Top 10 Practice Changers in Gastroenterology: 2013
Top 10 Practice Changers in Gastroenterology: 2013
Surawicz CM, Brandt LJ, Binion DG, et al
Am J Gastroenterol. 2013;108:478-498
Abstract
Clostridium difficile infection (CDI) presents a rapidly evolving challenge in the battle against hospital-acquired infections. Recent advances in CDI diagnosis and management include rapid changes in diagnostic approach with the introduction of newer tests, such as detection of glutamate dehydrogenase (GDH) in stool and polymerase chain reaction (PCR) to detect the gene for toxin production, which will soon revolutionize the diagnostic approach to CDI. New medications and multiple medical society guidelines have introduced changing concepts in the definitions of severity of CDI and the choice of therapeutic agents, whereas rapid expansion of data on the efficacy of fecal microbiota transplantation (FMT) heralds a revolutionary change in the management of patients suffering multiple relapses of CDI.
This American College of Gastroenterology guideline provides a comprehensive review of current diagnosis and treatment. Notable strong recommendations include:
Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections
Surawicz CM, Brandt LJ, Binion DG, et al
Am J Gastroenterol. 2013;108:478-498
Abstract
New Guidelines for Clostridium difficile
Clostridium difficile infection (CDI) presents a rapidly evolving challenge in the battle against hospital-acquired infections. Recent advances in CDI diagnosis and management include rapid changes in diagnostic approach with the introduction of newer tests, such as detection of glutamate dehydrogenase (GDH) in stool and polymerase chain reaction (PCR) to detect the gene for toxin production, which will soon revolutionize the diagnostic approach to CDI. New medications and multiple medical society guidelines have introduced changing concepts in the definitions of severity of CDI and the choice of therapeutic agents, whereas rapid expansion of data on the efficacy of fecal microbiota transplantation (FMT) heralds a revolutionary change in the management of patients suffering multiple relapses of CDI.
Viewpoint
This American College of Gastroenterology guideline provides a comprehensive review of current diagnosis and treatment. Notable strong recommendations include:
Only patients with diarrhea (a stool that takes the shape of the container) should be tested for CDI.
Initial testing should be done with glutamate dehydrogenase or nucleic acid amplification test for CDI, without repeat testing unless suspicion for infection is high and initial GDH testing is done.
Patients with resolution of diarrhea should not be tested to document cure of CDI.
Initial antibiotic treatment for patients with mild to moderate CDI infection should be metronidazole 500 mg 3 times daily orally (provided there is no drug allergy contraindication).
Initial treatment for severe CDI or failure to respond to 5-7 days of metronidazole should be vancomycin 125 mg 4 times daily orally. If severe or complicated CDI, intravenous metronidazole 500 mg 3 times daily should be added.
In patients with severe ileus or complicated CDI, the best antibiotic plan is intravenous metronidazole 500 mg 3 times daily plus oral vancomycin 500 mg 4 times daily with vancomycin 500 mg in 500 cc fluid 4 times daily (given rectally by retention enema).
First recurrence of CDI can be treated with the initial regimen if it induced an appropriate clinical response.
Second recurrence of CDI should be treated with pulsed vancomycin.
If third recurrence or unresponsive severe CDI, FMT should be considered.
Current data suggest limited, if any, value of probiotics for CDI treatment or prevention of relapse.
High-level disinfection (sporicidal label claim or 5000 ppm chlorine-containing cleaning agents) of environmental surfaces in bathrooms; if inpatient, disinfection of contact surfaces is recommended.
Contact precautions should be continued at least until resolution of the patient's diarrhea.
