Category Archives: C. diff. for Healthcare Providers

American Society of Colon and Rectal Surgeons (ASCRS) June 2021 Clinical Practice Guidelines: Management of a CDI

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Clostridioides difficile Infection

Poylin, Vitaliy M.D.1; Hawkins, Alexander T. M.D., M.P.H.2; Bhama, Anuradha R. M.D.3; Boutros, Marylise M.D.4; Lightner, Amy L. M.D.5; Khanna, Sahil M.B.B.S., M.S.6; Paquette, Ian M. M.D.7; Feingold, Daniel L. M.D.8; Prepared by the Clinical Practice Guidelines Committee of The American Society of Colon and Rectal Surgeons

Author Information
Diseases of the Colon & Rectum: June 2021 – Volume 64 – Issue 6 – p 650-668
doi: 10.1097/DCR.0000000000002047
 

The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. Although not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines.

These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician considering all the circumstances presented by the individual patient.

STATEMENT OF THE PROBLEM

Clostridioides difficile, formerly known as Clostridium difficile, is an anaerobic, gram-positive, bacillus bacterium that can be a normal inhabitant of the human colon and is most commonly transmitted via a fecal-oral route.1 Alterations in the bacterial component of the microbiota, most often due to the use of antibiotics, can lead to ecological changes that select for both population growth of C difficile as well as the induction of pathogenic behavior.2,3 Although the number of patients with C difficile infection (CDI) in the United States appears relatively stable over the past decade (estimated 476,400 cases in 2011 associated with 29,000 deaths and 462,100 cases in 2017 associated with an estimated 20,500 deaths), the prevalence of the disease remains high.3–5 Although the bacterium is present in the stool of approximately 3% of healthy adults, up to 50% of those exposed to an inpatient facility may be asymptomatic carriers.5–8 Higher rates of CDI have been reported in patients after exposure to a prolonged duration of antibiotics including perioperative antibiotics and in patients with underlying comorbid conditions such as IBD or immunosuppression.9–15

Clinical manifestations of C difficile can range from an asymptomatic carrier state to mild CDI to severe, fulminant, life-threatening infection. Although descriptions of presentation and severity of disease vary in the literature, commonly used definitions are included in Table 1.16–19C difficile infection most commonly involves the colon, where it can manifest with pseudomembranes covering the colonic mucosa (“pseudomembranous colitis”). In rare circumstances, CDI may also involve the small bowel.20,21 In the early 2000s, predominantly in North America, but also in Europe, there was an increased incidence of more severe CDI due to the emergence of certain bacterial strains (ie, ribotypes) like the BI/NAP1/027/toxinotype III strain, which is associated with a life-threatening infection.22–25 Although rates of infection with this “hypervirulent” strain recently decreased in North America, rates remain significant globally.26,27

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https://journals.lww.com/dcrjournal/Fulltext/2021/06000/The_American_Society_of_Colon_and_Rectal_Surgeons.5.aspx

American College of Gastroenterology Issued New Guidelines On Management Of Clostridioides difficile (C. diff., C. difficile, CDI)

The American College of Gastroenterology has issued new guidelines on the management of Clostridioides difficile infection (CDI), with recommendations reflecting developments from the availability of biologics to the growing use of fecal microbiota transplantation (FMT).

“These guidelines are a step forward in our understanding of C. difficile,” commented Sahil Khanna, MBBS, MS, a professor of medicine at Mayo Clinic in Rochester, Minn., who was not involved in the guideline development.

“For the practicing provider, there are some big changes in the treatment and testing of the disease,” Dr. Khanna said. For example, although the 2013 ACG guidelines on the topic recommended metronidazole or vancomycin for treatment of a first mild to moderate episode of CDI, he said, the new guidelines now suggest vancomycin or fidaxomicin (Dificid, Merck) for a first episode of non-fulminant CDI. Metronidazole now is suggested only as treatment for initial non-severe CDI in very low-risk patients.

“Metronidazole has already been on the decline in clinical use, and I think these guidelines will lead to further reduction of its use,” Dr. Khanna said.

A notable update in the new guidelines is a recommendation that bezlotoxumab (Zinplava, Merck) be considered for the prevention of CDI recurrence in patients at high risk for recurrence, he said. “This is the first time bezlotoxumab has made it into a major society guideline for the gastroenterology and infectious disease community, and I think it will help get the drug covered more often by payors and make it available more widely to the practicing clinician.”

ACG 2021
Annual Scientific Meeting & Postgraduate Course

The Premier GI Clinical Meeting
& Postgraduate Course

October 22-27, 2021 • Mandalay Bay

Another update that reflects the evolving body of evidence that has emerged over the past several years is a strong recommendation that FMT be considered for use after two CDI recurrences, or in patients with severe and fulminant CDI refractory to antibiotic therapy, particularly when they are poor surgical candidates, Dr. Khanna said. “The previous recommendation in 2013 was to consider FMT, but the body of research has grown to demonstrate its efficacy,” he said.

