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Clostridioides difficile Infections in Adults by Sarah Kessler, PharmD, BCPS, BCGP Background

Lesson 1 of 6

In Progress

Background

Clostridioides difficile (C. diff)
- Anaerobe
- Spore forming
- Gram positive bacillus
- Toxin production (A & B)
Previously named clostridium difficile
- Renamed in 2016 in order to differentiate C. diff from other Clostridium species
Transmitted via fecal-oral route
- Occasionally via environment

Epidemiology

Widely present in the environment
- Asymptomatic carriers
- Infected patients
- Animals gut microbiome (canine, feline, porcine, avian)
Large proportion of the population are carriers
- Adults:
  - 3-26% in acute care settings
  - 5-7% in elderly patients in long term care facilities
  - < 2% in asymptomatic adults without healthcare exposure
Infants:
- 15-70%

Burden of Disease

Most common healthcare-associated infection

~ 500,000 infections in 2017
- Incidence highest in those ≥ 65 years old
- Higher incidence in women
- Higher incidence in white individuals
Over 2/3^rds → healthcare associated

Onset – Defining Location

Classification

Initial
First Recurrence
Second or Subsequent Recurrence
Fulminant

Risk Factors

Risk Factors – Antibiotics

Virtually all antibiotic agents have been associated with increased risk of C. diff
Higher risk classes include:
- 3^rd and 4^th generation cephalosporins
- Fluoroquinolones
- Carbapenems
- Clindamycin
Longer duration or multiple antibiotics → ↑ risk
Risk of developing CDI increases for 3 months following antibiotic cessation (highest in 1^st month)

Risk Factors for Complicated Disease

Older age
Leukocytosis
Renal failure
Multiple comorbidities
Special populations:
- Inflammatory bowel diseases
  - Particularly ulcerative colitis
- Solid organ transplant recipients
  - 5x greater prevalence than general medicine patients
- Hematopoietic stem cell transplants
  - 9x greater prevalence

Risk Factors for Recurrence

Advanced age
Ongoing antibiotics
Proton Pump Inhibitors
Strain type
Previous fluoroquinolone use

Mortality

Pathogenesis

Clinical Presentation

Large amount of variability
Mild – Moderate – Life Threatening
Watery diarrhea, abdominal pain, fever

Screening

≥ 3 unformed stools
Within 24 hours
Hold laxatives before testing!

Laboratory and Clinical Values

Testing

Repeat Testing

Should NOT be performed
- During the same episode of diarrhea
- Within 7 days of initial testing