Disclosure None C. Difficile Infections Hueylan Chern MD - PowerPoint PPT Presentation

3/8/2014 Disclosure • None C. Difficile Infections Hueylan Chern MD Assistant Professor of Surgery UCSF Outline Pathogenesis • Pathogenesis • Anaerobic, Gram-positive, spore forming rod • Epidemiology • Toxin damaging to the colonic mucosa • Clinical presentation • Toxins A and B cause marked systemic inflammatory response • Diagnosis • Medical management • Surgical options 1

3/8/2014 Epidemiology Risk Factors • Increasing incidence, morbidity and mortality • Strongest risk factor • NAP1/B1/027 hypervirulent strain – antimicrobial exposure – up to 98% patients having at least one dose of antibiotics in the preceding 2 weeks • Incidence rates up to 9.5 cases per 10k patient- • Wide range of antibiotics implicated in CDI days from 3.8 in Canada • Elderly, PPIs , immunosuppressed, IBD • Up to 1096.5 discharges per 100k from 463.1 in patients Michigan Cohen et al; Infect Control Hosp Epidemiol 2010;31(5):431–45511 VerLee et al; Public Health Rep 2012;127(1):62–71 Clinical presentation Diagnosis • Watery diarrhea, non bloody • Lab confirmation of C difficile toxin • Ileus, distension, fever, tachycardia, sepsis, • Leukocytosis, hypoalbuminemia (protein- shock losing enteropathy) • Abdominal Xray to evaluate for colonic distention, free air • CT can show colonic thickening, stranding, ascites 2

3/8/2014 Medical Management Medical Management • Inciting antibiotics should be stopped if possible • Fidaxomicin similar in efficacy to vanco in • Antidiarrheal medications should be discontinued initial clinical cure and more effective in • Oral metronidazole 10-14 days for mild case is first-line preventing recurrence; but expensive • Consider low dose vanco for more severe infection Louie et al. N Engl J Med 2011;364(5):422–31. • High dose PO Vancomycin AND IV metronidazole for complicated CDI (shock, megacolon, ICU admission) • Rectal Vancomycin enema helpful in cases of severe ileus Operative Management • Acute surgical abdomen requires emergency surgery • Deciding when to intervene is more difficult • Mortality in patients after colectomy as high as 34 to 57% • Predictors of mortality: multiorgan failure 94% 10 weeks after transplant vs 23% and 31% response rate 3

3/8/2014 Operative Management Operative Management • Subtotal colectomy with end ileostomy • Diverting loop ileostomy and colonic lavage – How to manage Rectal stump – Followed by antegrade vancomycin enemas and iv metronidazole – 93% colon preserve, 19% mortality Neal et al. Ann Surg 2011;254 (3):423–427 Summary • Clostridium Difficile infection is increasing in prevalence and severity • Antibiotic exposure is the strongest risk factor • Metronidazole and Vancomycin are the main medical treatment • Surgery should be considered for complicated infection or fulminant disease • Subtotal colectomy with end ileostomy 4