Review the management of Clostridioides difficile Infections (CDI).
A 71-year-old man is evaluated for a 7-day history of diarrhea. He has been diagnosed with Clostridioides difficile 5 times in the past 6 months, during which he has been treated 3 times with oral vancomycin 125 mg 4 times daily and 2 times with fidaxomicin. The duration of treatments has been 14–21 days after which his symptoms improve. This is his sixth episode. Currently, he has 4 to 8 episodes of nonformed liquid stools per day. He reports no fevers, vomiting, abdominal pain, or other constitutional symptoms. His prior history is significant for hypertension and dyslipidemia for which he takes HCTZ with lisinopril and atorvastatin for the past 7 years. He lives at home with his wife.
Physical examination discloses a comfortable patient who is afebrile. His pulse in 98 and regular. Blood pressure is 118/72. The abdomen is soft, nontender, and not distended. Bowel sounds are normal. Laboratory studies show normal blood count, normal BUN/creatinine and normal ESR. Enzyme immunoassay and PCR testing in the stool are both positive for C. difficile. An abdominal CT scan with contrast is unremarkable.
Which of the following is the most appropriate next step in the management of this patient?
- a. Oral vancomycin at 500 mg 4 times daily for 3–4 weeks
- b. Oral metronidazole for 3–4 weeks
- c. Fecal microbiota transplantation (FMT)
- d. Colonoscopy
A 42-year-old woman is hospitalized with health care-related pneumonia. In the intensive care unit she is treated with intravenous (IV) vancomycin and piperacillin-tazobactam after which there is stabilization of symptoms. On day 6 she develops 5–6 loose liquid bowel movements over 24 hours. The next morning her temperature is 39.3° C, blood pressure 96/64, pulse 116, and she has lower abdominal pain. The exam is remarkable for abdominal distension, abdominal tenderness, and absent bowel sounds. Rebound tenderness is absent. Lab tests show white blood cell count of 21,500/mm3, normocytic anemia, normal platelets, and elevated creatinine 2 times her baseline level. Liver related enzymes are within normal limits and albumin 2.2 g/dL.
Along with adequate volume resuscitation, which of the following is the next best step in management of this patient?
- a. Oral vancomycin 125 mg 4 times per day
- b. Oral fidaxomicin
- c. IV metronidazole
- d. Oral vancomycin 500 mg 4 times per day along with IV metronidazole
Which of the following is an indication for the use of probiotics in the prevention of CDI in patients being treated with antibiotics?
- a. A 56-year-old man with history of recurrent CDI admitted to the ICU with a diabetic foot infection and started on piperacillin-tazobactam and vancomycin
- b. A 44-year-old woman with mild CDI and lung abscess started on 4–6 weeks of clindamycin and meropenem
- c. A 71-year-old man who resides in a nursing home and is recently discharged from the hospital after he received a prolonged antibiotic course of ceftriaxone and azithromycin for community acquired pneumonia
- d. None of the above