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Edited by Yimaitong, please do not reprint without authorization.
Clostridium difficile infection (CDI) is the most common medical-related infection worldwide.
As an important pathogen of infectious diarrhea in hospitals and communities, especially pseudomembranous enteritis and other related diseases, it has attracted more and more clinical attention.
The outcome of CDI patients can range from asymptomatic bacterial colonization to severe diarrhea, and can also progress to toxic megacolon, intestinal perforation, septic shock, and even death.
Risk factors for CDI Current or recent (within 8 weeks) antibiotic use is one of the most important risk factors for CDI.
Clindamycin, third-generation cephalosporins, amoxicillin and fluoroquinolones are all associated with increased risk of CDI .
Other risk factors include age ≥ 65 years, exposure to medical and health care facilities, including outpatient clinics, hospitalizations, and long-term nursing homes.
In addition, recent gastrointestinal surgery (especially colectomy), immune insufficiency (such as malignant tumors, diabetes and HIV infection), application of anti-tumor drugs, proton pump inhibitors, and comorbid conditions (such as inflammatory bowel Disease, chronic or end-stage renal disease) are also associated with CDI.
Diagnosis of CDI With the development of high-sensitivity diagnostic detection technology, in order to avoid wasting medical resources and over-treatment of asymptomatic carriers/colonized persons, it is necessary to stratify patients with suspected CDI.
First, a comprehensive assessment of the patient’s past history is required to rule out other causes of diarrhea, including the use of laxatives within 48 hours before the onset of diarrhea, the application of chemotherapy drugs, enteral feeding, abdominal surgery, and comorbid conditions (including IBD and bowel disease).
Acute syndrome) and other non-infectious causes.
CDI diagnostic tests include toxin-producing culture (TC), cell culture cytotoxicity neutralization test (CCCNA), toxin A and toxin B enzyme immunoassays (EIAs), nucleic acid amplification tests (NAATs), and glutamate dehydrogenase ( GDH) test.
The current CDI diagnosis method uses a combination test or a multi-step algorithm.
The multi-step algorithm includes a combination test, that is, GDH test plus EIAs, NAAT plus EIAs, or GDH test plus EIAs, which are judged by NAAT in the pre-defined stool sample detection standards.
The two-step method uses GDH test or NAATs for screening, and then uses EIAs to test positive samples to confirm the presence of Clostridium spp.
producing toxins.
In addition, evaluation of fecal biomarkers such as fecal calprotectin and lactoferrin can determine the correlation between the severity of CDI and the risk of recurrence.
Treatment of CDI The purpose of treatment of CDI is to solve diarrhea and prevent recurrence, thereby reducing the burden of disease.
If possible, minimizing unnecessary antibiotic use and immediately stopping irritating antibiotics are very important in the treatment of CDI.
Antibiotic management plans and infection control measures (such as hand hygiene) are the most cost-effective ways to significantly reduce the incidence and recurrence of CDI.
For all patients diagnosed with CDI, supportive measures such as fluid rehydration and correction of electrolyte disturbances should be taken.
The treatment of CDI depends on the severity of the disease.
Initial CDI is defined as the onset of symptoms, a positive diagnostic test and no history of CDI in the first 8 weeks.
Metronidazole has always been the first choice for the treatment of CDI, but the 2018 IDSA/SHEA guidelines recommend vancomycin (125mg, oral, 4 times/d, 10d) or fidaxomycin (200mg, oral, 2 times/d, Take 10 days) as the first-line treatment for patients with initial attacks of non-severe CDI.
Recurrent CDI is defined as recurring symptoms and a positive diagnostic test result within 2-8 weeks after the onset of the initial CDI.
Approximately one-quarter of CDI patients will experience at least another attack, especially those who were treated with metronidazole or vancomycin for the first infection.
The main risk factors associated with the recurrence of CDI include: age ≥ 65 years, immune insufficiency, continuous use of antibiotics, severe initial attack of CDI, infection of highly toxic Clostridium difficile strains, application of gastric acid inhibitors, etc.
The treatment plan for the first recurrence of CDI includes: vancomycin tapering and pulsed dose (125mg, 4 times/d, 10d; 125mg, 2 times/d, 7d; 125mg, 1 time/d, 7d; 125mg, 1 time/ 2-3 days, 2-8 weeks), if the initial use of vancomycin for relapse treatment, Fidaxomycin can also be used.
For CDI patients who have relapsed many times and failed appropriate antibiotic therapy, fecal bacterial transplantation (FMT) can also be considered.
The criteria for severe CDI are body temperature>38.
5°C, white blood cell WBC count>15×109/L, and creatinine>1.
