How is C. difficile diagnosed. What are the primary treatment options for C. difficile infection. Can C. difficile infection recur after initial treatment. What are the risk factors for recurrent C. difficile infection. How is recurrent C. difficile infection managed.

Diagnosing C. difficile Infection: Methods and Considerations

C. difficile infection (CDI) is a serious condition that requires prompt and accurate diagnosis. Doctors typically suspect CDI in patients with diarrhea and other risk factors associated with the infection. To confirm the diagnosis, several testing methods are available:

Stool Tests: The Primary Diagnostic Tools

Stool tests are the most common and reliable methods for diagnosing CDI. These tests detect the toxins produced by C. difficile bacteria or the genes responsible for toxin production. The main types of stool tests include:

• Polymerase Chain Reaction (PCR)
• Glutamate Dehydrogenase (GDH) / Enzyme Immunoassay (EIA) combination
• Enzyme Immunoassay (EIA) alone
• Cell Cytotoxicity Assay

Is PCR the most accurate test for C. difficile diagnosis? PCR is indeed considered highly accurate and can rapidly detect the C. difficile toxin B gene in stool samples. This molecular test offers a high level of sensitivity and specificity, making it a preferred choice in many clinical settings.

When Should Stool Testing Be Performed?

It’s crucial to note that C. difficile testing should only be performed on diarrheal or watery stool samples. Testing is unnecessary and potentially misleading in patients without active diarrhea. Moreover, follow-up testing after treatment is generally not recommended unless symptoms recur.

Additional Diagnostic Procedures

In certain cases, especially when the diagnosis is uncertain or complications are suspected, doctors may employ additional diagnostic procedures:

1. Colon Examination: A flexible sigmoidoscopy or colonoscopy may be performed to visualize the colon’s interior, looking for signs of inflammation or pseudomembranes characteristic of CDI.
2. Imaging Tests: Abdominal X-rays or CT scans can help detect complications such as colon wall thickening, bowel expansion, or rare cases of intestinal perforation.

Treatment Strategies for C. difficile Infection

Once CDI is diagnosed, prompt and appropriate treatment is crucial to manage symptoms and prevent complications. The treatment approach typically involves the following steps:

Discontinuation of Triggering Antibiotics

The first step in treating CDI is often to stop the antibiotic that triggered the infection, if possible. This allows the gut microbiome to begin recovering and reduces the selective pressure favoring C. difficile growth.

Antibiotic Therapy for C. difficile

Paradoxically, the primary treatment for CDI involves using different antibiotics that specifically target C. difficile. The most commonly prescribed antibiotics include:

• Vancomycin (Vancocin HCL, Firvanq)
• Fidaxomicin (Dificid)

In rare cases where vancomycin or fidaxomicin are unavailable, metronidazole (Flagyl) may be used, although it’s generally considered less effective and potentially more toxic.

How do these antibiotics work against C. difficile? These antibiotics specifically target C. difficile bacteria, inhibiting their growth and allowing the normal gut flora to recover. This action helps resolve diarrhea and other CDI-related complications.

Surgical Intervention in Severe Cases

In severe cases of CDI, particularly those involving intense pain, organ failure, toxic megacolon, or abdominal wall inflammation, surgical intervention may be necessary. This typically involves removing the diseased portion of the colon to prevent life-threatening complications.

Managing Recurrent C. difficile Infections

Recurrent C. difficile infections pose a significant challenge in CDI management. Up to 20% of patients experience recurrence, either due to incomplete eradication of the initial infection or reinfection with a different strain.

Risk Factors for Recurrent CDI

Several factors increase the risk of recurrent CDI:

• Age over 65 years
• Concurrent antibiotic use for other conditions
• Severe underlying medical disorders (e.g., chronic kidney failure, inflammatory bowel disease, chronic liver disease)

Treatment Approaches for Recurrent CDI

Managing recurrent CDI often requires a different approach than initial infections. Treatment strategies may include:

1. Antibiotic Therapy: Guidelines generally recommend using a different antibiotic regimen than the one used for the initial infection. The effectiveness of antibiotic therapy tends to decrease with each subsequent recurrence.
2. Fecal Microbiota Transplantation (FMT): This emerging treatment option involves transferring stool from a healthy donor to the patient’s colon, aiming to restore a healthy gut microbiome.
3. Probiotics: While not a primary treatment, probiotics may be considered as an adjunct therapy to help restore gut flora balance.

Fecal Microbiota Transplantation: A Promising Treatment for Recurrent CDI

Fecal microbiota transplantation (FMT) has emerged as a highly effective treatment option for recurrent C. difficile infections. This procedure, also known as a stool transplant, aims to restore a healthy balance of gut bacteria by introducing fecal matter from a healthy donor into the patient’s colon.

The FMT Procedure

How is fecal microbiota transplantation performed? FMT can be administered through various routes:

• Colonoscopy: The donor stool is introduced directly into the colon during a colonoscopy procedure.
• Nasogastric tube: A tube is passed through the nose and into the stomach or small intestine to deliver the donor stool.
• Capsules: In some cases, freeze-dried donor stool may be encapsulated and taken orally.

Donor Screening and Safety Measures

To ensure the safety of FMT, donors undergo rigorous screening processes:

1. Medical history assessment to rule out any conditions that could pose a risk to the recipient
2. Blood tests to screen for infectious diseases
3. Stool screening for parasites, viruses, and pathogenic bacteria

Efficacy of FMT

Research has shown impressive success rates for FMT in treating recurrent CDI. Studies indicate that one or more FMT procedures can achieve a success rate higher than 85% in resolving recurrent infections. This high efficacy has led to increased interest in FMT as a treatment option, particularly for patients who have failed multiple rounds of antibiotic therapy.

The Role of Probiotics in C. difficile Management

While not a primary treatment for CDI, probiotics have garnered attention as a potential adjunct therapy. Probiotics are live microorganisms that, when administered in adequate amounts, may confer health benefits to the host.

Potential Benefits of Probiotics

How might probiotics help in managing C. difficile infections? Probiotics may offer several potential benefits:

• Restoration of gut microbiome balance
• Competition with C. difficile for resources in the gut
• Enhancement of the gut’s natural defense mechanisms
• Modulation of the immune response

Current Evidence and Recommendations

While some studies have shown promising results for certain probiotic strains in preventing CDI, particularly in patients taking antibiotics, the overall evidence for their use in treating active CDI remains mixed. Current guidelines generally do not recommend probiotics as a standalone treatment for CDI but suggest they may have a role in prevention or as part of a comprehensive management strategy.

Preventing C. difficile Infections: Strategies and Best Practices

Given the potential severity and recurrence risk of C. difficile infections, prevention plays a crucial role in managing this condition. Several strategies can help reduce the risk of CDI, particularly in healthcare settings where the infection is most commonly acquired.

Antibiotic Stewardship

One of the most effective ways to prevent CDI is through judicious use of antibiotics. This involves:

• Prescribing antibiotics only when necessary
• Using narrow-spectrum antibiotics when possible
• Limiting the duration of antibiotic therapy to the shortest effective period
• Regularly reviewing and reassessing antibiotic prescriptions

Infection Control Measures

In healthcare settings, strict infection control practices are essential to prevent the spread of C. difficile:

1. Hand hygiene: Proper handwashing with soap and water, as alcohol-based hand sanitizers are not effective against C. difficile spores
2. Contact precautions: Using gloves and gowns when caring for patients with known or suspected CDI
3. Environmental cleaning: Thorough cleaning and disinfection of surfaces with sporicidal agents
4. Patient isolation: Separating patients with CDI from other patients when possible

Patient Education

Educating patients about CDI risk factors, symptoms, and prevention strategies is crucial. This includes informing patients about:

• The importance of completing prescribed antibiotic courses as directed
• The need to inform healthcare providers about recent antibiotic use or hospitalization
• Proper hand hygiene practices
• The importance of seeking medical attention promptly if diarrhea develops, especially after antibiotic use

Emerging Therapies and Future Directions in C. difficile Management

As C. difficile continues to pose significant challenges in healthcare settings, researchers are actively exploring new treatment options and preventive strategies. Several promising approaches are currently under investigation:

Microbiome-Based Therapies

Building on the success of fecal microbiota transplantation, researchers are developing more targeted microbiome-based therapies:

• Defined microbial consortia: Carefully selected combinations of beneficial bacteria designed to restore gut health
• Engineered probiotics: Genetically modified bacteria designed to target C. difficile or enhance the gut’s natural defenses

Immunotherapies

Several immunotherapy approaches are being explored for CDI prevention and treatment:

1. Vaccines: Targeting C. difficile toxins or surface proteins to stimulate protective immunity
2. Monoclonal antibodies: Designed to neutralize C. difficile toxins or enhance the immune response against the bacteria

Novel Antibiotics and Antibiotic Alternatives

Researchers are working on developing new antibiotics with improved efficacy against C. difficile and reduced impact on the normal gut flora. Additionally, alternative approaches to combat C. difficile are being investigated, such as:

• Bacteriophage therapy: Using viruses that specifically target C. difficile
• Antimicrobial peptides: Naturally occurring or synthetic molecules with antibacterial properties

What potential advantages do these emerging therapies offer? These novel approaches aim to provide more targeted treatments with fewer side effects, reduce the risk of recurrence, and potentially offer alternatives for patients who have failed conventional therapies.

