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Clostridium Difficile or C. Diff
Gotam Varma, DO discusses Clostridium Difficile or C. Diff. He shares the main clinical symptoms, which patients are at increased risk, how C. diff is transmitted, and what happens in the hospital once Clostridium difficile is detected.
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Learn more about Gotam Varma, DO
Gotam Varma, DO
Gotam Varma, DO is an Infectious Disease speciallist.Learn more about Gotam Varma, DO
Transcription:
Expert Insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit, please click on the link and complete the episode’s posttest.
Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I’m Melanie Cole and today, we’re discussing C. Diff. and joining me is Dr. Gotam Varma. He’s an Infectious Disease physician at the Carle Foundation Hospital. Dr. Varma, it’s a pleasure to have you here. First, give a working definition of C. Diff. and what diseases result and can result from a C. Diff. infection?
Gotam Varma, DO (Guest): C. Diff. is a bacterial infection that most commonly can cause diarrhea. It’s diarrhea we see in the hospital setting quite often and it can range from simple diarrhea to fulminant organ failure and cause something called toxic megacolon which is a bowel dilation which can be fatal in a lot of cases. So, the range of type of infection can be quite broad.
Host: So, what patients are at an increased risk and tell us while you are telling that, how it’s transmitted? Where is it found?
Dr. Varma: So, it can reside in our colon. It can also reside in the environment. And the type of person that can get it is wide ranging. We do see it a lot in hospitalized patients and different risk factors that can lead to C. Diff. is antibiotic use. So, those who take antibiotics for say pneumonia or a skin infection, what happens in those situations, is the antibiotics can – they are systemic antibiotics so they go through the whole system and they can start to decrease the population of good bacteria in our gut which can give the bad bacteria a chance to overgrow and that can lead to C. Diff. proliferating and causing infection.
Host: So, as we’re talking about proliferating, what’s the difference between C. Diff. colonization and actual infection?
Dr. Varma: C. Diff. colonization means that we may be having the bacteria in our system but it’s not actually causing a disease. So, for example, just to kind of parallel it, if you take a swab of my skin right now, you’re going to find different bacteria on my skin but it’s not causing an actual infection. It’s just colonizing that area. But for example, if I started developing redness and my skin became more painful and tender and started having drainage, we could then say that the bacteria that were on my skin that were colonizing it started acting up and causing infection. Likewise, the key to diagnosis of C. Diff. is not actually a diagnostic test, it’s symptoms. So, if somebody has diarrhea characterized by three or more watery stools within a 24 hour period and there is not another reason why they’re having diarrhea; that would be a hallmark of then checking for C. Diff. So, colonization means someone having a test done, a diagnostic test done and testing positive but not having any actual symptoms versus someone having symptoms and then having the test done and testing positive.
Host: So, then should testing for C. Diff. be performed more than once? You’re speaking to other providers here, so, if they are seeing a single episode of C. Diff. to improve diagnostic accuracy, could there be false positive results?
Dr. Varma: There definitely can be false positives. So, testing should only be done if someone meets the clinical criteria. Meaning that someone starts to have formed stools and starts to come in and have watery stools, the three or more loose or watery stools; that would be an indication for testing. Now our testing is quite sensitive and it’s actually a two stage test. So, if someone tests not negative on that test, we would not recommend repeating the C. Diff test. It’s negative predictive value is quite high meaning that if it’s negative, there’s a good chance that it’s not a false negative so then other reasons for why a person has diarrhea should be looked into.
Host: So, let’s talk about C. Diff. itself. Is it contagious on surfaces? Speak about the contagious factor of it. Can somebody be around? Do they need PPE? Should they be quarantined? Tell us a little bit about some of the protocols.
