Posted on September 15, 2018 in: Professional Practice
By Maxwell Trombly, Pharm.D.; Ashley Liakos, Pharm.D.; Janelle Dykstra, Pharm.D.; Alexandra Simon, Pharm.D., PGY1 residents, Mercy Health Muskegon
Clostridium difficile is a gram positive, anaerobic, spore-forming rod that is the leading cause of healthcare-associated diarrhea. The prevalence of gastrointestinal colonization and subsequent infection with Clostridium difficile has been documented to be near 20 percent of all hospitalized patients in some reports and is highly correlated to the use of antimicrobial agents.1 Clostridium difficile infections (CDIs) are associated with significant morbidity and mortality, especially in patients greater than 65 years of age.2 The economic impact of this infectious agent is also vast, with over one billion dollars being attributed to CDI treatment in the United States alone.3 Given all these factors, increasing efforts are being dedicated to the treatment and prevention of CDI in our healthcare systems.
Published in 2018, the Infectious Disease Society of America provided a long-awaited update to their 2010 CDI guidelines. Major highlights from the update include advocacy for the use of oral vancomycin or fidaxomicin over metronidazole for all incidences of CDI, whenever possible (strong recommendation, high quality of evidence). This is a large change from the 2010 guidelines in which metronidazole was regarded as a first-line therapy for the treatment of mild and moderate CDI. Although no longer a first-line therapy, metronidazole still retains its use in specific populations, including pediatric patients, for use intravenously alongside vancomycin for fulminant presentations or if access to vancomycin/fidaxomicin is limited (weak recommendation, high quality of evidence). In addition to therapeutic agent selection, duration of therapy has been decreased to 10 days from the previous 10 to 14, as there was no effect observed in reduction of recurrence rates when a longer regimen was selected. Current recommendations also discuss the preference of tapered/pulsed vancomycin over standard dosing to reduce recurrence rates.
Treatment choices for recurrent CDI have also been changed from the previous guidelines. Though a weak recommendation with low/moderate quality of evidence, it is now recommended that patients with a recurrent CDI be treated with a pulsed and tapered regimen of vancomycin or a 10-day course of fidaxomicin over standard 10-day vancomycin courses. In addition, the guidelines make a strong case for fecal microbiota transplantation for patients that have had multiple recurrences despite appropriate antibiotic therapy (strong recommendation, moderate quality). One of the clinical definitions for CDI has been updated in the new guideline; what was previously termed “initial episode, severe complicated” is now referred to as “initial episode, fulminant.” Regarding probiotic use, the new guidelines do not provide a recommendation for or against their use, in contrast to 2010's low recommendation against their use. Although this is a minor change, caution still should be used regarding their use due to the lack of evidence on the subject.
There are several consistencies between the previous CDI guideline and the new guideline that are important to highlight to ensure proper treatment continues to be implemented in conjunction with the new updates. Patients who are asymptomatic should not have a stool test performed to prevent unnecessary treatment, and additionally, repeat testing of stool should not be performed during the same episode of diarrhea. Contact precautions, private rooms, gowns and gloves should be used to prevent transmission to other individuals. Vancomycin 500 mg is only indicated for patients who initially have a fulminant presentation, defined as patients with hypotension, shock, ileus or megacolon. Antimicrobial stewardship is an important intervention for lowering rates of CDI, as antibiotic use increases risk for CDI. Limiting the number, frequency and duration of high risk antibiotics prescribed can reduce the risk of CDI (strong recommendation, moderate quality of evidence)4. Antibiotics considered high-risk for CDI include fluoroquinolones, clindamycin and broad-spectrum penicillins and cephalosporins; however, any antibiotic can increase risk for CDI.
Pharmacists play an important role in recommending evidence-based drug therapy and stewardship of antibiotics. As this update has provided changes in standards of care for patients with CDI, pharmacists have an opportunity to intervene and educate if out-of-date guidelines are utilized. Stay up-to-date on guidelines, provide updated recommendations when necessary and ensure the appropriate treatment of CDI.
To learn more information and access the most up-to-date practice guidelines visit the Infectious Disease Society of America website at www.idsociety.org.
1. Aljarallah, KM. Conventional and alternative treatment approaches for clostridium difficile infection. Int J Health Sci (Qassim). 2017;11(1):1-10.
2. Burke, K; Lamont J. Clostridium difficile infection: A worldwide disease. Gut Liver. 2014; 8(1):1-6.
3. Dubberke E; Olsen M. Burden of Clostridium difficile on the healthcare system. Clin Infect Dis. 2012;55(Suppl 2):S88-S92.
4. Infectious Diseases Society of America. 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). Clinical Infectious Diseases. IDSA website. http://www.idsociety.org/Guidelines/Patient_Care/IDSA_Practice_Guidelines/Infections_By_Organ_System-81567/Gastrointestinal/Clostridium_difficile/.
5. Cohen, SH; Gerding, DN; 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.