Diagnostic Advancements

Improved diagnostic tools are also in development, focusing on:

1. Rapid, point-of-care tests for quicker diagnosis and treatment initiation
2. Biomarkers to predict disease severity and recurrence risk
3. Advanced imaging techniques for better visualization of CDI-related intestinal damage

As research in these areas progresses, it is hoped that new therapies and diagnostic tools will lead to more effective prevention, diagnosis, and treatment of C. difficile infections, ultimately improving patient outcomes and reducing the burden of this challenging infection on healthcare systems.

C. difficile infection – Diagnosis and treatment

Diagnosis

Doctors often suspect C. difficile in anyone who has diarrhea and who has other risk factors for C. difficile. In such cases, doctors are likely to order one or more of the following tests.

Stool tests

Toxins produced by C. difficile bacteria can usually be detected in a sample of your stool. Several main types of lab tests exist, and they include:

• Polymerase chain reaction. This sensitive molecular test can rapidly detect the C. difficile toxin B gene in a stool sample and is highly accurate.
• GDH/EIA. Some hospitals use a glutamate dehydrogenase (GDH) test in conjunction with an enzyme immunoassay (EIA) test. GDH is a very sensitive assay and can accurately rule out the presence of C. difficile in stool samples.
• Enzyme immunoassay. The enzyme immunoassay (EIA) test is faster than other tests but isn’t sensitive enough to detect many infections and has a higher rate of falsely normal results. This is typically not the only test used.
• Cell cytotoxicity assay. A cytotoxicity test looks for the effects of the C. difficile toxin on human cells grown in a culture. This type of test is sensitive, but it is less widely available, is more cumbersome to do and requires 24 to 48 hours for test results. It’s typically used in research settings.

Testing for C. difficile is unnecessary if you’re not having diarrhea or watery stools, and isn’t helpful for follow-up treatment. If you aren’t having diarrhea, stool shouldn’t be tested for C. difficile.

Colon examination

In rare instances, to help confirm a diagnosis of C. difficile infection and look for alternative causes of your symptoms, your doctor may examine the inside of your colon. This test (flexible sigmoidoscopy or colonoscopy) involves inserting a flexible tube with a small camera on one end into your colon to look for areas of inflammation and pseudomembranes.

Imaging tests

If your doctor is concerned about possible complications of C. difficile, he or she may order an abdominal X-ray or a computerized tomography (CT) scan, which provides images of your colon. The scan can detect the presence of complications such as thickening of the colon wall, expansion of the bowel or, more rarely, a hole (perforation) in the lining of your colon.

Treatment

The first step in treating C. difficile is to stop taking the antibiotic that triggered the infection, when possible. Depending on the severity of your infection, treatment may include:

• Antibiotics. Ironically, the standard treatment for C. difficile is another antibiotic. These antibiotics keep C. difficile from growing, which in turn treats diarrhea and other complications. Your doctor may prescribe vancomycin (Vancocin HCL, Firvanq) or fidaxomicin (Dificid).

  Metronidazole (Flagyl) may be rarely used if vancomycin or fidaxomicin aren’t available.

• Surgery. For people who have severe pain, organ failure, toxic megacolon or inflammation of the lining of the abdominal wall, surgery to remove the diseased portion of the colon may be the only option.

Recurrent infection

Up to 20% of people with C. difficile get sick again, either because the initial infection never went away or because they’ve been reinfected with a different strain of the bacteria.

Your risk of recurrence is higher if you:

• Are older than 65
• Are taking other antibiotics for a different condition while being treated with antibiotics for C. difficile infection
• Have a severe underlying medical disorder, such as chronic kidney failure, inflammatory bowel disease or chronic liver disease

Treatment for recurrent disease may include:

• Antibiotics. Antibiotic therapy for recurrence may involve one or more courses of a medication. In general, guidelines recommend not repeating the same therapy used for an initial infection for a recurrent infection. The effectiveness of antibiotic therapy declines with each subsequent recurrence.

• Fecal microbiota transplant (FMT). Also known as a stool transplant, FMT is emerging as an alternative strategy for treating recurrent C. difficile infections. Though FMT is considered experimental and is not yet approved by the FDA, clinical studies are currently underway.

  FMT restores healthy intestinal bacteria by placing another person’s (donor’s) stool in your colon through a colonoscope or nasogastric tube. Donors are screened for medical conditions, their blood is tested for infections, and stools are carefully screened for parasites, viruses and other infectious bacteria before being used for FMT.

  Research has shown that FMT done one or more times has a success rate higher than 85% for treating C. difficile infections.

• Probiotics. Probiotics are organisms, such as bacteria and yeast, and are available over the counter. The role of these products in C. difficile infection is controversial. Research hasn’t consistently shown that currently available products are helpful in preventing or treating infection with C. difficile. Advanced probiotics are currently being studied for their potential use in C. difficile treatment or prevention but aren’t currently available.

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Lifestyle and home remedies

Supportive treatment for diarrhea includes:

• Plenty of fluids. Choose fluids containing water, salt and sugar, such as diluted fruit juice, soft drinks and broths.
• Good nutrition. If you have watery diarrhea, eat starchy foods, such as potatoes, noodles, rice, wheat and oatmeal. Other good choices are saltine crackers, bananas, soup and boiled vegetables. If you aren’t hungry, you may need a liquid diet at first. After your diarrhea clears up, you may have temporary difficulty digesting milk and milk-based products.

Jan. 04, 2020

What is the best antibiotic treatment for C.difficile-associated diarrhea?

Case

An 84-year-old woman presents with watery diarrhea. She recently received a fluoroquinolone antibiotic during a hospitalization for pneumonia. Her temperature is 101 degrees, her heart rate is 110 beats per minute, and her respiratory rate is 22 breaths per minute. Her abdominal exam is significant for mild distention, hyperactive bowel sounds, and diffuse, mild tenderness without rebound or guarding. Her white blood cell count is 18,200 cells/mm3. You suspect C. difficile infection. Should you treat empirically with antibiotics and, if so, which antibiotic should you prescribe?

Overview

C. difficile is an anaerobic gram-positive bacillus that produces spores and toxins. In 1978, C. difficile was identified as the causative agent for antibiotic-associated diarrhea.1 The portal of entry is via the fecal-oral route.

Some patients carry C. difficile in their intestinal flora and show no signs of infection. Patients who develop symptoms commonly present with profuse, watery diarrhea. Nausea, vomiting, and abdominal pain also can be seen. Severe cases of C. difficile-associated diarrhea (CDAD) can present with significant abdominal pain and multisystem organ failure, with toxic megacolon resulting from toxin production and ileus. 2 In severe cases due to ileus, diarrhea may be absent. Risk of mortality in severe cases is high, with some reviews citing death rates of 57% in patients requiring total colectomy.3 Risk factors for developing CDAD include the prior or current use of antibiotics, advanced age, hospitalization, and prior gastrointestinal surgery or procedures.4

Risk factors for developing CDAD include: antibiotic use, advanced age, hospitalization, and prior gastrointestinal surgery or procedures. Metronidazole and oral doses of vancomycin are the most common treatments.

The initial CDAD treatment involves removal of the agent that incited the infection. In most cases, this means discontinuation of an antimicrobial agent. Removal of the inciting agent allows restoration of the normal bowel flora. In mild CDAD cases, this may be sufficient therapy. However, most CDAD cases require treatment. Although many antimicrobial and probiotic agents have been used in CDAD treatment, metronidazole and vancomycin are the most commonly prescribed agents. There is an ongoing debate as to which should be considered the first-line agent.

Review of the Data

Metronidazole and vancomycin have the longest histories of use and are the most studied agents in CDAD. Metronidazole is prescribed 250 mg four times daily (or 500 mg twice daily) for 14 days. It is reasonably tolerated, although it can cause a metallic taste in the mouth. Vancomycin is given 125 mg four times daily (or 500 mg three times daily) for 10 to 14 days. Unlike metronidazole, which can be given by mouth or intravenously, only oral vancomycin is effective in CDAD.

Historically, metronidazole has been prescribed more frequently as the first-line agent in CDAD. Proponents of the drug tout its low cost and the importance of minimizing the development of vancomycin-resistant enteric pathogens. There are two small, prospective, randomized studies comparing the efficacy of the agents against one another in the treatment of C. difficile infection, with similar efficacy demonstrated in both studies. In the early 1980s, Teasley and colleagues randomized 94 patients with C. difficile infection to either metronidazole or vancomycin.5 All the patients receiving vancomycin resolved their disease; 95% of patients receiving metronidazole were cured. The differences were not statistically significant.

In the mid-1990s, Wenisch and colleagues randomized patients with C. difficile infection to receive vancomycin, metronidazole, fusidic acid, or teicoplanin therapy.6 Ninety-four percent of patients in both the vancomycin and metronidazole groups were cured.

However, since 2000, investigators have reported higher failure rates with metronidazole therapy in C. difficile infections. For example, in 2005, Pepin and colleagues reviewed cases of C. difficile infections at a hospital in Quebec.7 They determined the number of patients with C. difficile infection initially treated with metronidazole who required additional therapy had markedly increased. Between 1991 and 2002, 9.6% of patients who initially were treated with metronidazole required a switch to vancomycin (or the addition of vancomycin) because of a disappointing response. This figure doubled to 25.7% in 2003-2004. The 60-day probability of recurrence also increased in the 2003-2004 test group (47.2%), compared with the 1991-2002 group (20.8%). Both results were statistically significant. Such data contributed to the debate regarding whether metronidazole or vancomycin is the superior agent in the treatment of C. difficile infections.