Dr. Varma: C. Diff. can be passed through fecal oral transmission. So, it can be passed. We are in a day of Coronavirus so, words like airborne and droplet are in the media a lot. This is not something that’s related to that, but it can exist on surfaces. It can exist in one’s stools so, in a hospital setting, good hand hygiene as well as good preventative measures are essential. So, for example, in our hospital, what we do if someone tests positive for C. Diff. they are usually isolated to a single room. If they need to be cohorted, they’d be cohorted with someone else with the same infection. All staff members are required to wear what we call contact plus isolation, so gowns, and gloves during examination. And then good hand hygiene is always recommended because C. Diff. exists in the spore form so, in order to get rid of those spores, alcohol sanitizing agents are at a minimum, but we usually recommend hand hygiene and of course, gowns and gloves. So, gowns, gloves, good hand hygiene are paramount. And then we do recommend good cleaning protocols within the hospital room itself once the patient leaves.
Host: So, how is it treated? What’s the best approach to drug selection for the first episode and what would you like other providers to know about treating recurring C. Diff?
Dr. Varma: Sure so, guidelines changed a bit in 2017. Before 2017, first someone comes in, they test positive for C. Diff. it’s their first bout and I’m talking to the old guidelines, not what we currently recommend. Firstline treatment was something called metronidazole, you could also use something called oral vancomycin. So, that was the old way of doing things for quite some time. The new guidelines now say for first bout of C. Diff. they recommend as first line treatment, not using the metronidazole and going straight to the oral vancomycin. So, if someone comes in, does not have toxic megacolon; they would recommend 10 to 14 days of oral vancomycin. The dose is 125 milligrams oral q. six hours. Also not inferior to that, and a second treatment modality that would be an option is something called fidaxomicin. The treatment for that is usually 200 milligrams twice a day for 10 days. So, that’s first line treatment. So, if somebody has a first bout of C. Diff.
Now if someone has C. Diff., they are at a higher chance of reoccurrence. So what happens at the reoccurrence? So, if you have your first reoccurrence or second bout of C. Diff. what they recommend is actually oral vancomycin with something called a taper. So, you are doing the full treatment dose which is the every six hours for 10 to 14 days and then you would go down and taper down slowly. So, we go from every six hours to maybe twice a day for a week and then once a day for a week and then every other day for a month. And the thought process there is to help give your bowels time to repopulate flora and give a longer treatment course to help get rid of the bacteria. So, that’s called the vancomycin pulse taper.
Another option is doing fidaxomicin as well for 10 days. So, that’s what they would recommend if you’re doing your first reoccurrence or second bout. What happens if you have say someone has three, four or five bouts of C. Diff., they still recommend the vancomycin pulse taper or fidaxomicin but we’re having quite good outcomes with fecal transplant. So that would be requiring gastroenterology colleagues where they would have stool that’s been properly looked at for any other concomitant infection and they would actually physically insert this stool whether it be through EGD or a colonoscopy into the bowel to help repopulate the bowel with good flora. So, when we have a person who has had multiple bouts of C. Diff. and they’re not getting better with medicinal ways of doing things; we’ve had good outcomes with fecal transplant.
Host: Wow, that’s so interesting. Dr. Varma, do you feel personally that antibiotic and antimicrobial stewardship programs might reduce the incidence of C. Diff. or as well as probiotics? Can they help to prevent the antibiotic associated diarrhea and maybe reduce C. Diff. associated diarrhea in children and adults?
Dr. Varma: I’ll start off with the probiotics. Unfortunately, the data is not conclusive if probiotics will actually help prevent or reduce chances of C. Diff. So, there’s some meta analyses that are small studies that say they may help but looking at the Infectious Disease Society of America guidelines, they can’t say officially that probiotics would help prevent that. So, what I usually tell a patient is someone wants to take a yogurt or take some probiotics, I’m not going to stand in the way or speak negatively about it. we can’t say for sure that it’s going to help prevent anything. So, it is just with that understanding.
