Name:
An 82-Year-Old with Diarrhea
Description:
An 82-Year-Old with Diarrhea
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T00H05M10S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
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CATHY: Hi! Welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy. And I'm Charlie Wiener. And we're coming to you from the Johns Hopkins School of Medicine. Welcome to Harrison's Podclass. This is Episode 7: An 82 Year-Old woman with Diarrhea. I'll read the question. An 82-year-old woman with a history of dementia has been living in a nursing home for the past five years. She was seen by her primary care provider for evaluation of diarrhea four weeks ago.
CATHY: At that time, a stool sample was positive for C-difficile by PCR. She was treated for ten days with oral metronidazole, with improvement in her symptoms. However, she's had five loose bowel movements per day, starting four days ago, and now has increasing abdominal tenderness. A repeat stool PCR for C-difficile is positive. Cathy, what are your initial thoughts on this patient?
CATHY: The major risk factors here for C-difficile infection are her older age of 82, and the fact that she lives in a nursing home. Other risk factors that aren't mentioned here would be antibiotic use, a lot of comorbid disease or gastric acid suppression. We also hear that after initial treatment she did get better and her diarrhea improved. But then she started having diarrhea again. As a side note, if she'd continued to do well, we wouldn't have needed to retest her with repeat PCR on her stool.
CATHY: But because she's having new symptoms, it wasn't appropriate to retest her and she's still positive, so has recurrent C-dif infection. This is seen in up to 30% of patients after initial treatment and it can be because of either relapse of the primary infection or re-infection if the same risk factors exist. For example, here we hear that she's still in a nursing home, so her older age and being in a health care facility are additional risk factors for recurrent disease.
CHARLIE: Great! So, the question asks, "Which of the following is the most appropriate therapy at this time?" Option A is fecal microbiota transplantation; Option B is intravenous immunoglobulin; Option C is oral metronidazole; Option D is oral nitazoxanide; and Option E is oral vancomycin.
CATHY: Well, it isn't mentioned here, but when possible, you want to try and stop any medications that could be contributing to the increased risk of disease. For example, if she were on antibiotics, that could be stopped. In this case, the patient was initially treated with metronidazole, and this is actually no longer recommended as first-line therapy. The most recent guidelines that were put out by the IDSA or Infectious Disease Society of America, suggest oral vancomycin or fidaxomicin for ten days as initial treatment for C-difficile infection.
CATHY: If either of those are unavailable, you could still use metronidazole but it's no longer supposed to be first-line therapy. However, we have recurrent disease so definitely, in recurrent disease, you would want to use vancomycin, so choice E is really the right answer. If fidaxomicin was available or mentioned, that would also be another choice.
CHARLIE: What about the other choices that were offered in this question?
CATHY: The other choices are only indicated for refractory or severe disease so would not apply to our patient. For example, fecal microbiota transplantation has been growing in popularity for severe or refractory disease in recent years, but it's not FDA approved. But the goal with that therapy is to restore normal colonic microbial flora.
CHARLIE: Well, not mentioned in this question, the other topic that always comes up when talking about C-difficile is which antibiotics expose the patients to the greatest risk? Any thoughts on that?
CATHY: Clindamycin, ampicillin and cephalosporins were the earliest antibiotics to be associated with C-difficile disease. More recently we've heard about broad-spectrum fluoroquinolones like moxifloxacin and ciprofloxacin also being associated. But in reality, any antibiotic, including the ones that we used to treat the disease such as vancomycin and metronidazole, can disrupt the colonic microbiota and therefore can increase the risk of C-dif infection. Another comment on prevention: remember that C-dif is a spore-forming organism, and appropriate hand hygiene with soap and water is needed in the hospital to try and prevent nosocomial infection.
CATHY: The topical alcohol-based solutions which we use most commonly are not really adequate to kill the spores from C-dif infections, so soap and water is the way to go.
CHARLIE: And let's make sure that we are diligent about our isolation because many of these infections are transferred nosocomially or institutionally from patient to patient. The teaching point here for this case is that there are new recommendations for the treatment of C-difficile that recommend first-line treatment with vancomycin or fidaxomicin, not metronidazole, which we've been using for many, many years. For a non-severe first recurrence, you can also re-treat with vancomycin or fidaxomicin.
CATHY: For more information, you can see the chapter on C-difficile infection in the Infectious Disease section of Harrison's Internal Medicine, and we'd refer you to the recent clinical practice guidelines for Clostridium difficile infection, published in Clinical Infectious Diseases on April 1, 2018. ♪ (music) ♪