In 2007, Zar and colleagues studied the efficacy of metronidazole and vancomycin in the treatment of CDAD patients, but the study stratified patients according to disease severity.8 This allowed the authors to investigate whether one agent was superior in treating mild or severe CDAD. They determined disease severity by assigning points to individual patient characteristics. Patients with two or more points were deemed to have “severe” CDAD.

The investigators assigned one point for each of the following patient characteristics: temperature >38.3 degrees Celsius, age >60 years, albumin level <2.5 mg/dL, and white blood cell count >15,000 cells/mm3 within 48 hours of enrolling in the study. Any patient with endoscopic evidence of pseudomembrane formation or admission to the intensive-care unit (ICU) for CDAD treatment was considered to have severe disease.

This was a prospective, randomized controlled trial of 150 patients. Patients were randomly prescribed 500 mg metronidazole by mouth three times daily or 125 mg of vancomycin by mouth four times daily. Patients with mild CDAD had similar cure rates: 90% metronidazole versus 98% vancomycin (P=0.36). However, patients with severe CDAD fared statistically better when treated with oral vancomycin. Ninety-seven percent of severe CDAD patients treated with oral vancomycin had a clinical cure, while only 76% of those treated with metronidazole were cured (P=0.02). Recurrence of the disease was similar in each treatment group.

Based on this study, metronidazole and vancomycin appear equally effective in the treatment of mild CDAD, but vancomycin is the superior agent in the treatment of patients with severe CDAD.

Back to the Case

Our patient had several risk factors predisposing her to developing CDAD. She was of advanced age and took a fluoroquinolone antibiotic during a recent hospitalization. She also presented with signs consistent with a severe case of CDAD. She had a fever, a white blood cell count >15,000 cells/mm3, and was older than 60. Thus, she should be treated with supportive care, placed on contact precautions, and administered oral vancomycin 125 mg by mouth every six hours for 10 days as empiric therapy for CDAD. Stool cultures should be sent to confirm the presence of the C. difficile toxin.

Bottom Line

The appropriate antibiotic choice to treat CDAD in any patient depends upon the clinical severity of the disease. Treat patients with mild CDAD with metronidazole; prescribe oral vancomycin for patients with severe CDAD. TH

Dr. Mattison, instructor of medicine at Harvard Medical School, is a hospitalist and co-director of the Inpatient Geriatrics Unit at Beth Israel Deaconess Medical Center (BIDMC) in Boston. Dr. Li, assistant professor of medicine at Harvard Medical School, is director of hospital medicine and associate chief of BIDMC’s Division of General Medicine and Primary Care.

References

1.Bartlett JG, Moon N, Chang TW, Taylor N, Onderdonk AB. Role of C. difficile in antibiotic-associated pseudomembranous colitis. Gastroenterology. 1978;75(5):778-782.

2.Poutanen SM, Simor AE. C. difficile-associated diarrhea in adults. CMAJ. 2004;171(1):51-58.

3.Dallal RM, Harbrecht BG, Boujoukas AJ, et al. Fulminant C. difficile: an underappreciated and increasing cause of death and complications. Ann Surg. 2002;235(3):363-372.

4.Bartlett JG. Narrative review: the new epidemic of C. difficile-associated enteric disease. Ann Intern Med. 2006;145(10):758-764.

5.Teasley DG, Gerding DN, Olson MM, et al. Prospective randomized trial of metronidazole versus vancomycin for C. difficile-associated diarrhea and colitis. Lancet. 1983;2:1043-1046.

6.Wenisch C, Parschalk B, Hasenhündl M, Hirschl AM, Graninger W. Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of C. difficile-associated diarrhea. Clin Infect Dis. 1996;22:813-818.

7.Pepin J, Alary M, Valiquette L, et al. Increasing risk of relapse after treatment of C. difficile colitis in Quebec, Canada. Clin Infect Dis. 2005;40:1591-1597.

8.Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vancomycin and metronidazole for the treatment of C. difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45(3):302-307.

C. Diff Treatments & Medications

Medically reviewed by Anis Rehman, MD

Last Updated: 10/5/2020

Clostridium difficile (C. difficile, or C. diff) is a common and usually harmless bacterial infection of the large intestine. It often produces no symptoms or a little bit of watery diarrhea. Paradoxically, however, treatment with antibiotics can fire up a C. difficile infection in the large intestine that can quickly progress to a life-threatening medical condition. Fortunately, most C. difficile infections usually happen in a hospital or healthcare facility, so treatment begins immediately at the first sign of trouble.

What is C. diff?

Clostridium difficile lives inside the large intestine. While it usually is a common and harmless bacteria, antibiotic use can jump-start a C. difficile infection that may rapidly progress to a severe and even life-threatening medical illness called pseudomembranous colitis.

C. difficile is a common bacteria that is found all around us. When infected with C. difficile, the body’s immune system and other bacteria colonies in the intestine keep it in check, so most infections are asymptomatic.

Antibiotic treatment can throw off this delicate balance. A long course of antibiotics wipes out many of the bacteria in the gut, including beneficial ones. C. difficile, on the other hand, is more rugged than other bacteria. The active form (the “vegetative” type) is resistant to many antibiotics, such as penicillins, cephalosporins, fluoroquinolones, and clindamycin. Its inactive form called a “spore” is mostly unaffected by antibiotics.

Antibiotic use and hospital stays are the high-risk factors for C. difficile infections. About 3 out of 5 C. difficile infections happen in hospitals, long-term care facilities, or other healthcare facilities.

However, 2 out of 5 C. difficile infections are community-acquired. We can encounter C. difficile everywhere, so other risk factors include:

• Advanced age
• Use of acid-reducing ulcer medications (proton pump inhibitors)
• Cancer chemotherapy
• Chronic kidney or liver disease
• Inflammatory bowel disease
• A compromised immune system
• Malnutrition

Clostridium difficile produces two potent toxins that create many of the symptoms of Clostridium difficile colitis: toxin A and toxin B. Toxin A causes swelling of the intestinal tissues, and toxin B kills cells in the colon. A new, more deadly strain of C. difficile appeared in the United States and Canada in the 1990s. This strain is more virulent and produces 10 times the amount of toxin A and 23 times the amount of toxin B than other strains.

Once an infection takes hold, the C. difficile toxins cause watery diarrhea and intestinal swelling. At this point, the infection is a mild to moderate Clostridium difficile infection, or CDI, or Clostridium difficile-associated disease (CDAD).

As the disease becomes more advanced, the colon becomes coated in a “pseudomembrane,” a thick, gray coating of immune cells, dead cells, debris, and fibrous material. This more severe stage of CDI, characterized by severe diarrhea, abdominal pain, and low fever, is called pseudomembranous colitis.

In some cases, the infection can progress rapidly in a few hours or a couple of weeks after the initial symptoms into a life-threatening illness called fulminant CDI. The C. difficile poisons cause the colon to swell to massive proportions—a condition called toxic megacolon. Colon muscles stop moving, and the colon gradually fills with waste. Parts of the colon die. At this point, the only life-saving treatment may be to remove part or all of the colon. This stage is called severe CDI with complications, and the mortality rate is high.

Once the initial infection clears, about 3 out of 10 patients will develop a new C. difficile infection in about two weeks, called recurrent CDI or rCDI. Antibiotics may treat the infection, but they do not always kill bacteria in their spore form. Half of all those who develop a second infection will develop a third infection in a few weeks.

The Centers for Disease Control and Prevention (CDC) estimates that around half a million people in the United States are diagnosed with CDI every year. Of them, about 29,000 will die from the disease within 30 days of the first diagnosis, and 14,000 of these deaths are directly attributable to the infection. Most of the deaths involve people older than 65.

How is C. diff diagnosed?

Healthcare providers are looking for risk factors, clinical systems, and evidence of the bacteria in stools. The clinical symptoms of Clostridium difficile infection are:

• Watery diarrhea with mucus and maybe blood,
• Lower abdominal pain,
• Loss of appetite,
• Low fever, and
• Nausea and vomiting.

Stool samples will be subject to a sequence of tests:

• Antigen test (enzyme immunoassay for glutamate dehydrogenase) uses antibodies to detect a protein on the bacteria’s cell wall (glutamate dehydrogenase).
• Toxin B test (enzyme immunoassay for toxin B) looks for the presence of C. difficile toxin B in the stool.
• Polymerase chain reaction (PCR) test (or nucleic acid amplification test) analyzes the blood for the C. difficile genetic material that codes for the two C. difficile toxins. This is the most commonly done test in hospitalized patients.
• Cytotoxin neutralization assay (or cell cytotoxicity assay) cultures the stool sample and infects sample human tissue to prove C. difficile toxins’ presence. It is highly accurate but can take two or more days to finish.

In the United States, the clinical practice guidelines of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (IDSA/SHEA) are only to use a PCR test or use the first two tests immediately and PCR if the test results are contradictory.

The clinical symptoms and tests will be enough for a diagnosis. The doctor will not need to image the colon unless there’s a risk of complications. The doctor may examine the colon using a colonoscopy or sigmoidoscopy if the infection is very advanced, and the patient’s life is at risk.

C. diff treatment options

Time is of the essence. Healthcare providers cannot predict how fast the infection will progress, so a diagnosis, even a mild CDI, is considered a medical emergency.

Antibiotics

Upon diagnosis, treatment will immediately begin with:

• Immediate treatment with the antibiotics vancomycin, fidaxomicin, or metronidazole
• Termination of any other antibiotic treatment, however, your physician needs to evaluate the risks
• Discontinuation of other medications, such as narcotics, anti-diarrhea medications, or ulcer medications, that make the condition worse

Depending on the severity of the infection, some patients will be put on fluid and electrolyte replacement and isolated from other people.

