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Therapy of Clostridium Difficile Infection

May 11 , 2018

Forwarded on behalf of the Edmonton Zone Antimicrobial Stewardship Working Group 

2018-05-11 AHS COV Logo

OUR GOAL: Provide interim recommendations and a status update about treatment of Clostridium difficile infection (CDI) in adult patients in the Edmonton Zone, while existing CDI algorithms are under review.

WHY?

This is an interim communication to Edmonton Zone acute care sites, regarding the status of CDI therapy guidelines in AHS. New C. difficile infection (CDI) guidelines were recently published in the US (1) and a national guideline is forthcoming in Canada. To interpret and apply new guidelines in the provincial context, both a full review of CDI algorithms across the province and an assessment of formulary issues that may arise with any changes in treatment recommendations are underway.

Patient Population: All adult patients with symptomatic CDI who require antimicrobial therapy.

Key points - Diagnosis:

    • Non-diarrheal stool should not be sent for CDI testing.
    • Asymptomatic patients should NOT be tested, and repeat testing after therapy is not recommended
    • Laboratory tests for C. difficile are very sensitive. A toxin gene PCR positive result (reported when toxin is NOT detected) can be seen in colonization, past infection, or possibly current infection; therefore, other causes of diarrhea should be considered. Laboratory bulletins from UAH Provlab and DynaLIFE laboratories, detailing changes in laboratory reporting, will be distributed and posted soon.
    • Contact precautions are recommended for any patient with diarrhea (usually until after diarrhea resolves).

Key Points – Therapy (Adults):

    • The 2017 IDSA guidelines list vancomycin 125 mg po QID as first line therapy for CDI in adult patients regardless of severity (1), and metronidazole is recommended as an alternate if oral vancomycin cannot be accessed.
    • In fulminant CDI with shock/megacolon, the addition of metronidazole 500 mg IV q8h to oral vancomycin is suggested, with consideration for rectal vancomycin by retention enema if ileus is present.
    • The role of metronidazole in treatment of mild-to-moderate severity CDI in AHS is under evaluation. A provincial stakeholder group will review current guidelines and references to apply them in our local context, as the data supporting superiority of oral vancomycin compared to oral metronidazole is primarily in severe CDI.
    • Fecal microbiota transplantation (FMT) should be considered after the second recurrence/3rd episode (accessed through consultation to Dr. Dina Kao, UAH Gastroenterology.)

Current status - formulary:

    • The therapeutic interchange from oral vancomycin to oral metronidazole in mild-to-moderate CDI has been suspended.
    • The non-formulary status and requirement for Short Term Exceptional Drug Therapy (STEDT) approval prior to use of fidaxomicin for inpatients remains, pending review of formulary status and development of restrictions/guidelines.

Next Steps:

    • Alberta Health has been made aware of the IDSA guidelines, to promote their concurrent review of outpatient coverage (Alberta Drug Benefit List [ADBL]) issues for use of oral vancomycin and fidaxomicin.
    • There are seven CDI pre-printed patient care orders (PPCOs) in use across the province – a Clinical Knowledge Topic review is currently underway which will inform updates to these documents.

1. L Clifford McDonald, Dale N Gerding, Stuart Johnson, et al. 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 2018;66:e1–e48. https://doi.org/10.1093/cid/cix1085

 

Edmonton Zone Antimicrobial Stewardship Membership LIst
Area/Site Represented Name
Infectious Diseases Lynora Saxinger (Co-Chair)
Bonita Lee
Alena Tse
Holly Hoang
Integrated Quality Management Vanessa Moorgen (Co-Chair)
Microbiology Mao-Cheng Lee
Tanis Dingle
Prenilla Naidu
Infection Prevention & Control Uma Chandran
Stephanie Smith
Melody Cordoviz
Pharmacy Services - Executive Director Kelly Olstad (Co-Chair)
Pharmacy Services - Clinical Practice Lead Mary Gunther
Pharmacy Services - Drug Stewardship Pharmacist Michael Guirguis
Antimicrobial Stewardship/ Infectious Diseases Susan Fryters
Pharmacy
Covenant Health Owen Degenhardt
Karen Zurek
Suburban - Ft. Sask Kristina Haagsma
Suburban - Westview Shelly Proft
RAH Roberta Stasyk
UAH/MAZ/Stollery Gordon Bell
Cecilia Lau
Serena Bains
Sturgeon Kim Fitzgerald
CCI Melanie Varughese
Corrections Kory Sloan
Suzanne Henry
Continuing Care Sandra Leung
Redwater Maryann Chmilar
Clinical Operations
Zone Operative Service Quality and Patient Safety Committee Heather Carew
Covenant Health Gordon Stewart
Suburban Marg Hadley
Prescribers - Physicians and Nurse Practitioners
Suburban - Westview Health Centre Dr. Stephen Chihrin
Suburban - Leduc Community Hospital Dr. Keith Barry
Suburban - Fort Saskatchewan Community Hospital Dr. Qaiser Rizvi
Suburban - Devon Community Hospital Dr. Donna Klay
Suburban - Strathcona Community Hospital Daris Klemmer
Suburban - Northeast Community Health Centre Dr. Alex Yeung
UAH/MAZ Dr. Justin Cheng
Sturgeon Dr. Edel Dromey
Corrections Dr. Rabia Ahmed
Continuing Care Dr. Douglas Faulder

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