Nneoma Odoemena

Preceptor Richard Williams

February 23, 2018

Summary of CDI

C difficile is a gram-positive, spore-forming, anaerobic, toxin-producing bacillus that is

transmitted via the fecal-oral route.8,9 Spores are typically spread via unclean surfaces, through

contact with contaminated feces and/or dirty hands, and through failure to notify the receiving

healthcare facility when patients with an existing CDI infection are transferred from another

healthcare facility. Approximately 30% of patients admitted to hospitals in the United States are

asymptomatic carriers of C difficile, with prevalence increasing to 50% in patients with a history

of long-term hospitalization. Although presence of asymptomatic carriers in nosocomial settings

increases the risk of transmission to others, it does not increase the risk of CDI in the carrier and

may actually be protective against symptomatic disease. Some risk factors of C. Diff include

taking proton pump inhibitors, antibiotics, going through chemotherapy. Some other risk factors

include chronic conditions such as inflammatory bowel disease, immunocompromising

conditions and even being older than 65 years old.

Symptoms of CDI can range from carriers who are asymptomatic to patients with

fulminant colitis and multi organ failure. C. Diff is a watery diarrhea with a foul odor occurring

every 1 to 2 hours with abdominal cramps, sub febrile temperature, and leukocytosis.

Leukocytosis can precede diarrhea by 1 to 2 days. Mild symptoms consist of diarrhea without

colitis signs/symptoms. Moderate colitis with fever, abdominal cramps/ discomfort. Severe

symptoms are with white blood cells more than $15,000 c/mL; with a serum albumin of >3g/dL
and aSCr 1.5 time greater. There are two treatment guidelines available: one from the Society for

Healthcare Epidemiology of America (SHEA) with the Infectious Diseases Society of America

(IDSA), and a separate statement by the American College of Gastroenterology (ACG)

Several tests confirm CDI; each has pros and cons. Real-time polymerase chain reaction

(RT-PCR) and nucleic amplification tests (NAAT) are the standard of care.9 One limitation of

RT-PCR testing is that it detects toxin genes but does not indicate if these are active toxins, and

it is not quantitative, so the value in asymptomatic carriers is unclear. RT-PCR testing is also

potentially limited by the prevalence of a symptom. Research surrounding new therapies has

been a focus in the last decade because of the increasing prevalence of CDI and resistant and

pathogenic strains. Therapies investigated include vaccines, monoclonal antibodies, new

antibiotics, and synthetic stool products. Several vaccines are currently in development that

contain modified C difficile toxins to lead a serum antibody response, resulting in

seroconversion.

Research surrounding new therapies has been a focus in the last decade because of the

increasing prevalence of CDI and resistant and pathogenic strains. Therapies investigated include

vaccines, monoclonal antibodies, new antibiotics, and synthetic stool products. Several vaccines

are currently in development that contain modified C difficile toxins to lead a serum antibody

response, resulting in seroconversion. The vaccines furthest along in development are all three-

dose series that would be indicated for primary prevention. Considerable efforts by pharmacists

and other members of the healthcare team would be required, therefore, to identify patients at

greatest risk for CDI. The vaccines would not be indicated for prevention of recurrent infections.
 CDI remains a prevalent public health concern in the U.S. Emerging therapies may play a

role in both primary prevention of CDI and limiting recurrence in patients who have had CDI

previously