5 mg/dL.
The initial treatment of severe CDI includes vancomycin 125 mg, orally, 4 times/d, for 10 days; or fidaxomycin 200 mg, orally, 2 times/d, for 10 days.
In addition, for patients with severe CDI, intravenous metronidazole can also benefit.
Severe CDI can also be considered for FMT treatment.
Fulminant CDI refers to patients with hypotension, shock, end-organ failure or serious complications, such as intestinal obstruction, toxic megacolon, colon perforation caused by CDI.
Because fulminant CDI can progress rapidly and has a high mortality rate, early diagnosis and treatment are very important.
Antibiotic treatment for fulminant CDI includes enteric-coated vancomycin 500 mg, orally or via nasogastric tube, 4 times a day, and intravenous metronidazole 500 mg, 1 time/8h.
If the patient has intestinal obstruction, 500mg of vancomycin (dissolved in 100ml of normal saline) can be given via Foley catheter to rectal retention enema once every 6h, but the risk of colon perforation should be paid attention to.
Patients with no improvement in drug therapy or elevated serum lactate level (≥2.
2 mmol/L) and white blood cell count (WBC) ≥20,000 require early surgical evaluation.
Total colectomy combined with terminal ileostomy has the lowest mortality and reoperation rate.
References: 1.
Wu KS, Syue LS.
Cheng A.
et al.
Recommendations and guidelines for the treatment of Clostridioides difficile infection in Taiwan.
J Microbiol Immunol Infect.
2020 Apr;53(2):191-208.
doi: 10.
1016 /j.
jmii.
2020.
02.
002.
2.
Infectious Disease Laboratory Medicine Expert Committee of the Laboratory Physician Branch of the Chinese Medical Doctor Association.
Expert consensus on the diagnosis and treatment of Clostridium difficile infection in adults.
Union Medical Journal.
2017, 8(2-3): 131- 138.
3.
Massimo Antonelli1,Ignacio Martin?Loeches.
et al.
Clostridioides difficile (formerly Clostridium difficile) infection in the critically ill: an expert statement.
Intensive Care Med.
2020 Feb;46(2):215-224.
doi: 10.
1007/ s00134-019-05873-x.
4.
McDonald LC, Gerding DN, Johnson S, et al.
: Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).
Clin Infect Dis.
2018; 66(7): e1–e48.
10.
1093/cid/cix1085.
Clostridium difficile infection (CDI) is the most common medical-related infection worldwide.
As an important pathogen of infectious diarrhea in hospitals and communities, especially pseudomembranous enteritis and other related diseases, it has attracted more and more clinical attention.
The outcome of CDI patients can range from asymptomatic bacterial colonization to severe diarrhea, and can also progress to toxic megacolon, intestinal perforation, septic shock, and even death.
Risk factors for CDI Current or recent (within 8 weeks) antibiotic use is one of the most important risk factors for CDI.
Clindamycin, third-generation cephalosporins, amoxicillin and fluoroquinolones are all associated with increased risk of CDI .
Other risk factors include age ≥ 65 years, exposure to medical and health care facilities, including outpatient clinics, hospitalizations, and long-term nursing homes.
In addition, recent gastrointestinal surgery (especially colectomy), immune insufficiency (such as malignant tumors, diabetes and HIV infection), application of anti-tumor drugs, proton pump inhibitors, and comorbid conditions (such as inflammatory bowel Disease, chronic or end-stage renal disease) are also associated with CDI.
Diagnosis of CDI With the development of high-sensitivity diagnostic detection technology, in order to avoid wasting medical resources and over-treatment of asymptomatic carriers/colonized persons, it is necessary to stratify patients with suspected CDI.
First, a comprehensive assessment of the patient’s past history is required to rule out other causes of diarrhea, including the use of laxatives within 48 hours before the onset of diarrhea, the application of chemotherapy drugs, enteral feeding, abdominal surgery, and comorbid conditions (including IBD and bowel disease).
Acute syndrome) and other non-infectious causes.
CDI diagnostic tests include toxin-producing culture (TC), cell culture cytotoxicity neutralization test (CCCNA), toxin A and toxin B enzyme immunoassays (EIAs), nucleic acid amplification tests (NAATs), and glutamate dehydrogenase ( GDH) test.
The current CDI diagnosis method uses a combination test or a multi-step algorithm.
The multi-step algorithm includes a combination test, that is, GDH test plus EIAs, NAAT plus EIAs, or GDH test plus EIAs, which are judged by NAAT in the pre-defined stool sample detection standards.
The two-step method uses GDH test or NAATs for screening, and then uses EIAs to test positive samples to confirm the presence of Clostridium spp.
producing toxins.