The guideline authors recommend that FMT be repeated for patients experiencing a recurrence of CDI within eight weeks of an initial FMT. In addition, for patients with recurrent CDI who are not candidates for FMT, have relapsed after FMT, or require ongoing or frequent courses of antibiotics, the guidelines suggest using long-term suppressive oral vancomycin.

For patients with a first recurrence of CDI, the guidelines suggest use of tapering or pulsed-dose vancomycin or fidaxomicin if patients were previously administered vancomycin or metronidazole.

The guidelines recommend testing only of patients with symptoms suggestive of active CDI and use of a highly sensitive and specific CDI testing algorithm to help distinguish between colonization and active infection.

According to the guidelines, severe CDI is diagnosed if the white blood cell count is 15,000 cells/mm3 or higher or serum creatinine is greater than 1.5 mg/dL, and fulminant CDI should be diagnosed if the patient has hypotension, shock, ileus or megacolon in the presence of typical CDI symptoms.

For patients with fulminant CDI, the guideline authors urge adequate volume resuscitation and oral vancomycin for the first 48 to 72 hours, with the possible addition of parenteral metronidazole, and use of vancomycin enemas for patients with an ileus.

The panel also recommends against discontinuing antisecretory therapy when it is indicated in patients with CDI. They also include a recommendation against the use of probiotics to prevent CDI or recurrent CDI.

There are several recommendations specifically targeted to the inflammatory bowel disease population, including CDI testing of IBD patients presenting with an acute flare and diarrhea. Other population-specific recommendations target patients who are pregnant, lactating or immunocompromised.

 

ACG 2021
Annual Scientific Meeting & Postgraduate Course

The Premier GI Clinical Meeting
& Postgraduate Course

October 22-27, 2021 • Mandalay Bay

 

Changes In Electronic Health Records (EHR) To Guide Clinicians In C. diff. Diagnostic Stewardship – To Pause Testing When Not Clinically Indicated

An intervention that required administrative approval of all Clostridioides difficile testing after

hospital day 3 out-performed electronic health record-based support in reducing

C. difficile testing, according to a study.

“We made a series of changes in the electronic health records (EHRs) that we hoped would discourage clinicians from ordering C. difficile tests when testing was not clinically indicated, such as when patients with diarrhea had a more likely explanation such as recent laxative use, or when testing was ordered on patients who were not having diarrhea or other symptoms of C. difficile infection at all,” Lewis said. “In addition, one hospital in our system independently implemented a physician ‘gatekeeper’ to approve all C. difficile test orders for admitted patients.”

“We performed this work as part of a larger quality improvement initiative with the goal of improving the accuracy of diagnosis of C. difficile infection in order to improve quality of care for patients and decrease our health system’s publicly reported rates of C. difficile,” Sarah S. Lewis, MD, MPH, associate professor of medicine in the division of infectious diseases at Duke University Medical Center, told Healio.

“We made a series of changes in the electronic health records (EHRs) that we hoped would discourage clinicians from ordering C. difficile tests when testing was not clinically indicated, such as when patients with diarrhea had a more likely explanation such as recent laxative use, or when testing was ordered on patients who were not having diarrhea or other symptoms of
C. difficile infection at all,” Lewis said. “In addition, one hospital in our system independently implemented a physician ‘gatekeeper’ to approve all C. difficile test orders for admitted patients.”

Lewis and colleagues tested the three EHR-based interventions at three hospitals. The first intervention, initiated in January 2018, alerted clinicians ordering a test if laxatives were administered within 24 hours. The second, initiated in October 2018, canceled test orders after 24 hours. Implemented in July 2019, he third intervention involved “contextual rule-driven order questions” that required justification when laxatives were administered or there was a lack of EHR documentation of diarrhea. In February 2019, one of the three hospitals then implemented the “gatekeeper intervention” requiring approval for all C. difficile tests after 3 days in the hospital.

Sarah S. Lewis

Lewis and colleagues estimated the impact of the interventions on C. difficile testing and hospital-onset C. difficile infection (HO-CDI) using an interrupted time-series analysis. They found that C. difficile testing was already declining in the preintervention period (annual change in incidence rate [IR] = 0.79; 95% CI, 0.72-0.87) and did not decrease further with the EHR interventions.

The study demonstrated, however, that the laxative alert was temporally associated with a trend reduction in HO-CDI (annual change in IR from baseline = 0.85; 95% CI, 0.75-0.96) at two hospitals. Meanwhile, the gatekeeper intervention at the third hospital was associated with level (incidence rate ratio [IRR[ = 0.5; 95% CI, 0.42-0.6) and trend reductions in C. difficile testing (annual change in IR = 0.91; 95% CI, 0.85-0.98) and level (IRR = 0.42; 95% CI, 0.22-0.81) and trend reductions in HO-CDI (annual change in IR = 0.68; 95% CI, 0.5–0.92) relative to the baseline period, the researchers reported.