From an antibiotic stewardship standpoint, I think that’s paramount and key to helping prevent C. Diff. or reduce the chances of obtaining it. For example, doctors can sometimes give antibiotics for say a pneumonia and it could be a simple viral pneumonia that they can give a bacterial course. In those situations, I think looking at a patient clinically is key because you can receive antibiotics for something say as benign as a pneumonia, a simple pneumonia that may not have needed those antibiotics and now have developed C. Diff. So, I think antibiotic stewardship is key. So, one, limiting antibiotics if they are not necessary. Two, reducing the course of antibiotics. So, different disease processes require different lengths of antibiotics, so, sticking with the pneumonia idea, you can treat a pneumonia for anywhere from five to 14 days. So, if a person is getting better quickly, and doesn’t need a long course of antibiotics, infectious disease guidelines actually state giving shorter courses for different illnesses if a person is improving versus longer courses.
And then the third thing one can do is while any antibiotic can lead to C. diff., there have even been anecdotal cases that Flagyl or metronidazole when it was being used as first line can actually cause C. Diff. too. But any antibiotic can cause C. Diff. but there’s certain antibiotics that have a higher risk. Things like clindamycin, cephalosporins, fluoroquinolones. So, reducing the use of those, depending on the given illness.
Host: Well thank you for that and as we wrap up, give us your best advice for the healthcare setting to hopefully prevent the spread of C. Diff., what you want healthcare facilities to know in response to increased rates or the emergence of a new strain. Really what you’d like them to know about preventing the spread of C. Diff.
Dr. Varma: I think the keys are one, appropriate testing. Knowing when to test someone who is on say a laxative is going to have loose stools in the first place, so knowing when to appropriately test, looking at the overall clinical picture, three or more loose stools within 24 hours that wasn’t existing at first, any concomitant abdominal pain, any elevation in WBC count or white blood cell count. Looking at the clinical picture first decide if testing is even needed, I think is the first step. And then while in the hospital, good hand hygiene, making sure one is gowned and gloved appropriately, making sure one is using hand hygiene before and after leaving the patient’s room. And I think antibiotic stewardships are the keys to helping reduce C. Diff. occurrence in our society.
Host: What a great informative segment Dr. Varma. Thank you so much for joining us. And that concludes this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit our website at www.carleconnect.com for more information and to get connected with one of our providers. We hope the information gained will be applicable to your work and life. I’m Melanie Cole.
Expert Insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit, please click on the link and complete the episode’s posttest.
Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I’m Melanie Cole and today, we’re discussing C. Diff. and joining me is Dr. Gotam Varma. He’s an Infectious Disease physician at the Carle Foundation Hospital. Dr. Varma, it’s a pleasure to have you here. First, give a working definition of C. Diff. and what diseases result and can result from a C. Diff. infection?
Gotam Varma, DO (Guest): C. Diff. is a bacterial infection that most commonly can cause diarrhea. It’s diarrhea we see in the hospital setting quite often and it can range from simple diarrhea to fulminant organ failure and cause something called toxic megacolon which is a bowel dilation which can be fatal in a lot of cases. So, the range of type of infection can be quite broad.
Host: So, what patients are at an increased risk and tell us while you are telling that, how it’s transmitted? Where is it found?
Dr. Varma: So, it can reside in our colon. It can also reside in the environment. And the type of person that can get it is wide ranging. We do see it a lot in hospitalized patients and different risk factors that can lead to C. Diff. is antibiotic use. So, those who take antibiotics for say pneumonia or a skin infection, what happens in those situations, is the antibiotics can – they are systemic antibiotics so they go through the whole system and they can start to decrease the population of good bacteria in our gut which can give the bad bacteria a chance to overgrow and that can lead to C. Diff. proliferating and causing infection.
Host: So, as we’re talking about proliferating, what’s the difference between C. Diff. colonization and actual infection?
