Gut Reaction

The Hospitalist. 2011 December;2011(12):

December 1, 2011 | The Hospitalist

While a broad-spectrum antibiotic might be necessary at first, once the results of cultures are received, the treatment should be finely tailored to kill only the problem bacteria so that the body’s natural defenses aren’t broken down, Dr. Gould explains.

“If someone is very sick and you’re not sure what is going on, it’s very reasonable to treat them empirically with broad-spectrum antibiotics,” she says. “The important thing is that you send the appropriate cultures before so that you know what you’re treating and you can optimize those antibiotics with daily assessments.”

Dr. Cohen

It’s clear why an overreliance on broad-spectrum drugs prevails in U.S. health settings, Dr. Cohen acknowledges. Recent literature suggests treating critically ill patients with wide-ranging antimicrobials as the mortality rate can be twice as high with narrower options. “I think people have gotten very quick to give broad-spectrum therapy,” he says.

continued below...

Knocking Out Clostridium Difficile

Listen to Dr. Gould

Here are the guidelines on treatment of C. diff infections (CDI) as recommended by the Infectious Diseases Society of America:

First steps:

Discontinue therapy with the inciting antimicrobial agent(s) as soon as possible as this may inﬂuence the risk of CDI recurrence.
When severe or complicated CDI is suspected, initiate empirical treatment as soon as the diagnosis is suspected.
If the stool toxin assay result is negative, the decision to initiate, stop, or continue treatment must be individualized.
If possible, avoid use of antiperistaltic agents as they may obscure symptoms and precipitate toxic megacolon.

Treatment of initial episode:

Metronidazole is the drug of choice for the initial episode of mild to moderate CDI. The dosage is 500 mg orally three times per day for 10 to 14 days.
Vancomycin is the drug of choice for an initial episode of severe CDI. The dosage is 125 mg orally four times per day for 10 to 14 days.
Vancomycin administered orally (and per rectum if ileus is present) with or without intravenously administered metronidazole is the regimen of choice for the treatment of severe complicated CDI. The vancomycin dosage is 500 mg orally four times per day and 500 mg in approximately 100 mL normal saline per rectum every six hours as a retention enema, and the metronidazole dosage is 500 mg intravenously every eight hours.

Severely ill patients:

Consider colectomy for severely ill patients. Monitoring the serum lactate level and the peripheral blood white blood cell count may be helpful in prompting a decision to operate because a serum lactate level rising to 5 mmol/L and a white blood cell count rising to 50,000 cells per mL have been associated with greatly increased perioperative mortality. If surgical management is necessary, perform subtotal colectomy with preservation of the rectum.

Treatment of recurrences:

Treatment of the ﬁrst recurrence of CDI is usually with the same regimen as for the initial episode but should be stratiﬁed by disease severity (mild-to-moderate, severe, or severe complicated) as is recommended for treatment of the initial CDI episode.
Do not use metronidazole beyond the ﬁrst recurrence of CDI or for long-term chronic therapy because of potential for cumulative neurotoxicity.
Treatment of the second or later recurrence of CDI with vancomycin therapy using a tapered and/or pulse regimen is the preferred next strategy.

Probiotics:

Administration of currently available probiotics is not recommended to prevent primary CDI as there are limited data to support this approach and there is a potential risk of bloodstream infection.

Source: Cohen SH, Gerding DH, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control and Hospital Epidemiology. 2010;31(5):431–455.