Surgery

Most cases will resolve with antibiotic therapy. If the infection advances to toxic megacolon, part or all of the colon may have to be surgically removed in a colectomy procedure.

Fecal microbiota transplantation (FMT)

Patients with recurrent CDI might receive fecal microbiota transplantation to recolonize the colon with normal gut bacteria that keep C. difficile in check. Fecal matter taken from a family member will be injected into the patient’s colon to recolonize the gut with beneficial bacteria. Fecal transplants have been used to treat recurrent CDI since the 1950s and have a 90% success rate when used with antibiotics.

Probiotics

Some patients with recurrent Clostridium difficile infections may take probiotics or live cultures of beneficial bacteria that will restore a healthy population of bacteria in the gut. Evidence is mixed, however. In the United States, probiotic therapy used alongside antibiotics is not recommended by the Infectious Diseases Society of America (IDSA) or the Society for Healthcare Epidemiology of America (SHEA).

C. diff medications

Antibiotics are the standard of care for the treatment of Clostridium difficile infection. They will be started immediately upon diagnosis.

The patient will also be taken off certain medications that may be contributing to the problem:

• Antibiotics such as penicillins, cephalosporins, fluoroquinolones, and clindamycin,
• Proton-pump inhibitors,
• Narcotics, or
• Diarrhea medications.

Antibiotics

Patients with CDI will immediately receive rectal or oral vancomycin, oral fidaxomicin, or intravenous metronidazole. The intravenous formulation of vancomycin is not used to treat C. difficile infections as it’s not secreted into the gut. These are antibiotics that effectively eliminate active C. difficile infections. Rifaximin may also be used.

Patients with recurrent C. difficile infections will receive “pulsed” vancomycin or fidaxomicin. Full doses are administered for a few days, followed by a rest period, and then readministered at full dose, followed by a rest. Antibiotics do not kill C. difficile spores, so the goal is to kill the spores when they germinate.

A new experimental antibiotic, ridinilazole, is designed to kill only C. difficile while leaving other gut bacteria alone. The drug is in the third phase of clinical trials and looks promising.

Antibodies

The body produces antibodies to the C. difficile toxins that neutralize their poisonous effects. The drug bezlotoxumab is a synthetic antibody that neutralizes C. difficile toxin B and protects colon tissues. It is prescribed along with antibiotics for patients with recurrent C. difficile infections.

What is the best medication for C. diff?

Drug treatment for Clostridium difficile colitis is limited to a few antibiotics: vancomycin, fidaxomicin, and, less commonly, metronidazole and rifaximin. Vancomycin (oral) and fidaxomicin are equally effective at resolving the infection, while fidaxomicin treatment reduces the risk of recurrent C. difficile infections. Metronidazole (oral) is the least effective at fighting off C. difficile, but if the large intestine muscles stop contracting, oral antibiotics such as oral vancomycin or fidaxomicin aren’t useful. Physicians follow a protocol when deciding which antibiotic to use. They will also tailor the prescription to the patient’s history of sensitivity to antibiotics.

Best medication for C. diff
Vancocin (vancomycin)	Antibiotic	Oral, enema	4, 125 mg capsules every 6 hours	Nausea, abdominal pain, fever
Metronidazole	Antibiotic	Intravenous	Dose depends on weight and is administered every 6 hours	Nausea, headache, abdominal pain
Dificid (fidaxomicin)	Antibiotic	Oral	1, 200 mg tablet twice daily	Nausea, vomiting, abdominal pain
Zinplava (bezlotoxumab)	Monoclonal antibody	Oral	1 injection, dose determined by weight at the beginning of antibiotic therapy	Nausea, fever, headache

Many of the standard dosages above are from the U.S. Food and Drug Administration (FDA). Dosage is determined by your doctor based on your medical condition, response to treatment, age, and weight. Other possible side effects exist. This is not a complete list.

What are the common side effects of C. diff medication?

Different classes of medications have different side effects. However, this is not a complete list, and you should consult with a healthcare professional for possible side effects and drug interactions based on your specific situation.

Oral antibiotics typically can cause upset stomach, intestinal problems, nausea, and loss of appetite. Vancomycin has a high incidence of serious side effects, such as kidney damage (1 in 20 patients), hearing loss, and anaphylaxis (a dangerous drop in blood pressure). For this reason, physicians prescribe it only for the most severe infections, like C. difficile. Fidaxomicin, too, can cause serious side effects such as megacolon, gastrointestinal bleeding, and high blood sugar. Sensitivity reactions are always a significant concern with antibiotics. At least 1 in 15 people have allergies to one or more antibiotics, and these allergies could be life-threatening.

Monoclonal antibodies (MAB) are relatively safe. Their most serious side effect is typically immunogenicity—when the body gradually develops antibodies to the drug that eventually renders it therapeutically useless.

What is the best home remedy for C. diff?

Antibiotics treat Clostridium infections, but home remedies are necessary to manage the symptoms and prevent complications like dehydration. Drinking plenty of fluids rich in electrolytes and carbohydrates, and eating highly nutritious, easily digested food are helpful.

Using probiotics to restore a healthy bacteria colony in the gut may seem like a logical home remedy, but if you’re on antibiotics, the “good” bacteria cultures in the probiotics will be killed off. It may take a few days after the end of antibiotic exposure before probiotics can survive in the gut.

You mustn’t spread the infection. In a hospital, patients with C. diff infections are usually isolated to prevent infecting others. For mild or moderate cases of Clostridium infection treated at home, infection control and contact precautions are paramount:

• Follow proper hand hygiene, wash your hands regularly, and make sure to wash them after using the toilet.
• Only chlorhexidine soap or hypochlorous acid hand sanitizer can kill C. diff spores on your hands. Alcohol and soap do not kill the spores.
• If possible, do not share a bathroom with other people.
• Clean surfaces of the home with bleach or chlorhexidine mixed with water.
• If you can, wash linens, towels, and clothes in bleach. If not, soak them in the hottest water possible.

Frequently asked questions about C. diff

Can C. diff go away on its own?

Asymptomatic Clostridium difficile infections usually go away on their own without even being noticed. When a C. diff infection does become symptomatic, research has shown that 1 in 5 infections will resolve without medications. The danger is that C. difficile colitis can rapidly and unpredictably become a medical emergency. Seek medical care at the first signs of infection.

Can C. diff be treated naturally?

Scientists are taking a serious look at natural treatments for Clostridium difficile infections. Medical science has only a limited set of antibiotics they can use against C. diff, and healthcare professionals are worried that they will someday come up against a C. diff strain that isn’t treatable with antibiotics. Unfortunately, no herbal or traditional medical treatment can reduce C. diff infections.

What foods should be avoided with C. diff?

As with any condition involving diarrhea, like Clostridium difficile, your diet should be focused on fluids, electrolytes, nutrients, and energy. The secondary goal is not to irritate the gastrointestinal system any more than necessary. Liquids, salts, starchy foods, high nutrient foods, bland foods, and easy-to-digest foods should be on the menu. Avoid the opposite: meats, fats, junk food, spicy foods, acidic foods, and anything else that might cause stomach upset or gas.

What is the first-line treatment for C. diff?

Antibiotics are the first-line treatment for a Clostridium difficile infection. Healthcare providers have only a limited arsenal of antibiotics they can use, starting with vancomycin or fidaxomicin. In some cases, however, the colon muscles stop working, and oral or rectal antibiotics become useless. Neither vancomycin nor fidaxomicin can get into the gut if given intravenously. The only antibiotic left is intravenous metronidazole, which is less effective than either vancomycin or fidaxomicin.

What is the best medication for C. diff?

Vancomycin and fidaxomicin are the most effective antibiotics against Clostridium difficile infections. They are both equally effective at wiping out an initial infection. However, patients treated with fidaxomicin have a lower rate of a recurrent C. diff infection (about 15%) versus patients treated with vancomycin (about 25%). Long-term treatment with vancomycin also runs the risk of kidney damage (about 5% of patients) and hearing loss.

What probiotics kill C. diff?

Probiotics do not kill Clostridium difficile. Probiotics are “good” bacteria and fungi that colonize the intestines and do things that promote intestinal health. They compete with C. difficile bacteria, and some probiotics, such as Lactobacillus or Saccharomyces boulardii, also produce chemicals that prevent other bacteria from growing. Scientists call this “colonization resistance.” Along with the immune system, colonization resistance keeps C. diff in check. However, probiotics are not an effective treatment against a primary C. diff infection.

How do you treat C. diff at home?

Home treatment for Clostridium difficile should support the antibiotic therapy, maintain sufficient fluids and electrolytes in the body, provide the body with nutrition and energy, and prevent anyone else in the home from being infected.

How long does it take to recover from C. diff?

A mild or moderate Clostridium difficile infection typically takes 10 to 14 days of antibiotic treatment to clear up. Depending on the antibiotic used to treat the initial infection, about 15% to 25% of patients will develop a second C. diff infection about two weeks after the first one clears up. It’s essential to realize this. Many patients develop a second C. diff infection and believe they have come down with something else. They let it go too long and end up in the hospital. Recurrent C diff infection may require several weeks of “pulsed” antibiotic therapy or fecal microbiota transplantation to resolve.

Related resources for C. diff

Treating and Preventing C. difficile Infections

Archived: This report is greater than 3 years old. Findings may be used for research purposes, but should not be considered current.