Dr. Varma: C. Diff. colonization means that we may be having the bacteria in our system but it’s not actually causing a disease. So, for example, just to kind of parallel it, if you take a swab of my skin right now, you’re going to find different bacteria on my skin but it’s not causing an actual infection. It’s just colonizing that area. But for example, if I started developing redness and my skin became more painful and tender and started having drainage, we could then say that the bacteria that were on my skin that were colonizing it started acting up and causing infection. Likewise, the key to diagnosis of C. Diff. is not actually a diagnostic test, it’s symptoms. So, if somebody has diarrhea characterized by three or more watery stools within a 24 hour period and there is not another reason why they’re having diarrhea; that would be a hallmark of then checking for C. Diff. So, colonization means someone having a test done, a diagnostic test done and testing positive but not having any actual symptoms versus someone having symptoms and then having the test done and testing positive.
Host: So, then should testing for C. Diff. be performed more than once? You’re speaking to other providers here, so, if they are seeing a single episode of C. Diff. to improve diagnostic accuracy, could there be false positive results?
Dr. Varma: There definitely can be false positives. So, testing should only be done if someone meets the clinical criteria. Meaning that someone starts to have formed stools and starts to come in and have watery stools, the three or more loose or watery stools; that would be an indication for testing. Now our testing is quite sensitive and it’s actually a two stage test. So, if someone tests not negative on that test, we would not recommend repeating the C. Diff test. It’s negative predictive value is quite high meaning that if it’s negative, there’s a good chance that it’s not a false negative so then other reasons for why a person has diarrhea should be looked into.
Host: So, let’s talk about C. Diff. itself. Is it contagious on surfaces? Speak about the contagious factor of it. Can somebody be around? Do they need PPE? Should they be quarantined? Tell us a little bit about some of the protocols.
Dr. Varma: C. Diff. can be passed through fecal oral transmission. So, it can be passed. We are in a day of Coronavirus so, words like airborne and droplet are in the media a lot. This is not something that’s related to that, but it can exist on surfaces. It can exist in one’s stools so, in a hospital setting, good hand hygiene as well as good preventative measures are essential. So, for example, in our hospital, what we do if someone tests positive for C. Diff. they are usually isolated to a single room. If they need to be cohorted, they’d be cohorted with someone else with the same infection. All staff members are required to wear what we call contact plus isolation, so gowns, and gloves during examination. And then good hand hygiene is always recommended because C. Diff. exists in the spore form so, in order to get rid of those spores, alcohol sanitizing agents are at a minimum, but we usually recommend hand hygiene and of course, gowns and gloves. So, gowns, gloves, good hand hygiene are paramount. And then we do recommend good cleaning protocols within the hospital room itself once the patient leaves.
Host: So, how is it treated? What’s the best approach to drug selection for the first episode and what would you like other providers to know about treating recurring C. Diff?
Dr. Varma: Sure so, guidelines changed a bit in 2017. Before 2017, first someone comes in, they test positive for C. Diff. it’s their first bout and I’m talking to the old guidelines, not what we currently recommend. Firstline treatment was something called metronidazole, you could also use something called oral vancomycin. So, that was the old way of doing things for quite some time. The new guidelines now say for first bout of C. Diff. they recommend as first line treatment, not using the metronidazole and going straight to the oral vancomycin. So, if someone comes in, does not have toxic megacolon; they would recommend 10 to 14 days of oral vancomycin. The dose is 125 milligrams oral q. six hours. Also not inferior to that, and a second treatment modality that would be an option is something called fidaxomicin. The treatment for that is usually 200 milligrams twice a day for 10 days. So, that’s first line treatment. So, if somebody has a first bout of C. Diff.
Now if someone has C. Diff., they are at a higher chance of reoccurrence. So what happens at the reoccurrence? So, if you have your first reoccurrence or second bout of C. Diff. what they recommend is actually oral vancomycin with something called a taper. So, you are doing the full treatment dose which is the every six hours for 10 to 14 days and then you would go down and taper down slowly. So, we go from every six hours to maybe twice a day for a week and then once a day for a week and then every other day for a month. And the thought process there is to help give your bowels time to repopulate flora and give a longer treatment course to help get rid of the bacteria. So, that’s called the vancomycin pulse taper.
