Critical Care Management of the Patient with Clostridioides difficile

 

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.

Corticosteroids in severe COVID-19: a critical view of the evidence

 

Corticosteroids in severe COVID-19: a critical view of the evidence

 

by Daniel De Backer, Elie Azoulay and Jean-Louis Vincent 

 

Critical Care volume 24, Article number: 627 (2020)

 

Since December 2019, SARS-CoV-2 has infected millions of people worldwide, causing excess deaths and a surge in demand for ICU beds. With no effective therapies against SARS-CoV-2, randomized trials of several potential therapeutic agents, including steroids, have been conducted. Although use of steroids in patients with ARDS [1] and severe viral pneumonia [2, 3] has been challenged, several arguments support the biological plausibility of steroid use in patients with severe COVID-19. First, autopsy studies in COVID-19 patients showed lymphocyte alveolitis, acute fibrinous injury and organizing pneumonia [4], which are all probably steroid-sensitive. Second, COVID-19 leads to activation of endothelial cells causing not only systemic inflammation but also microvascular thrombosis, pulmonary infarcts and venous thromboembolism [4, 5]. Admittedly, there are also arguments against steroid use. First, viral particles are often found at autopsy [4], and steroids may decrease viral clearance. Second, steroids only influence the inflammatory component of the inflammation–thrombosis–hypoxia interaction [6], suggesting that steroids may be less effective once thrombi have developed.

The RECOVERY trial compared administration of 6 mg/day dexamethasone for 10 days to usual care in 6425 hospitalized patients with SARS-CoV-2 infection. Survival was significantly higher in the dexamethasone-treated patients, especially in the subgroup of 1007 patients receiving invasive mechanical ventilation [7]. As a result of the RECOVERY findings, three further steroid trials, focusing on ICU patients, were stopped prematurely after inclusion of 384 [8], 299 [9] and 149 [10] patients, respectively. A meta-analysis of the available data concluded that administration of systemic steroids was associated with a decrease in 28-day mortality [11]. Nevertheless, although administration of steroids appears promising, several limitations must be considered when interpreting the results