Is This Information Right for Me?

This information is right for you if:

What will this summary tell me?

This summary will answer these questions:

• What is a C. difficile infection?
• How is CDI treated?
  • What have researchers found about treatments for CDI?
  • What are possible side effects of treatments for CDI?
• What can I do to help prevent CDI?
• What should I think about when deciding on treatment for my CDI?

What is the source of this information?

This information comes from a research report that was funded by the Agency for Healthcare Research and Quality, a Federal Government agency.

To write the report, researchers looked at 56 scientific research articles reporting on studies to prevent and treat CDI. The studies were published through April 2015.

Health care professionals, researchers, experts, and the public gave feedback on the report before it was published.

Understanding Your Condition

What is a C. difficile infection?

A C. difficile infection (CDI) results from a type of bacteria (or germ) called Clostridium difficile infecting your large intestine. C. difficile bacteria are common and can be found everywhere. These bacteria can be found in the air, in water, or on items such as door knobs, sinks, and countertops. Small amounts of C. difficile bacteria are even found in many people’s intestines.

If C. difficile bacteria in your intestines grow out of control, they can cause an infection. This can happen after a person takes antibiotics. Antibiotics are a type of medicine that fight infections caused by bacteria. When you take antibiotics, the normal bacteria in your intestines that help keep you healthy can also be killed. When this happens, bacteria such as C. difficile can grow out of control. When a person has CDI, chemicals called toxins produced by the C. difficile bacteria make him or her sick.

CDI affects about 500,000 people in the United States each year. CDI can be mild to severe. The most common symptoms of CDI include watery diarrhea (three or more times a day for 2 or more days) and cramping in your belly. Some people with CDI can become very sick. In rare cases, severe CDI can be life threatening.

Symptoms of severe CDI may include:

• Having watery diarrhea often (as many as 15 times) throughout the day and night
• Cramping and pain in your belly that may be severe
• Blood or pus (a thick, yellowish substance) in your bowel movements
• Tenderness in your belly
• A swollen belly
• A fever
• Nausea
• Vomiting
• Not enough water in your body (called “dehydration”)
• Loss of appetite
• Weight loss

What increases the risk of CDI?

Anyone can get CDI, but some people have a higher risk. You may be at a higher risk for getting CDI if you:

Can CDI come back after treatment?

For some people, CDI may return after treatment ends. Out of every 10 people who have had CDI in the past, as many as 3 to 6 people will have CDI again.

Understanding Your Options

How is CDI treated?

There are several treatments for CDI, including:

• Antibiotics to treat your CDI.
• Probiotics to take with an antibiotic to help keep your CDI from coming back.
• Fecal microbiota transplantation if antibiotics do not help your CDI or if your CDI keeps coming back.

What about antidiarrhea medicines?
Talk with your health care professional before taking any over-the-counter antidiarrhea medicines (such as Pepto-Bismol®, Kaopectate®, or Imodium®) for your CDI. These medicines may make CDI worse.

Antibiotics

If your CDI happened after you took an antibiotic, your health care professional may have you stop taking the antibiotic. Your health care professional will likely give you a different antibiotic to help treat your CDI. The antibiotic your doctor recommends may depend on the availability and cost of the antibiotic, what is covered by your health insurance plan, and how severe your CDI is.

Note: You should never stop taking any medicine without first talking with your health care professional.

Your health care professional will likely first recommend one of these antibiotics:

• Metronidazole (Flagyl®)
• Vancomycin (Vancocin®)

If metronidazole (Flagyl®) and vancomycin (Vancocin®) do not work to treat your CDI, your health care professional may recommend a newer kind of antibiotic:

• Fidaxomicin (Dificid®)
  • Fidaxomicin is much more expensive than both metronidazole and vancomycin. The cost to you depends on your health insurance plan.
  • Most health insurance plans will only cover fidaxomicin after you have tried metronidazole and vancomycin and neither one worked.

What did researchers find about antibiotics for CDI?

What are possible side effects of antibiotics to treat CDI?

The U.S. Food and Drug Administration (FDA) lists the following possible side effects of antibiotics to treat CDI. Just because a side effect is possible does not mean you will have it.

Probiotics

To help keep your CDI from coming back, your health care professional may suggest that you take probiotics along with the antibiotic to treat your CDI. Probiotics are healthy bacteria and other microscopic organisms that are normally found in your body. Probiotics are taken as dietary supplements. They come in some foods, such as yogurt, kefir (a drink made from fermented milk), soy drinks, buttermilk, some soft cheeses, and enriched milk. Probiotics also come as a pill you can take by mouth.

Note: The FDA approves the quality and safety of all prescription and over-the-counter medicines. But dietary supplements such as probiotics do not need FDA approval. When considering a dietary supplement, always check the label to see if the supplement has been tested for quality.

What did researchers find about probiotics?

The chart below lists some different types of probiotics and what researchers found about each.

What are possible side effects of probiotics?

Probiotics are usually safe for people who are generally healthy. Possible side effects of probiotics may include gas and bloating.

For people with a weak immune system, S. boulardii may cause severe side effects, such as a life-threatening fungal infection. It is important to always talk with your health care professional before taking probiotics.

Fecal Microbiota Transplantation

Fecal microbiota transplantation (FMT) is a newer type of treatment for CDI. Your health care professional may suggest FMT if antibiotics do not help your CDI or if your CDI keeps coming back. FMT is meant to help put some of the “good” bacteria back into your intestines. To do this, your health care professional takes a small amount of stool containing healthy bacteria from a person who does not have CDI and places it into your intestine. The stool may come from a close family member or from a healthy donor from a stool bank.

What did researchers find about FMT?

Researchers found that FMT appears to help stop diarrhea and to help keep CDI from coming back, but more research is needed to know this for sure.

What are possible side effects of FMT?

There is not much research on the short-term and long-term side effects of FMT. There is a chance of bleeding or infection, but the risk is low.

Other possible side effects of FMT may include:

• Diarrhea
• Stomach cramps
• Nausea
• Belching
• Constipation

What can I do to help prevent CDI?

• Only take antibiotics when your health care professional prescribes them. Take all antibiotics exactly as instructed. Never stop taking an antibiotic without first talking with your health care professional (even if you start to feel better).
• When caring for someone with CDI:
  • Wash your hands often. To help prevent CDI, it is best to use soap and water instead of hand sanitizer.
  • Clean often-touched surfaces such as door knobs, sinks, and countertops with a disinfectant, such as bleach.

Making a Decision

What should I think about when deciding on treatment for my CDI?

You and your health care professional can decide what might be best to treat CDI and help keep it from coming back. Talk with your health care professional about whether this is your first time to have CDI or whether you have had CDI in the past and it has come back.

Ask your health care professional

• If my CDI happened after taking an antibiotic, should I stop taking the antibiotic? Is there a different antibiotic I can take with less risk of causing CDI?
• Which other antibiotic might be best to help treat my CDI?
• What possible side effects of the antibiotic for CDI should I watch for?
• Might probiotics help keep my CDI from coming back?
• If antibiotics do not work or if my CDI keeps coming back, might FMT help?
• What possible side effects from FMT would I need to watch for?

Source

The information in this summary comes from Butler M, Olson A, Drekonja D, Shaukat A, Schwehr N, Shippee N, Wilt TJ. Early Diagnosis, Prevention, and Treatment of Clostridium difficile: Update. Comparative Effectiveness Review No. 172. (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-2012-00016-I.) AHRQ Publication No. 16-EHC012-EF. Rockville, MD: Agency for Healthcare Research and Quality; March 2016.

Additional information came from the MedlinePlus website, a service of the National Library of Medicine and the National Institutes of Health.

This summary was prepared by the John M. Eisenberg Center for Clinical Decisions and Communications Science at Baylor College of Medicine, Houston, TX. It was written by Amelia Williamson Smith, M.S., Daniel Musher, M.D., Frank Domino, M.D., and Michael Fordis, M.D. People who have had CDI gave feedback on this summary.

Clostridium difficile-Associated Diarrhea – American Family Physician

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FAQs for Clinicians about C. diff

• Using gloves to prevent hand contamination remains the cornerstone for preventing C. diff transmission via the hands of healthcare personnel; any theoretical benefit from instituting soap and water must be balanced against the potential for decreased compliance resulting from a more complex hand hygiene message.
• If your institution experiences an outbreak, consider using only soap and water for hand hygiene after removing gloves while caring for patients with CDI.
• Use gowns when entering patients’ rooms and during patient care.
• Dedicate or perform cleaning of any shared medical equipment.
• Continue these precautions until diarrhea ceases.
  • Because C. diff-infected patients continue to shed the organism for a number of days following cessation of diarrhea, some institutions routinely continue isolation and contact precautions for either several days beyond symptom resolution or until discharge, depending upon the type of setting and average length of stay.
• Implement an environmental cleaning and disinfection strategy.
  • Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently.
    • Ensure daily and terminal cleaning of patient rooms.
  • Use an Environmental Protection Agency (EPA)-registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions. (Note: Only hospital surface disinfectants listed on EPA’s List Kexternal icon are registered as effective against C. diff spores.)
  • Follow the manufacturer’s instructions for disinfection of endoscopes and other devices.

Recommended infection control practices in long-term care and home health settings are similar to those practices taken in traditional healthcare settings.

What can I use to clean and disinfect surfaces and devices?

