequate fluid and electrolyte replacement
- Antibiotics when: a) severe or persistent symptoms (i.e. all hospitalized patients), b) elderly and/or patients with underlying medical conditions, or c) concomitant antibiotic treatment
- Non-severe course (i.e. outpatient): metronidazole (3 x 400 mg orally or 3 x 500 mg i.v.) x 10 to 14 days.
- In the hospital, or severe course or pregnant: vancomycin orally or nasogastric tube (4 x 125-500 mg) x 10 days, and as an enema (4 x 500 mg in 100 ml NaCL; in transit disorder: metronidazole 3 x 500 mg IV vancomycin
- Intolerance: Dificlir (Fidaxomicin) (2 x 250 mg)
- Life-threatening clinical pictures (pseudomembranous colitis, toxic megacolon - TMC): combined therapy with vancomycin (oral or via enteral tubes) and metronidazole (i.v.)
- First recurrence: same as first therapy. From the second recurrence: vancomycin in tapering doses: 4 x 125 mg x 14 days, 2 x 125 mg x 7 days, 1 x 125 mg x 7 days, 1 x 125 mg/2-3 days x 2-8 weeks
Surgery consult: > 65 years, leukocytes > 20,000 µl, sepsis, TMC, severe ileus, peritonitis, perforation
More on Clostridioides Difficile Infection (CDI) on EndoCollab
Phenomenal results using fecal microbiota transplant (FMT) to treat Clostridioides difficile infection (CDI)
Thanks for reading The Practicing Endoscopist Newsletter! Subscribe for free to receive new posts and support my work.