⭐️The new C. difficile guidelines!
Here are the 🧠s behind the new guidelines!
What's in a name?
Clostridium difficile ▶️ clostridioides difficile
Community acquired CDI is on the rise.
Diagnosis can be tricky!
GDH is sensitive but not specific
Toxin EIA is specific but not sensitive
PCR is sensitive, but not specific
Watch out for symptomatic colonization (+PCR)
PI-IBS occurs in about 25% of cases treated for CDI
Sensitive ▶️ specific
Metronidazole: cheapest
Oral vancomycin: 10x more $$$ than metronidazole
Fidaxomycin: 30x more $$$ than metronidazole; most narrow spectrum; prevents recurrence the best
Non-severe initial episode: vancomycin or fidaxomicin
IDSA: never use metronidazole
@AmCollegeGastro: can use metronidazole in low-risk patients
Severe initial episode: vancomycin or fidaxomicin
⛔️metronidazole
Fulminant: fluids, surgery consult, imaging, high dose vancomycin AND metronidazole
With ileus, consider vancomycin enema
If no response in 24-28 h, consider ✂️
New recommendation: can consider multiple (avg 3) #FMT +vanc for 1st episode
Pregnant: vanc, no metronidazole
Immunocompromised: vanc or fidaxo
#IBD: vanc for MINIMUM 14d; consider #FMT for rCDI
First recurrence: fidaxomicin or tapering/pulse dosed vancomycin
NNT = 3 for #FMT preventing CDI recurrence
Can use FMT at second recurrence (3rd episode). Colonoscopic or "crapsule." Repeat FMT if recur within 8 weeks of FMT
There is no role for #probiotics in the primary or secondary prevention of CDI; the guidelines explicitly recommend against.
#microbiome
Suppressive oral vancomycin in patients who are not candidates for #FMT or fail FMT
OVP can be considered in high risk patients getting antibiotics
Bezlotoxumab: consider in those with high risk of recurrence.
Careful in patients with heart failure
Do not discontinue PPI (unless they don't need in the first place!)
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