Surfaces should be kept clean, and body substance spills should be managed promptly, as outlined in CDC’s Guidelines for Environmental Infection Control in Health-Care Facilities. Routine cleaning should be performed prior to disinfection. EPA-registered disinfectants with a sporicidal claim have been used with success for environmental surface disinfection in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of C. diff.

Note: EPA-registered disinfectants (List K) are recommended for use in patient-care areas. When choosing a disinfectant, check product labels for inactivation claims, indications for use, and instructions.

New Clostridium difficile Guidelines – Society for Healthcare Epidemiology of America

Updated guidelines on the diagnosis and treatment of Clostridium difficile (C. diff.) by IDSA and the Society for Healthcare Epidemiology of America (SHEA) have published in Clinical Infectious Diseases. Diagnosis and treatment of C. diff. has evolved significantly since the last guidelines were published in 2010.

C. diff. is diagnosed based on a patient’s medical history, signs and symptoms, combined with test results. The optimal method for laboratory diagnosis of C. diff. is the subject of debate and depends on how carefully patients are selected for testing. The updated guidelines recommend only testing patients with new onset and unexplained diarrhea (three or more unformed stools in 24 hours).

While immunoassays were the most common diagnostics employed previously, molecular testing – which has its pros and cons – is now used by more than 70 percent of hospital labs. Molecular tests can help rule out C. diff. infection, as well as reduce transmission by detecting C. diff. colonization in patients with diarrhea from other causes. But because they are very sensitive and can lead to over diagnosis, when there are no pre-agreed institutional criteria that limit testing to patients with significant unexplained diarrhea of three or more unformed stools in 24 hours, the guidelines recommend that a C. diff. common antigen test and a stool toxin test (such as an immunoassay) be used as part of a two- or three-step test process.

Not everyone diagnosed with C. diff. requires treatment. The guidelines include new recommendations for treatment when warranted, including:

• Vancomycin or fidaxomicin – Antibiotics vancomycin or fidaxomicin should be used for initial treatment of even mild C. diff., rather than metronidazole, which the previous guidelines recommended as first-line therapy. Research shows the cure rates are higher for vancomycin and fidaxomicin than for metronidazole.
• Fecal microbiota transplantation (FMT) – The guidelines recommend FMT for treatment of people with two or more recurrences of C. diff. and for whom traditional antibiotic treatment has not worked. FMT is a new treatment since the last guidelines were published but is not approved by the Food and Drug Administration (FDA). However, FDA has issued Guidance for Industry regarding the use of FMT to treat C. diff. infection not responsive to standard therapies. FMT involves transferring fecal bacteria from a healthy person’s stool to the gut of a person with recurrent C. diff., to replenish the good bacteria and control the disease-causing bacteria.

The guidelines include the same suggestions for preventing the spread of C. diff. as the 2010 guidelines – including isolating infected patients and ensuring healthcare workers and visitors use gloves and gowns – but also call for increased attention to antibiotic stewardship to reduce the unwarranted use of the drugs. While nearly all antibiotics predispose people to C. diff., some are of particular concern, including the fluoroquinolones, cephalosporins and clindamycin.

The new guidelines also include recommendations for epidemiologic surveillance, diagnosis, and treatment of C. diff. in children, which the 2010 guidelines did not address.

The IDSA/SHEA guidelines panel was co-chaired by L. Clifford McDonald, MD; Dale N. Gerding, MD, FIDSA; and Stuart Johnson, MD, FIDSA. Panel members included: Johan S. Bakken, MD, PhD, FIDSA; Karen C. Carroll, MD, FIDSA, Susan E. Coffin, MD, FIDSA; Erik R. Dubberke, MD, MSPH, FIDSA; Kevin W. Garey, PharmD, MS; Carolyn V. Gould, MD; Ciaran Kelly, MD; Vivian Loo, MD; Julia Shaklee Sammons, MD, MSCE; Thomas J. Sandora, MD, MPH; and Mark H. Wilcox, MD.

90,000 What antibiotics are best for treating exacerbations in people with cystic fibrosis with persistent pulmonary infection with Burkholderia cepacia complex?

Review question

We searched for evidence as to which antibiotics are best for treating people with cystic fibrosis at the height of symptoms who have persistent lung infection with Burkholderia cepacia complex .

Relevance

Cystic fibrosis is a common hereditary disease in which the lungs are often clogged with mucus.This damages the lungs’ defenses and often leads to chronic, persistent infections that cannot be cured with antibiotics. People with cystic fibrosis often require courses of antibiotics to relieve symptoms (such as cough, excess mucus / phlegm, and shortness of breath) during periods of illness or worsening. These episodes are called flare-ups and are usually treated with intravenous antibiotics (through an IV line into a vein). One group of bacteria that can infect the lungs of people with cystic fibrosis is Burkholderia cepacia complex .These closely related bacteria are widespread in the environment and do not cause infections in healthy people who do not have cystic fibrosis. Infections caused by these bacteria are especially difficult to treat because they are resistant to many commonly used antibiotics. Currently, doctors do not know which antibiotics are best for treating these infections; what combinations of antibiotics should be used; how long antibiotics should be used, and are there additional treatments that might also help.This is an update to a previously published review.

Search date

Evidence is current to: May 29, 2019.

Research characteristics

We did not find any trials in people with an exacerbation of cystic fibrosis infected with the bacteria Burkholderia cepacia complex who were randomly assigned to receive different treatments.

Highlights

More research is needed to find out which treatments are best for improving lung function and survival, and for reducing side effects and length of hospital stay in people infected with Burkholderia cepacia complex during an exacerbation.

“Please do not drink the antibiotics and hormones prescribed by your friends!”

Many myths have emerged around COVID-19 and the complications it causes. Low awareness of people and mistrust of medicine have created a favorable environment for a boom in self-medication. Lists of drugs that have nothing to do with real treatment are circulating on social media, and people are prescribing drugs for themselves that can lead to a dramatic deterioration in their condition. In an interview with Novaya Gazeta, the chief physician of the GKB No. 23 named.Davydovsky, Professor Elena Vasilieva spoke about the dangers of self-medication from coronavirus and what should not be done in any case.

Vlad Dokshin, Ekaterina Ganicheva, Gleb Schultz / “Novaya Gazeta”

– Let’s talk about the treatment of coronavirus. Who really needs this treatment?

– It must be understood that approximately 80-85 percent of people with covid, either recover on their own, or they have it in a relatively mild form.This is both very good and at the same time a big problem, because people are contagious during this period. They do not know that they are sick, they are spreading the virus, and this is the insidiousness of the new pandemic. Why does a huge percentage of patients recover on their own? Because we have our own immune system. First, there is a nonspecific immune response, then a specific immune response to this particular virus is developed, antibodies are produced, and cells begin to attack other cells infected with coronavirus.Do I need to do something with a person during this period?

If he is asymptomatic, if he does not have severe concomitant diseases, he should be left alone. You don’t need antibiotics, you don’t need hormones, you don’t need a long list of drugs that can be listed endlessly. As it happens with us now, when a person gets sick: first a doctor comes from a polyclinic and recommends some drugs. Then the patient asks his acquaintances – one, the other, the third. Those send lists of those recommended by neighbors, friends, and someone else.I often see lists of 20-25 drugs that people are taking.

With regard to the so-called antiviral drugs remdesivir and favipiravir, the evidence [of effectiveness] is either not very strong, or none at all.

There is not a single reliably proven drug that would avoid the severe course of covid.

– When we talk about some drugs, I’m scared, because we will tell you about this and people, as we have seen, will just run and start sweeping it off the pharmacy shelves.

– No, in no case should you give anything without a doctor’s prescription. A person may not know, for example, that anticoagulants are contraindicated for him. There are no drugs without side effects. If you are told that the medicine has no side effects, it is a scam. If a medicine works, it always works in both directions, it can be beneficial and harmful. Therefore, it is imperative to always consult a doctor for serious medications.

– Let’s go again.If you test positive for coronavirus, you have covid – you are lying at home. And if there are no serious symptoms, then it’s all like a common cold.

– Don’t just “lie at home”. Firstly, you don’t have to lie down, but you still have to walk around the apartment, this is the prevention of blood clots.

Secondly, if the temperature rises and lasts for several days or it is higher than 38.5–39 ˚С, of course, you should consult your doctor. If it has lasted long enough or if any symptoms of shortness of breath appear, oxygen saturation should be checked.Now there is such an opportunity, I know that in Moscow they give pulse oximeters free of charge. And if the pulse oximetry is below 93, for example, you already need to worry. If accompanied by shortness of breath, call a doctor or ambulance.

– And if a person has chronic diseases – diabetes, cardiovascular, – should he immediately need to collect things in the hospital or also not to get nervous yet?

– Firstly, the harder and harder it is, the less you need to be nervous. Unfortunately, many doctors have this panic.It is clear why: doctors are at risk, but panic interferes, doctors ‘panic, patients’ panic interferes with real treatment. This is what I do for several hours a day – I do psychotherapy, I manage a lot of patients on an outpatient basis, and my psychotherapy boils down to what I was just talking about. Please, do not take antibiotics, do not take hormones and drugs according to the long list sent by friends. All this should be done only according to indications. In particular, hormones, when given to people without indications, that is, the patient is not severe, worsen the prognosis.They are indicated when the condition becomes worse, when a person is dependent on oxygen. And all the rest of them are not just not necessary to accept, but absolutely impossible.

– In general, people began to panic when they began to say and write that doctors did not have a single protocol for treating covid. Is it true, isn’t it?

