Critical Care Management of the Patient with
Clostridioides difficile
by Adelman, Max W.; Woodworth, Michael H.; Shaffer, Virginia
O.; Martin, Greg S.; Kraft, Colleen S.
Critical Care
Medicine: January 2021
- Volume 49 - Issue 1 - p 127-139
OBJECTIVES:
To review published clinical evidence on management of
Clostridioides difficile infection in critically ill patients.
DATA SOURCES: We obtained relevant studies from a PubMed
literature review and bibliographies of reviewed articles.
STUDY SELECTION: We selected English-language studies
addressing aspects of C. difficile infection relevant to critical care
clinicians including epidemiology, risk factors, diagnosis, treatment, and
prevention, with a focus on high-quality clinical evidence.
DATA EXTRACTION: We reviewed potentially relevant studies
and abstracted information on study design, methods, patient selection, and
results of relevant studies. This is a synthetic (i.e., not systematic) review.
DATA SYNTHESIS: C. difficile infection is the most common
healthcare-associated infection in the United States. Antibiotics are the most
significant C. difficile infection risk factor, and among antibiotics,
cephalosporins, clindamycin, carbapenems, fluoroquinolones, and
piperacillin-tazobactam confer the highest risk. Age, diabetes mellitus,
inflammatory bowel disease, and end-stage renal disease are risk factors for C.
difficile infection development and mortality. C. difficile infection diagnosis
is based on testing appropriately selected patients with diarrhea or on
clinical suspicion for patients with ileus. Patients with fulminant disease (C.
difficile infection with hypotension, shock, ileus, or megacolon) should be
treated with oral vancomycin and IV metronidazole, as well as rectal vancomycin
in case of ileus. Patients who do not respond to initial therapy should be
considered for fecal microbiota transplant or surgery. Proper infection
prevention practices decrease C. difficile infection risk.
CONCLUSIONS: Strong clinical evidence supports limiting
antibiotics when possible to decrease C. difficile infection risk. For patients
with fulminant C. difficile infection, oral vancomycin reduces mortality, and
adjunctive therapies (including IV metronidazole) and interventions (including
fecal microbiota transplant) may benefit select patients. Several important
questions remain regarding fulminant C. difficile infection management,
including which patients benefit from fecal microbiota transplant or surgery.
