1) Risk factors:
- Age >65yrs
- Recent antibiotic use (all and any abx use will put patients at risk for C. diff but increased risk if multiple abx and prolonged use)
- Recent hospitalization or residence in a nursing home/health care facility
- Treatment with PPI
- Comorbidities (DM, liver disease, CKD, cancer on treatment, solid organ transplant)
- Initial episode, mild/moderate
- WBC less than 15, Creat less than 1.5 x baseline
- Treat with metronidazole 500mg PO TID x 10-14 days
- Initial episode, severe
- WBC greater than 15, Creat greater than 1.5 x baseline
- Treat with Vancomycin 125mg PO QID x 10-14 days
- Initial episode, severe + complicated
- WBC greater than 15, Creatinine greater than 1.5 x baseline
- PLUS toxic megacolon, ileus, shock
- Vanco 500mg PO QID and consider rectal instillation if ileus
- IV Metronidazole 500mg Q8H
- Surgical consult
- Initial recurrence
- Classify as mild/moderate/severe/complicated and treat appropriately
- Ok to treat with metronidazole if mild disease, however avoid prolonged metronidazole to avoid neurotoxicity
- Second recurrence
- Treat according to severity, otherwise treat with Vancomycin 125mg PO QID with a tapered regimen
- See the IDSA guidelines for more details: IDSA Clinical Treatment guidelines for C. diff 2010
2) Diagnosis of Toxic Megacolon:
- Etiology: IBD, infectious (c. diff, CMV, shigella, salmonella, e.coli, etamoeba histiolytica etc.)
- Diagnosis:
- Radiographic findings (greater than 10cm)
- At least three of: fever, elevated WBC, tachycardia, anemia, dehydration, altered sensorium, electrolyte abN, hypotension.
- Treatment:
- Surgical consult!
- Medical Mx: ICU admission, NG tube for decompression, restart eteral feeding as soon as symptoms improve, consider IV steroids in IBD associated toxic megacolon
1 comment :
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