– This is so and not so. When covid began, it was a new disease, they did not know how to treat it, and it was quite justified to try different things. They did not know how covid flows, did not know many of the symptoms, they recognized it along the way and much later, after a month, two, three, four.We see more and more new manifestations of this virus now, and then we spontaneously tried different medicines. But today the picture is completely different.

Now we know that in 10-15 percent of patients the system starts to slip, it does not just fail, it begins to hyperactivize because of this failure.

– That is, it attacks?

– Yes. Imagine that the car is stuck on the ice or in deep snow, it starts making noise and skidding.You press on the gas, and it starts to slip even more. When this happens to the body, cytokines are released. In general, these are substances useful to us: when they are not in large quantities, they also activate the immune system. But when there are a lot of them, as is the case with covid, the so-called cytokine storm, they can damage tissues. Damage to the tissue leads to the release of even more substances that stimulate clotting, hypercoagulation begins; and, in fact, all this variety of symptoms that we see is the manifestation of these various cytokines.Less commonly, it is the direct action of the virus. And if you understand this, then the protocol is clear, and how to treat, and most importantly, this is already confirmed by randomized studies. When we just started, there was a moment of absolutely unsubstantiated medicine.

– That is, several months of 2020?

– Yes, we went back in history 20-30 years ago, when there was no evidence-based medicine. And returning to the treatment protocol: now people who have an advanced stage are admitted to the hospital, we do not put patients, as it was before, who simply have the very fact of covid or a positive test.As of today, we still have Dexamethasone, given on time, we still have anticytokine drugs, and we still have anticoagulants that should be given correctly, in the correct doses, this is very important. Now we have already learned many techniques, how to properly position the patient, how to give him oxygen, and we take a much smaller percentage of patients on mechanical ventilation and ECMO. When a patient comes to us who needs oxygen, the first thing we do is put him in a pr-position and give him oxygen.In different forms, it depends on the severity of the condition.

And we give almost everyone anticoagulants for blood clots.

And then we definitely take tests and see if a cytokine storm has developed or has not yet developed, it’s time to suppress it or not. When there is oxygen deficiency and this is confirmed by laboratory tests, then this is just the time to introduce certain hormones or anti-cytokine drugs. At the same time, we definitely look to see if there are signs of a bacterial infection, if they are not there, then antibiotics are not given. We also use fresh frozen plasma with a high titer of antibodies to coronavirus, while the person does not yet have their own antibodies.

– You have listed a lot, but did not say about CT, and this is the most popular procedure among the people now.

– CT should be done only if the doctor needs it for diagnosis.

My phone is being cut off now: “Can I have a CT scan at your place?” I don’t take anyone, as a rule!

Actually, this is one of my tasks in the interview – I really want to try at least a little to relieve the panic.Yes, this is a serious infection, but panic will only get in the way. I already said that this is a general rule: the stronger the question, the more calm and restrained you need to be and make decisions soberly.

– That is, when in the spring everyone with a positive test was sent to CT, is it simply because they did not understand how to work with it?

– You know, then it made a certain sense. Then there were up to 30 percent of false-negative tests, and CT was more sensitive. And this very much shifted the understanding in diagnostics, and at that stage it was very correct.Now the tests have become better, now we understand the disease better, and even CT does not always affect our actions. Because there are people who have a process of damage to the lungs, but at the same time normal pulse oximetry. And for someone, on the contrary, the percentage of damage is small, but he has a background lung disease, 20 percent is enough for him, therefore, the general condition of the patient, pulse oximetry, is much more important than just CT numbers.

– Let’s talk about antibiotics that have disappeared from pharmacies.

– This is the same panic topic. Thank God they are not there, because you do not need to self-medicate, especially with coronavirus.

– I’m asking now not so much about the coronavirus as in general.

– And it is not necessary at all. Where in the world can you buy an antibiotic without a prescription? Where?

– Can you buy from us without a prescription?

– Yes! They go and sweep away with us, because it is sold without a prescription. Nowhere in Europe, in America, you can buy an antibiotic without a prescription.My friends living abroad buy the recipe here and take it to their place.

– But does it somehow help, since they do it too?

– This is wrong. The massive, uncontrolled use of antibiotics is a huge problem. Resistance develops. But in the coronavirus, the problem is different, antibiotics are simply not needed by anyone. Do you understand? They simply do not need to be taken with covid at home. They are given only in the hospital and only in certain situations.

– Has the pandemic brought us anything good?

– The good news is that the doctors paid attention.In fact, we have worked before, and they can all call us at night – and not necessarily with covid: with a heart attack, with a stroke – and no one noticed this before. It is very important that this normal attitude towards doctors does not end with the pandemic. Otherwise, the Investigative Committee has become more active before that. Medical business has gone, and I really hope that it will end – business due to medical errors. Any doctor who makes this or that decision is not always 100 percent right, after all, a disease is always a choice, and you must understand that with such an analysis [it may be] so, but with such an analysis it is different… Our work is associated with certain risks, with certain difficulties, insomnia, constant stress, this was and is, now it is more, of course, than it was before.

And from the sad – this is the level of mistrust of doctors and vaccines now. This is extremely depressing.

For example, the Gamalea vaccine was made by professional people, I have known them for many years, and they are serious scientists. Yes, the third phase is not over yet, but it will be over and will show the clinical efficacy of the vaccine; safety was investigated in the first phase.

– So the vaccine is good and we need to be vaccinated?

– I myself was vaccinated with Sputnik and instilled in my whole family. The vaccine has already protected me once. It so happened, I was in very close contact with a person who fell ill, and there were already all the manifestations. That is, there was a very high concentration of the virus.

– It turns out that only mass vaccination gives herd immunity, but it is not developed naturally?

– Not yet.In Moscow, I have already had a lot of illnesses, but so far not enough to give real immunity.

– Now people are scared to appear in the hospital once again, even if they have serious illnesses. What does this lead to?

– It is a big trouble when patients with cardiovascular diseases have a protracted attack, which may indicate a heart attack: the arm does not move or the leg, and if there is a suspicion of a stroke, they endure and do not go to the hospital because they are afraid of the coronavirus.But in such a situation, you have to go immediately, just immediately.

– Not afraid of contracting coronavirus?

– Yes, because medicine is statistics. Natural mortality from a heart attack, if left untreated, is 30–33 percent. This is higher than the potential risk of dying from covid, an order of magnitude higher. Therefore, if you suspect a serious illness, you must go immediately.

– You say as if you have data and figures that people in such a serious condition do not go to the hospital.

– Yes, it is, and it saddens me insanely. People come to us on the second or third day after the onset of a heart attack, when it is very bad, when the heart is already beginning to break. We began to see gaps – this is something that we have not seen at all in recent years. We have a wonderful – true – working system for helping patients with heart attacks, I was even surprised by the results myself. It turned out that the time it took for an ambulance to reach a person with chest pains was ten minutes, and remained, despite all the workload of the ambulance on a covid.Pay attention if this is an acute situation. Don’t wait, call an ambulance. And vice versa, there is absolutely no need to suddenly go to the doctors now to be checked, as we like. We sat at home [without any complaints] and then decided to get checked. Please wait a couple of months and check it out when I hope it will be quieter.

Source: novayagazeta.ru

Clinical practice guidelines for the antibiotic therapy of urinary tract infections | Yakovlev S.V., Derevianko I.I.

MMA named after I.M. Sechenov, Research Institute of Urology, Ministry of Health of the Russian Federation, Moscow

Urinary tract infections

Upper divisions

Acute and chronic pyelonephritis

Acute and chronic pyelonephritis

Lower sections

Acute and recurrent cystitis

Acute and chronic prostatitis

Non-gonococcal urethritis

Symptoms of urinary tract infections

• Fever over 38 ° C
• Chills
• Intoxication
• Low back pain
• Dysuria
• Soreness in the lower abdomen
• Hematuria

Prostatitis symptoms:

• Difficulty and frequent urination
• Urinary retention
• Weakening the urine stream
• Dull pain in the perineum

Acute cystitis

Etiology:

In 90% – Escherichia coli, in other cases – other gram-negative bacteria

Symptoms:

• Cuts and burning when urinating
• Frequent urination
• urge to urinate
• Discomfort or soreness in the lower abdomen
• Hematuria

Diagnostics:

• Typical clinical picture
• Express test – strips:
  Leukocytes +
  Erythrocytes +
  Nitrite +
• Sediment microscopy:
  Leukocytes
  Erythrocytes
  Bacteria
• Bacteriuria is diagnostically significant> = 10 ² CFU / ml.

