UCSF Guidelines for Management of C. difficile Infection

PrintPrintPDFPDF

Click here to download pdf version.

Introduction

The Clostridium difficile management guideline establishes evidence-based standards for management of C. difficile infection (CDI) at UCSF Medical Center, VA Medical Center, and Zuckerberg San Francisco General Hospital. The protocol has been adapted from published consensus guidelines from the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the American College of Gastroenterology (ACG) with input from the Antimicrobial Stewardship Program, the Infectious Diseases Management Program, and the Infectious Diseases division.

Definitions

Abbreviation

Definition

CDI

Clostridium difficile infection

FMT

Fecal Microbiota Transplantation

ID

Infectious Diseases

GI

Gastroenterology

 

Principles of CDI management

·       Refer to the Hospital Epidemiology and Infection Control website for information on work-up of diarrhea and guidance on Infection Control issues pertaining to CDI at UCSF Medical Center (http://infectioncontrol.ucsfmedicalcenter.org/ucsf-clostridium-difficile-infection-prevention)

·       Stop all unnecessary antibiotics, shorten antibiotic courses, and narrow the spectrum of antibiotic activity when possible

·       Stop acid suppressive medications, especially proton-pump inhibitors, when possible

·       Do not use anti-peristaltic agents until acute symptoms of CDI improve

Treatment of CDI in Adult Patients, Initial episode

 

Clinical definition

Criteria

Treatment

Initial, mild-mod, Outpatient

Not meeting criteria for severe

Metronidazole 500 mg po q8h x 10-14 days

If no response @ 5 days, switch to vancomycin 125 mg po q6h x 10-14 days

Initial, mild-mod, Inpatient

Not meeting criteria for severe

Vancomycin 125 mg po q6h x 10-14 days

If unable to obtain upon discharge, okay to complete the course with metronidazole 500 mg po q8h

Initial, severe

WBC ≥ 15 OR Cr ≥ 1.5x baseline without hypotension, shock, ileus, and/or megacolon

Vancomycin 125 mg po q6h x 10-14 days

Initial, severe+complicated

Hypotension, shock, ileus, and/or megacolon

Vancomycin 500 mg po/ng q6h + metronidazole 500 mg IV q8h +/- rectal vancomycin

Rectal vancomycin should be considered in patients with ileus. It is given as 500 mg in 100 mL of 0.9% NaCl and instilled q6h (retain each dose for 1h)

Consult ID and General Surgery for consideration of colectomy versus diverting loop ileostomy with colonic lavage

 

Treatment of CDI in adult patients, recurrent disease

Recurrence is defined as the re-appearance of symptoms and signs of CDI within 8 weeks after completion of therapy for prior CDI episode for which symptoms and signs had resolved.

 

Clinical definition

Criteria

Treatment

1st recurrence

Except special populations below

Same as for initial therapy, stratified by illness severity

1st recurrence, special population

Hematologic cancer with neutropenia expected > 30 days

Recent bone-marrow transplant or treatment for GVHD

Solid-organ transplant < 3 mths

Otherwise not an FMT candidate

Fidaxomicin 200 mg po  q12h x 10 days

(be sure to check insurance coverage before prescribing for outpatients; if insurance does not cover can try the MERCK pt assistance program at www. merckhelps.com)

≥ 2nd recurrence

 

Vancomycin tapered and/or pulsed PLUS

Evaluate for FMT

Consult ID, GI

 

Vancomycin taper schedule for adults

125 mg po 4x daily x 14 days

125 mg po 2x daily x 7 days

125 mg po 1x daily x 7 days

125 mg po every other day x 8 days (4 doses)

125 mg po every 3 days x 2 weeks (5 doses)

 

Treatment of CDI in Pediatric Patients, initial episode

Clinical definition

Criteria

Treatment

Initial, mild-mod

Not meeting criteria for severe

Metronidazole 10 mg/kg/dose PO (max 500 mg/dose) q8h x 10-14 days

Initial, no response to metronidazole in 5 days

 

Switch to vancomycin 10 mg/kg/dose (max 125 mg/dose) po qid x 10-14 days

Initial, severe

WBC ≥ 15 OR Cr ≥ 1.5x baseline without hypotension, shock, ileus, and/or megacolon

Vancomycin 10 mg/kg/dose (max 125 mg/dose) PO q6h x 10-14 days

Initial, severe+complicated

Hypotension, shock, ileus, and/or megacolon

Vancomycin  10 mg/kg/dose (max 500 mg/dose) PO q6h  + metronidazole 10 mg/kg/dose  (max: 500 mg/dose) IV q8h

Consult ID and General Surgery

 

Treatment of CDI in Pediatric Patients, recurrent disease

Recurrence is defined as the re-appearance of symptoms and signs of CDI within 8 weeks after completion of therapy for prior CDI episode for which symptoms and signs had resolved.

 

Clinical definition

Treatment

1st recurrence

Same as for initial therapy, stratified by illness severity

≥ 2nd recurrence

Vancomycin tapered and/or pulsed PLUS

Evaluate for FMT

Consult ID, GI

 

Vancomycin taper schedule for CHIlDREN

10mg/kg/dose (max 125 mg/dose) po 4x daily x 14 days

10mg/kg/dose (max 125 mg/dose) po 2x daily x 7 days

10mg/kg/dose (max 125 mg/dose) po 1x daily x 7 days

10mg/kg/dose (max 125 mg/dose) po every other day x 8 days (4 doses)

10mg/kg/dose (max 125 mg/dose) po every 3 days x 2 weeks (5 doses)

 

Special situations

Comment on probiotics

Mixed data exist regarding use of probiotics for primary prevention of CDI. There is insufficient data to support use for secondary prophylaxis. Can consider use based on patient and provider preference. Relatively contraindicated in immunocompromised populations.

Comment on duration of therapy in patients receiving ongoing antibiotics

Extension of CDI therapy in patients receiving ongoing systemic antibiotics is not routinely recommended as there is no supporting literature and this practice could place the patient at high risk for unnecessary drug-related toxicities and promote further disruption of the microbiome. This includes extension of therapy to match a course of antibiotics prescribed for another indication or to provide a “tail” of CDI therapy after systemic antibiotics are completed.

Comment on secondary antibiotic prophylaxis for CDI

Routine use of secondary CDI prophylaxis in patients at high risk of CDI recurrence is not recommended as there is no supporting literature and this practice could place the patient at high risk for unnecessary drug-related toxicities and promote further disruption of the microbiome.

 

References

Cohen SH, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010; 31(5): 431-455.

Cornely OA, et al. Treatment of first recurrence of Clostridium difficile infection: fidaxomicin versus vancomycin. Clin Infect Dis 2012; 55(s2): S154-161.

Kelly CP and LaMont JT. Clostridium difficile—more difficult than ever. N Engl J Med 2008; 359: 1932-1940.

Schutze GE and Willoughby RE. Clostridium difficile infection in infants and children. Pediatrics 2013; 131: 196–200.

Surawicz CM, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol 2013; 108: 478-498.

Prepared by:

UCSFMC: Sarah Doernberg, MD, MAS; Catherine Liu, MD; Jennifer Babik, MD, PhD; Rachel Wattier, MD; Alexandra Hilt-Horeczko, PharmD; Jonathan Faldasz, PharmD

VA team: Harry Lampiris, MD; Daniel Maddix, PharmD

ZSFG team: Lisa Winston, MD; Gregory Melcher, MD; Camille Beauduy, PharmD

Approved by:

 

Group

Date

IDMP

2.29.16

Clinical ID group at VAMC

2.29.16

Clinical ID group at ZSFG

2.29.16