“Diagnostic stewardship, or the appropriate utilization of diagnostic tests, is important for improving quality of care. Electronic decision support in the form of alerts or background logic to reinforce the desired provider behavior is attractive because it is relatively low resource, easy to implement, and can be programmed in a way that is relatively unobtrusive to the clinical workflow,” Lewis said. “However, as we and others have seen, decision support often needs to be coupled with both provider education and some form of administrative restriction to achieve desired goals.”

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C. diff. Spores and More Live Broadcast Enters Season VI

Welcome to Season VI on 

C. diff. Spores and More

Live Broadcast, sponsored

by Clorox Healthcare.

 

With over 260 archived episodes ~ Listen At Your Leisure


It’s a new year with an entirely new line up of guests eager to share their C. difficile research, infection prevention methods, clinical trials in progress, the updates in the C. diff. community, and much more.

 

 

 

 

In March the post-Patient and Family Symposium presentations will broadcast, in the event you weren’t able to attend the live-online event hosted on January 15th. The first annual Patient and Family Symposium was sponsored by Seres Therapeutics

Do you have a specific topic of interest or would like to learn more about a specific product or procedure?  Send an email to info@cdifffoundation.org and share your suggestions and interests.

“None of us can do this alone ~ All of us can do this together.”

Join us every Tuesday at 1:00 p.m. EST for the Live Broadcast  www.cdiffradio.com

 

A Team, Led by Travis J. Carlson, Department of Clinical Sciences, High Point University Fred Wilson School of Pharmacy, Define Kidney Injuries as a CDI Disease Severity Marker

Travis Carlson, PharmD

A recent update (Oct. 2020)  of the guidelines for Clostridioides difficile infections (CDI) might allow clinicians to accurately predict viral severity in kidney disease patients.

In 2017, the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) revised their C. diff infection severity classification criteria to include an absolute serum creatinine (SCr) value above the threshold of at least 1.5 mg/dL as opposed to a relative increase from baseline of at least 1.5 times the premorbid level.

A team, led by Travis J. Carlson, Department of Clinical Sciences, High Point University Fred Wilson School of Pharmacy, sought to best define kidney injuries as a CDI disease severity marker to make it easier to assess severe outcomes linked to CDI.

In the multicenter, cohort study, the investigators assessed adult hospitalized patients with a C. diff infection for the presence of an acute kidney injury (AKI), chronic kidney disease (CKD), and CDI severity using the 2010 and 2017 IDSA/SHEACDI guidelines.

The investigators sought primary outcomes of all-cause inpatient mortality.

In the final analysis, the investigators examined 770 C. diff infection episodes from a total of 705 patients aged 65±17 years (female, 54%; CKD, 36.5%; AKI, 29.6%).

In addition, 82 episodes (10.6%) showed discordant severity classification results because of the inclusion of more patients with preexisting chronic kidney disease in the severe disease category using an absolute SCr threshold criterion.

The absolute SCr criterion better correlated with all-cause mortality (OR, 4.04; 95% CI, 1.76-9.28; P = 0.001) than the relative increase in SCr (OR, 1.34; 95% CI, 0.62-2.89; = 0.46).

The investigators found this corresponded with an increased likelihood of the 2017 CDI severity classification criteria to predict mortality (OR, 5.33; 95% CI, 1.81-15.72; = 0.002) compared to the 2010 criteria ( OR, 2.71; 95% CI, 1.16-6.32; = 0.02).

“Our findings support the 2017 IDSA/SHEA CDI severity classification criteria of a single pre-treatment SCr in future CDI guideline updates,” the authors wrote.

New data shows positive trends regarding C. diff infections and hospitalization within the last 10 years.

A team, led by Alice Y. Guh, MPH, identified cases of C. diff infections in stool specimens positive for C. diff in an individual at least 1-year-old with no positive test in the previous 8 weeks in 10 US sites.

Overall, they identified 15,461 cases in 2011—10,177 healthcare-associated cases and 5284 community-associated cases. In 2017, they identified 15,512 cases—7973 healthcare-associated cases and 7539 community-associated cases.

The estimated national burden of infections was 476,400 (95% CI, 419,900-532,900) in 2011 and 462,100 cases (95% CI, 428,600-495,600) in 2017.

After accounting for NAAT use, the adjusted estimate of the total burden of C. diff infection decreased by 24% from 2011 through 2017 (95% CI, 6-36).

The study, “Assessment of Kidney Injury as a Severity Criteria for Clostridioides difficile Infection,” was published online in Open Forum Infectious Diseases