In addition, evaluation of fecal biomarkers such as fecal calprotectin and lactoferrin can determine the correlation between the severity of CDI and the risk of recurrence.
Treatment of CDI The purpose of treatment of CDI is to solve diarrhea and prevent recurrence, thereby reducing the burden of disease.
If possible, minimizing unnecessary antibiotic use and immediately stopping irritating antibiotics are very important in the treatment of CDI.
Antibiotic management plans and infection control measures (such as hand hygiene) are the most cost-effective ways to significantly reduce the incidence and recurrence of CDI.
For all patients diagnosed with CDI, supportive measures such as fluid rehydration and correction of electrolyte disturbances should be taken.
The treatment of CDI depends on the severity of the disease.
Initial CDI is defined as the onset of symptoms, a positive diagnostic test and no history of CDI in the first 8 weeks.
Metronidazole has always been the first choice for the treatment of CDI, but the 2018 IDSA/SHEA guidelines recommend vancomycin (125mg, oral, 4 times/d, 10d) or fidaxomycin (200mg, oral, 2 times/d, Take 10 days) as the first-line treatment for patients with initial attacks of non-severe CDI.
Recurrent CDI is defined as recurring symptoms and a positive diagnostic test result within 2-8 weeks after the onset of the initial CDI.
Approximately one-quarter of CDI patients will experience at least another attack, especially those who were treated with metronidazole or vancomycin for the first infection.
The main risk factors associated with the recurrence of CDI include: age ≥ 65 years, immune insufficiency, continuous use of antibiotics, severe initial attack of CDI, infection of highly toxic Clostridium difficile strains, application of gastric acid inhibitors, etc.
The treatment plan for the first recurrence of CDI includes: vancomycin tapering and pulsed dose (125mg, 4 times/d, 10d; 125mg, 2 times/d, 7d; 125mg, 1 time/d, 7d; 125mg, 1 time/ 2-3 days, 2-8 weeks), if the initial use of vancomycin for relapse treatment, Fidaxomycin can also be used.
For CDI patients who have relapsed many times and failed appropriate antibiotic therapy, fecal bacterial transplantation (FMT) can also be considered.
The criteria for severe CDI are body temperature>38.
5°C, white blood cell WBC count>15×109/L, and creatinine>1.
5 mg/dL.
The initial treatment of severe CDI includes vancomycin 125 mg, orally, 4 times/d, for 10 days; or fidaxomycin 200 mg, orally, 2 times/d, for 10 days.
In addition, for patients with severe CDI, intravenous metronidazole can also benefit.
Severe CDI can also be considered for FMT treatment.
Fulminant CDI refers to patients with hypotension, shock, end-organ failure or serious complications, such as intestinal obstruction, toxic megacolon, colon perforation caused by CDI.
Because fulminant CDI can progress rapidly and has a high mortality rate, early diagnosis and treatment are very important.
Antibiotic treatment for fulminant CDI includes enteric-coated vancomycin 500 mg, orally or via nasogastric tube, 4 times a day, and intravenous metronidazole 500 mg, 1 time/8h.
If the patient has intestinal obstruction, 500mg of vancomycin (dissolved in 100ml of normal saline) can be given via Foley catheter to rectal retention enema once every 6h, but the risk of colon perforation should be paid attention to.
Patients with no improvement in drug therapy or elevated serum lactate level (≥2.
2 mmol/L) and white blood cell count (WBC) ≥20,000 require early surgical evaluation.
Total colectomy combined with terminal ileostomy has the lowest mortality and reoperation rate.
References: 1.
Wu KS, Syue LS.
Cheng A.
et al.
Recommendations and guidelines for the treatment of Clostridioides difficile infection in Taiwan.
J Microbiol Immunol Infect.
2020 Apr;53(2):191-208.
doi: 10.
1016 /j.
jmii.
2020.
02.
002.
2.
Infectious Disease Laboratory Medicine Expert Committee of the Laboratory Physician Branch of the Chinese Medical Doctor Association.
Expert consensus on the diagnosis and treatment of Clostridium difficile infection in adults.
Union Medical Journal.
2017, 8(2-3): 131- 138.
3.
Massimo Antonelli1,Ignacio Martin?Loeches.
et al.
Clostridioides difficile (formerly Clostridium difficile) infection in the critically ill: an expert statement.
Intensive Care Med.
2020 Feb;46(2):215-224.
doi: 10.
1007/ s00134-019-05873-x.
4.
McDonald LC, Gerding DN, Johnson S, et al.
: Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).
Clin Infect Dis.
2018; 66(7): e1–e48.
10.
1093/cid/cix1085.