Another option is doing fidaxomicin as well for 10 days. So, that’s what they would recommend if you’re doing your first reoccurrence or second bout. What happens if you have say someone has three, four or five bouts of C. Diff., they still recommend the vancomycin pulse taper or fidaxomicin but we’re having quite good outcomes with fecal transplant. So that would be requiring gastroenterology colleagues where they would have stool that’s been properly looked at for any other concomitant infection and they would actually physically insert this stool whether it be through EGD or a colonoscopy into the bowel to help repopulate the bowel with good flora. So, when we have a person who has had multiple bouts of C. Diff. and they’re not getting better with medicinal ways of doing things; we’ve had good outcomes with fecal transplant.
Host: Wow, that’s so interesting. Dr. Varma, do you feel personally that antibiotic and antimicrobial stewardship programs might reduce the incidence of C. Diff. or as well as probiotics? Can they help to prevent the antibiotic associated diarrhea and maybe reduce C. Diff. associated diarrhea in children and adults?
Dr. Varma: I’ll start off with the probiotics. Unfortunately, the data is not conclusive if probiotics will actually help prevent or reduce chances of C. Diff. So, there’s some meta analyses that are small studies that say they may help but looking at the Infectious Disease Society of America guidelines, they can’t say officially that probiotics would help prevent that. So, what I usually tell a patient is someone wants to take a yogurt or take some probiotics, I’m not going to stand in the way or speak negatively about it. we can’t say for sure that it’s going to help prevent anything. So, it is just with that understanding.
From an antibiotic stewardship standpoint, I think that’s paramount and key to helping prevent C. Diff. or reduce the chances of obtaining it. For example, doctors can sometimes give antibiotics for say a pneumonia and it could be a simple viral pneumonia that they can give a bacterial course. In those situations, I think looking at a patient clinically is key because you can receive antibiotics for something say as benign as a pneumonia, a simple pneumonia that may not have needed those antibiotics and now have developed C. Diff. So, I think antibiotic stewardship is key. So, one, limiting antibiotics if they are not necessary. Two, reducing the course of antibiotics. So, different disease processes require different lengths of antibiotics, so, sticking with the pneumonia idea, you can treat a pneumonia for anywhere from five to 14 days. So, if a person is getting better quickly, and doesn’t need a long course of antibiotics, infectious disease guidelines actually state giving shorter courses for different illnesses if a person is improving versus longer courses.
And then the third thing one can do is while any antibiotic can lead to C. diff., there have even been anecdotal cases that Flagyl or metronidazole when it was being used as first line can actually cause C. Diff. too. But any antibiotic can cause C. Diff. but there’s certain antibiotics that have a higher risk. Things like clindamycin, cephalosporins, fluoroquinolones. So, reducing the use of those, depending on the given illness.
Host: Well thank you for that and as we wrap up, give us your best advice for the healthcare setting to hopefully prevent the spread of C. Diff., what you want healthcare facilities to know in response to increased rates or the emergence of a new strain. Really what you’d like them to know about preventing the spread of C. Diff.
Dr. Varma: I think the keys are one, appropriate testing. Knowing when to test someone who is on say a laxative is going to have loose stools in the first place, so knowing when to appropriately test, looking at the overall clinical picture, three or more loose stools within 24 hours that wasn’t existing at first, any concomitant abdominal pain, any elevation in WBC count or white blood cell count. Looking at the clinical picture first decide if testing is even needed, I think is the first step. And then while in the hospital, good hand hygiene, making sure one is gowned and gloved appropriately, making sure one is using hand hygiene before and after leaving the patient’s room. And I think antibiotic stewardships are the keys to helping reduce C. Diff. occurrence in our society.
Host: What a great informative segment Dr. Varma. Thank you so much for joining us. And that concludes this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit our website at www.carleconnect.com for more information and to get connected with one of our providers. We hope the information gained will be applicable to your work and life. I’m Melanie Cole.