Clostridium difficile
Questionnaire/history:
Risk factors? - Age > 65?
- Broad-spectrum antibiotics recently?- Previous C. Diff. (recurrence rate ~20% after the first episode)?
- Exposure to known case?
- Underlying morbidity?
- Drugs (eg PPIs)?
Severity?
- Mild (well, normal WCC, < 3 stools/day)?
- Moderate (increased WCC but < 15, 3-5 stools/day)?
- Severe (WCC >15, increased creatinine, temp > 38.5, signs of severe colitis)?
Life threatening - shock, toxic megacolon?
Investigations:
Full blood cell count (FBC)
U&E
Stool sample:
- Don't wait for the result before initiating treatment
- Do not re-test if +ve test if still symptomatic within the same episode
- Only re-test to confirm recurrent C. Diff. if symptoms resolve then recur
- Do not test to confirm cure
Management:
Decisions on admission will be dictated by clinic judgement taking into account severity of symptoms and underlying risk factors (eg age, support at home, ?bloody diarrhoea, co-morbidities, risks of dehydration and ability to take oral antibiotics) +/- WCC/renal function
Review existing antibiotic use - stop unless essential - if essential can it be switched to lower risk abx
Review medications and stop if possible - PPIs, laxatives, SADMAN meds (eg NSAIDs, diuretics, ACEi, SGLT2i)
Treatment:
Consider prompt specialist advice prior to treatment
1st line: Vancomycin 125mg orally QDS for 10 days
2nd line: Fidaxomicin 200mg orally BD for 10 days
In children, treatment should be initiated by or after advice from a specialist
Advise on maintaining hydration, preventing spread, safety net.
Prebiotics or probiotics?
Cochrane found high dose probiotics (≥ 5 billion CFUs per day) are effective at reducing antibiotic-associated diarrhoea in children (NNT = 9), using Lactobacillus rhamnosus or Saccharomyces boulardii - there is uncertainty about other types of probiotic
Meta-analysis published in J Clin Gastroenterology 2021 showed a relative risk reduction in antibiotic-associated diarrhoea of 38% when probiotics were taken early in antibiotic treatment
NICE found 1 meta-analysis showing probiotics statistically significantly reduce the incidence of C. difficile infection in inpatients but not in outpatients or those in mixed settings
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