Appendix A

AIMS Practice Guidelines for CDI
Updated January 2013

Clostridium Difficile Infection

AIMS Practice Guidelines

*Updated January 2013

Infection Control

St. Vincent Hospital Guidelines

1.  Contact isolation for all patients with suspected or proven CDI

a.  If there is still high suspicion for Clostridium. difficile infection, continue isolation even if the patient tests negative for C. difficile toxin

b.  Removal of contact isolation is acceptable 24 hours after resolution of diarrhea as long as patient able to maintain good bowel hygiene

2.  Hand washing with soap and water for 20 seconds (without alcohol-based gels or foams)

Diagnosis

1.  Clinical diagnosis

a.  Diarrhea, defined as multiple watery or unformed stools per day, often associated with a characteristic foul odor, abdominal cramps, fever, leukocytosis, and hypoalbuminemia and no other established cause of the diarrhea. Symptoms usually (but not always) occur during or within 8 weeks of antibiotic exposure.

b.  Rarely, diarrhea may be absent in patients with severe Clostridium difficile infection. Paralytic ileus or toxic megacolon due to C. difficile may prevent passage of stool.

2.  Laboratory diagnosis

a.  Stool specimen for Clostridium difficle toxins A and/or B

i.  Enzyme immunoassay (EIA)

1.  Rapid (~8 hrs at St. Vincent)

a.  54.9% sensitive

2.  Non-rapid (24 hrs at St. Vincent)

a.  70-80% sensitive on average

ii. Polymerase chain reaction (PCR)

1.  Turn-around time ~16 hours at St. Vincent

a.  >90% sensitive

b.  Recommended approach: choose the most sensitive test available and avoid routine repeat stool testing during the same episode of diarrhea

c.  Do not perform a test of cure

Criteria for Severe Infection

Mild-Moderate / Severe
WBC<15K and creatinine level <1.5x level prior to CDI / WBC ≥15K or creatinine level ≥1.5x level prior to CDI

Treatment

·  Initial Episode

a.  Mild-Moderate illness

i.  Metronidazole 500 mg po every 8 hours X 10 days (extend to 14 days if diarrhea slow to resolve)

ii. Consider switching therapy to oral vancomycin liquid if symptoms not resolving after 4 days or if symptoms worsening

b.  Severe illness (see table above)

i.  Vancomycin 125 mg liquid po every 6 hours X 10 days (extend to 14 days if diarrhea slow to resolve)

ii. Gastroenterology, Infection Disease, and/or General Surgery consult if indicated

c.  With each episode, stop all antibiotics not being used to treat Clostridium difficile infection (if possible)

d.  Stop or minimize use of

i.  PPIs

ii. Opiates

iii.  Antiperistaltics

iv.  Anticholinergics

·  First Recurrence

a.  Repeat course of Metronidazole or Vancomycin (whichever was used during treatment of 1st episode) assuming patient responded initially

i.  Metronidazole 500 mg po every 8 hours X 10-14 days OR Vancomycin 125 mg liquid po every 6 hours for 10-14 days

ii. Again, use Vancomycin for severe disease

·  Second and Subsequent Recurrences

a.  Infectious Disease consultation is required when treating second and subsequent recurrences and when considering any of these treatment regimens

1.  Oral Vancomycin liquid for 10 days, followed by 4 weeks of Saccharomyces boulardii

2.  Tapered-Pulsed oral Vancomycin liquid for 6 weeks

a.  With or without Saccharomyces boulardii for 4 weeks beginning during the last 2 weeks of the tapered-pulsed regimen

3.  Oral Vancomycin liquid for 14 days followed by rifaximin

4.  IVIG

5.  Fecal Bacteriotherapy

b.  Avoid use of cholestyramine due to lack of efficacy in the only placebo-controlled trial of anion-exchange resins and due to its affinity to bind other drugs, including vancomycin

·  Fulminant Infection With Compromised GI Tract Function (Ileus/Toxic Megacolon)

a.  IV Metronidazole 500 mg IV every 8 hrs for 10-14 days AND

b.  Vancomycin 500 mg liquid po OR via NGT every 6 hours for 10-14 days AND

c.  General Surgery, GI, and/or ID consultation AND

d.  Consider Vancomycin enemas 500 mg in 100 ml normal saline every 4-12 hours

·  Fidaxomicin 200 mg po every 12 hours is an option for treatment of initial or recurrent CDI

a.  Equivalent cure rates compared to oral vancomycin but appears to lower rate of recurrences compared to oral vancomycin

b.  Most benefit seen in preventing recurrence in patients with severe disease

c.  Very expensive and use currently restricted to Infectious Disease physicians