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home - Colon - Colonic Infection - Clostridium Difficile Treatment Written by Dr Sebastian Zeki
Knowledge

Recognises the range of important inflammatory conditions of the
intestine other than inflammatory bowel disease
Knows the range of potential aetiologies including infection and
ischaemia
Understands how diverticular disease can give rise to complications mini-CEX, SCE 1
Knows how diseases can affect the peritoneum and how such
conditions can present both in the acute and chronic situation
Knows the range of both acute and chronic intestinal infections and
their various presentations
Knows the means of investigations of infectious diseases and
understands the principles and use of antimicrobial therapy

Skills
Makes a full clinical assessment of patients presenting with infective
and inflammatory conditions
Recognises the potential urgency of the clinical situation. Selects
appropriate investigations and treatments

Behaviours
Manages patients with inflammatory and infective conditions carefully,
competently and sympathetically.

Clostridium Difficile Treatment

Methods of Prevention:Use of least c.diff assoc antibiotics.Use of soap and water.Contact precautions.Indications for Treatment :Must be symptomatic AND have positive toxin. Treatment of antibiotic-associated diarrhea caused by Clostridium difficile Management of subsequent relapse —Tapering dose and intermittent antibiotic therapy +/- probiotics.Rifaximin — Vancomycin followed by rifaximin may be effective.NB:- exposure to rifamycins before development CDAD is risk factor for rifampin resistant C.difficile infection. Variant strain The NAP1/BI/027 hypervirulent strainIt produces binary toxin related to the iota strain in c.perfringens.It produces large quantities of toxin A and B.It has a partial deletion of tcdC gene which normally downregulates toxin production.It is associated with cipro and increased outbreaks in 2000-2003.It is resitant to treatment.It produces a more severe disease.It produces more toxin. Type 078 Alternative Treatments:1.Probiotics. 2.Alternative antibiotics.3.Anion-binding resins (eg cholestyramine).— Tolevamer resin specifically for c.diff- showing promise.Intravenous immunoglobulin — Not proven.Fecal bacteriotherapy — If severe and recurrent CDAD.Surgery — Colectomy+ ileostomy. Tests: Culture-most sensitive. Cytotoxic assay-most specific. ELISA-A or B/A and B (specific but as sens - tive as cytotoxin)- Don’t repeat following treatment (50% stay +ve after 6 wks). Latex-test for glutamate dehydrogenase. AXR. Flexible sigmoidoscopy. -Affects younger ages group/ Community associated/ Genetically similar to porcine isolates. -Truncated TXA gene - TXA0/TXB positive-Resistant to multiple antibiotics-Increased severe disease/death-Accounts for 10-50%-Associated with outbreaks -Only indicated for recurrent disease that is not severe; not for prevention.Mechanisms: Alters intestinal flora; Has antimicrobial activity; Increases intestinal barrier protection; Immunomodulation —Consider: fusidic acid, nitazoxanide, teicoplanin, rifampin, rifaximin, and bacitracin. Binds toxins without altering flora.Not effective but useful as adjunct in relapse.Also binds vancomycin so take 2-3hrs apart Colectomy outcome best if WBC> 20, lactate 2.2-4.9 and immunocompetent aged ≥65 years Written by Dr Sebastian Zeki Indications for surgery:Severe disease unresponsive to medical therapy within 48 hours.Bowel perforation or multi-organ failure.Peritonism.Severe ileus.Toxic megacolon. Metronidazole po for 10 daysIf ongoing diarrhoea give 125mg vancomycin qds for 10 daysIf ongoing: Increase vanc dose to 250mg qds/ add rifampicin

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