• About Us
    • Contact Us
    • Login
    • ObGFirst
  • COVID-19
  • Alerts
  • OB
  • 2T US Atlas
  • The Genome
  • GYN
    • GYN
    • Sexual Health
  • Primary Care
  • Your Practice
  • GrandRounds
  • My Bookshelf
  • Now@ObG
  • Media
About Us Contact Us Login ObGFirst
  • COVID-19
  • Alerts
  • OB
  • 2T US Atlas
  • The Genome
  • GYN
    • GYN
    • Sexual Health
  • Primary Care
  • Your Practice
  • GrandRounds
  • My Bookshelf
  • Now@ObG
  • Media
Primary Care

C. Diff Infection (CDI): From Diagnosis to Treatment

image_pdfFavoriteLoadingFavorite

SUMMARY:

Clostridioides difficile is a gram-positive spore-forming and toxin-producing bacteria that can cause disease ranging from mild diarrhea to severe and even fatal colonic inflammation. It is spread via the fecal-oral route. This infection often occurs after antibiotic use, as antibiotics change the normal gut flora and allows this bacterium to grow and produce its toxins. It is common in hospital and long-term facility settings but is also commonly seen in the outpatient setting.  C. diff infection (CDI) can produce a wide range of symptoms from mild diarrheal disease to toxic megacolon which can be fatal; early recognition and identification is key

Symptoms

Can range from mild to severe, with initial symptoms caused by GI interruptions and include

  • Acute watery diarrhea (at least 3 unformed stools in 24 hours)
  • Crampy abdominal pain
  • Nausea
  • Vomiting
  • Bloody diarrhea (rarely)
  • Fever, abdominal distension and tenderness in severe disease

Risk Factors

  • Antibiotic use (especially clindamycin, cephalosporins, quinolones)
  • Medications that reduce gastric acid such as proton pump inhibitors
  • Older age
  • Prior infection with C. diff
  • Immunocompromised state
  • Hospitalization or resident in a long-term care facility

Differential Diagnosis

Infectious Diarrhea

  • Many organisms such as E. Coli, Salmonella, Shigella can cause diarrhea
    • Differentiate with stool cultures

Acute abdomen in severe disease

  • Careful evaluation as C. diff can present with abdominal distension and tenderness like acute abdomen

Irritable Bowel Syndrome

  • Crampy, chronic abdominal pain, bloating, altered bowel habits including diarrhea, constipation or alternating between both

Inflammatory Bowel Disease

  • Diarrhea (may be bloody), abdominal pain, low grade fever, fatigue, weight loss

Celiac Disease

  • Chronic or recurrent diarrhea, weight loss, abdominal distension or bloating with certain foods due to malabsorption

Diagnosis

  • Definitive diagnosis
    • Send stool for C. Difficile toxin B
    • Testing done using PCR

Note: Reserve testing for appropriate clinical setting with high clinical suspicion due to high risk of false positive results

Treatment

  • Stop offending agent if antibiotic-induced (when possible)
  • Can initiate treatment with high pre-test suspicion before confirmation with PCR

Initial episode of mild disease (leukocytosis with WBC <15,000 cells/mL and Creatinine of <1.5mg/dL)

  • Fidaxomicin should be first-line for treatment: 200mg orally twice a day for 10 days (IDSA)
  • Vancomycin 125mg orally four times a day for 10 days as second-line
  • If no access to Vancomycin or Fidaxomicin, Metronidazole orally 500mg three times a day for 10 days

Initial episode of severe disease (leukocytosis with WBC >15,000 cells/mL and Creatinine of >1.5mg/dL)

  • Fidaxomicin 200mg orally twice a day
  • Vancomycin 125mg four times a day for 10 days is second-line

Initial episode with fulminant disease (hypotension, shock, ileus, megacolon)

  • Vancomycin PO 500mg four times a day and per rectum (if ileus is present) plus IV Metronidazole 500mg three times a day

Complications

Complicated CDI Definition

  • Infection with hypotension requiring vasopressor therapy | Sepsis | Organ dysfunction | Mental status changes | WBC count >50,000 | Elevated lactate

Recurrent CDI

  • Recurrent CDI can occur 1-2 weeks after stopping treatment
  • First recurrence
    • Vancomycin 125mg orally four times a day for 10 days if metronidazole was used for the first episode or
    • Tapered and pulsed vancomycin regimen: 125mg four times a day for 10 days followed by 125mg two times a day for a week followed by once per day for a week then every 2 to 3 days for 2 to 8 weeks or
    • Fidamoxicin 200mg orally twice a day for 10 days if vancomycin was used for the first episode
  • Second recurrence
    • Tapered and pulsed Vancomycin regimen or
    • Fidamoxicin 200mg orally twice a day for 10 days

Note: NEVER use antidiarrheal drugs in CDI as this can lead to toxic megacolon | Surgery consult is needed if antibiotics fail in severe disease or in cases of complicated CDI | Consider fetal microbiota transplant if there is a third recurrence

Prevention

  • Use of narrow spectrum antibiotics when possible
  • Hand washing with soap and water
    • Spores are not removed with ethyl alcohol-type hand sanitizer
  • Use contact precautions with gowns, gloves and use of disposable equipment when caring for an infected patient

Primary Sources – Learn More 

 American College of Gastroenterology: C. Difficile Infection

Infectious Disease Society of America Guideline

CDC: C. diff (Clostridioides difficile)

Want to stay on top of key guidelines and research papers?

ObGFirst® – Try It Free! »

image_pdfFavoriteLoadingFavorite
< Previous
All Primary Care Posts
Next >

Related ObG Topics:

Fecal Microbiota Transplant for C. difficile – Oral Capsules or Colonoscopy?
ACP Guidelines: Best Practices for Use of Short-Duration Antibiotics for Common Infections

Sections

  • COVID-19
  • Alerts
  • OB
  • GYN
    • GYN
    • Sexual Health
  • 2T US Atlas
  • The Genome
  • Primary Care
  • Your Practice
  • Grand Rounds
  • My Bookshelf
  • Now@ObG
  • Media

Are you an
ObG Insider?

Get specially curated clinical summaries delivered to your inbox every week for free

  • Site Map/
  • © ObG Project/
  • Terms and Conditions/
  • Privacy/
  • Contact Us/
© ObG Project
SSL Certificate


  • Already an ObGFirst Member?
    Welcome back

    Log In

    Want to sign up?
    Get guideline notifications
    CME Included

    Sign Up

Download Your ObG App
HERE!

Sign In

Lost your password?

Sign Up for ObGFirst and Stay Ahead

  • - Professional guideline notifications
  • - Daily summary of a clinically relevant
    research paper
  • - Includes 1 hour of CME every month

ObGFirst Free Trial

Already a Member of ObGFirst®?

Please log in to ObGFirst to access the 2T US Atlas

Password Trouble?

Not an ObGFirst® Member Yet?

  • - Access 2T US Atlas
  • - Guideline notifications
  • - Daily research paper summaries
  • - And lots more!
ObGFirst Free Trial

Media - Internet

Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Jointly provided by

NOT ENOUGH CME HOURS

It appears you don't have enough CME Hours to take this Post-Test. Feel free to buy additional CME hours or upgrade your current CME subscription plan

Subscribe

JOIN OBGFIRST AND GET CME/CE CREDITS

One of the benefits of an ObGFirst subscription is the ability to earn CME/CE credits from the ObG entries you read. Tap the button to learn more about ObGFirst

Learn More
Leaving ObG Website

You are now leaving the ObG website and on your way to PRIORITY at UCSF, an independent website. Therefore, we are not responsible for the content or availability of this site