Treatment:

• Outpatient

• Sufficient fluid intake (at least 1.5 liters per day)
• Avoid sexual intercourse for 5-7 days
• Antibiotic therapy

Antibiotic therapy

By mouth for 3 days:

• Ofloxacin 200 mg every 12 hours
• Norfloxacin 400 mg every 12 hours
• Ciprofloxacin 250 mg every 12 hours
• Levofloxacin 500 mg every 24 hours
• Pefloxacin 400 mg x 2 r at 12 h intervals

Alternative:

• Co-trimoxazole 960 mg every 12 hours

By mouth for 5 days:

• Amoxicillin / clavulanate 375 mg every 8 hours
• Cefuroxime axetil 250 mg every 12 hours

Alternative:

• Furagin 100 mg every 6-8 hours
• Furadonin 100 mg every 6 hours

Effective in a single dose:

• Fosfomycin trometamol 3 g

Risk Factors:

• Age over 65 years
• Pregnancy
• Diabetes mellitus
• Recurrence of cystitis

Acute cystitis in pregnant women

Microbiological diagnostics compulsory:

• Before starting therapy
• After the end of therapy

Antibiotic therapy

By mouth for 7 days:

• Amoxicillin / clavulanate 375 mg every 8 hours
• Cefuroxime axetil 250 mg every 12 hours

Alternative:

• Furagin 100 mg every 6-8 hours
• Furadonin 100 mg every 6 hours
• Fosfomycin trometamol 3 g (single dose)
  

  Antibacterial drugs that are contraindicated in pregnancy: Fluoroquinolones Co-trimoxazole Doxycycline

Recurrent cystitis

Diagnostics: seeacute cystitis

Additional examination:

• Microbiological examination of urine before and after treatment
• Ultrasound of the kidneys and pelvic organs
• Blood glucose

Treatment:

• Sufficient fluid intake
• Maintaining low urine pH (cranberry, lingonberry, methionine)
• Emptying the bladder immediately after intercourse

Antibiotic therapy

By mouth within 7 days:

• Ofloxacin 100 or 200 mg every 12 hours
• Levofloxacin 500 mg every 24 hours
• Norfloxacin 400 mg every 12 hours
• Ciprofloxacin 100 or 250 mg every 12 hours
• Lomefloxacin 400 mg every 24 hours
• Pefloxacin 400 mg every 12 hours

Alternative:

• Cefuroxime axetil 250 mg every 12 hours
• Amoxicillin / clavulanate 375 mg every 8 hours
• Cefixime 400 mg every 24 hours

Prevention of relapse

For exacerbations associated with intercourse – taking one dose of antibiotic after coitus:

• Pefloxacin 400 mg
• Norfloxacin 400 mg
• Ciprofloxacin 250 mg
• Co-trimoxazole 480 mg

Acute prostatitis

Symptoms:

• Fever, chills, intoxication
• Pain in the perineum, in the lower back or above the pubis
• Burning and pain when urinating
• Difficulty and frequent urination
• Weakening the urine stream
• Sometimes – mucopurulent discharge from the urethra

Diagnostics:

• General urinalysis
• Leukocytes (> 10 in p / sp) and bacteria in the first and middle portions of urine with a three-glass sample
• In urine culture – bacteriuria> 10 ³ CFU / ml
• Ultrasound of the prostate gland

Treatment:

• Bed rest
• Hydration
• Analgesics and antispasmodics
• Avoid sexual intercourse
• Antibiotic therapy

Antibiotic therapy (within 3-4 weeks)

In severe cases, intravenous antibiotics ( 3-5 days after improvement of symptoms, transfer to oral therapy is possible.):

• Levofloxacin 500 mg every 24 hours
• Moxifloxacin 400 mg every 24 hours
• Ofloxacin 200 mg every 12 hours
• Ciprofloxacin 200 mg every 12 hours
• Pefloxacin 400 mg every 12 hours

In case of mild course, antibiotics by mouth:

• Levofloxacin 500 mg every 24 hours
• Moxifloxacin 400 mg every 24 hours
• Norfloxacin 400 mg every 12 hours
• Ofloxacin 400 mg every 12 hours
• Pefloxacin 400 mg every 12 hours
• Ciprofloxacin 500 mg every 12 hours
• Co-trimoxazole ( In recent years, there has been a decrease in the sensitivity of pathogens to co-trimoxazole.) 960 mg every 12 hours

Chronic bacterial prostatitis

Symptoms:

• Discomfort and soreness in the perineum, sacrum
• Discomfort and pain during urination and ejaculation
• Frequent or difficult urination
• Weakening the urine stream
• Hematospermia
• Recurrent urinary tract infections

Diagnostics:

• General urinalysis
• Leukocytes (> 10 in p / sp) and bacteria in the third portion of urine and prostate secretion in a four-glass test according to the Meares and Stamey method
• In urine culture – bacteriuria> 10 ³ CFU / ml
• Ultrasound of the prostate gland

.

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90,000 Prescribing antibiotics for the treatment of COVID-19 at home can worsen the condition of patients

Published on November 22, 2020 at 13:38.
Updated on November 22, 2020 at 13:39.

Intensive care physician at the Kovid hospital Sergei Tsarenko, in the author’s column for KP, shared the pain of doctors in the era of Kovid: the widespread unjustified prescription of antibiotics

Sergey Vasilyevich Tsarenko – Deputy Chief Physician for Anesthesiology and Intensive Care at City Clinical Hospital No. 52 in Moscow.This clinic became one of the leading covid centers in Moscow during the spring outbreak of the epidemic. And now it is among the best Russian hospitals where serious patients with COVID-19 are being rescued.

“Antibacterial drugs are one of the brightest inventions of mankind and medicine,” says Sergei Tsarenko. – With their appearance, the treatment of not only infectious diseases has radically changed, but also the development of surgery and transplantology, oncology and hematology has become possible. People with diabetes mellitus survive because they have fewer bacterial complications.

Antibiotics are a powerful shield that shuts off humanity from disease, and they are one of the important reasons why people began to live longer. If we remember the beginning of the last century, we will see that people were dying of banal croupous pneumonia. With the advent of antibiotics, the situation has changed radically. However, now, unfortunately, medicine is in a very difficult situation. Most antibiotics, especially those used in hospital settings, have developed resistance (pathogens become immune to these drugs.- Ed.) We are talking about the whole world – everywhere doctors are dealing with a stable microbial flora. One of the most important reasons for this is the use and prescription of antibiotics when there is no indication for them. Antibiotics should not be taken to people just in case – the coronavirus pandemic has already proven this to us!

STRIKE ON PATIENTS ON IVL

– For example, what are the main problems with the survival of ventilated patients? The mechanical ventilation method leads to the fact that the lungs are restored, but through the endotracheal or tracheostomy tube to which the ventilator is connected, multidrug-resistant microbes (that is, resistant to many existing antibiotics) enter.- Ed.). And despite all the technological equipment of our intensive care units – ventilators, ECMO – this may not be enough. The problem can be prevented, first of all, by not using antibiotics where it is not necessary.

We are now dealing with a viral pandemic. It is not winter yet, and there are practically no bacterial infections – pneumococci, Haemophilus influenzae, Legionella, which cause bacterial pneumonia in winter. Therefore, the unreasonable intake of antibiotics by patients on an outpatient basis is absolutely ineffective and senseless, since it entails an increase in the resistance of the microbial flora to them.

INSTEAD OF HELP – SEVERE COMPLICATIONS

– There are clear rules for prescribing antibiotics based on the results of a study of a biomaterial containing a bacterium, as well as analyzes indicating a systemic inflammatory process, continues Sergey Tsarenko. – Unfortunately, when consulting colleagues from the regions, one has to deal with the fact that people thoughtlessly use antibiotics in order to help a patient. However, instead of help, a resistant microbial flora is formed.

And most importantly, the doctor is wasting time waiting for the effect of the prescribed drug! There will be no effect, since covid infection is not a disease of a weakened immune system, but quite the opposite, of an excess one. Therefore, it is necessary to prescribe an antibiotic to stop inflammation, one of the manifestations of which is high temperature. And an immunosuppressive drug that can remove this excess immune response.

DANGEROUS PROCESS SPEEDED

– Acquisition of antibiotic resistance has accelerated in recent years.Because bacteria, forming resistance to one antibiotic, automatically become resistant to another, similar in structure. Microbes even know how to transfer pieces of genetic material with ready-made resistance genes to each other. Therefore, our task is to look for new ways, models and ideas for the implementation of rational antibiotic therapy.

Why are antibiotics still prescribed for viral pneumonia? This is an old misconception based on this. We thought that the virus weakens the immune system, bacteria gets on the weakened immune system of the lungs.And since we cannot fight the virus, we need to protect the lungs from bacteria with antibiotics. But it has already become clear that this is not so! (see above: in fact, immunity is not weakened, but extremely activated. – Ed.)

IMPORTANT

“Now great efforts are being made to overcome the situation with the unjustified prescription of antibiotics,” says Sergei Tsarenko. – Special state structures have been created that will deal with the problem of antibiotic resistance, which in these conditions actually means – the safety of our country.We need to take measures so that new antibiotics appear, so that resistance to existing antibiotics does not grow, so that we adjust the account of bacterial complications that arise in nosocomial conditions. It is necessary to categorically prohibit the sale of antibiotics without a doctor’s prescription! The problem should be solved jointly. Otherwise, after an epidemic, a situation will arise when entire branches of medicine will suffer: surgery, oncology, hematology, transplantology, traumatology and others – those where antibiotics are really vital.

When you are sick with tuberculosis what are the symptoms

By admin To read 17 min. Views 4 Published April 2, 2021

Symptoms of tuberculosis

Symptoms of tuberculosis are the first manifestations of a dangerous disease that a person can detect at home. After identifying symptoms, treatment should be started immediately so as not to aggravate the clinical picture. In general, they can be different and depend on the type of development of the disease.

Symptoms of pulmonary tuberculosis

Everyone should be responsible for their health and pay attention to even the slightest changes in their own body.

Tuberculosis can manifest itself in the elderly, adults and adolescents. Basically, there is no symptomatology, and pulmonary tuberculosis does not manifest itself in any way, but can only be detected during fluorography. There are several stages of tuberculosis: primary and secondary. Also, the disease is divided into forms: open and closed.

Basically, pulmonary tuberculosis is chronic: with a strong cough that does not go away even after taking special medications.

The cough itself has a paroxysmal nature and worries the patient constantly. Sputum is also present. If this is an ulcerative form, then hemoptysis can also be observed. Pain and burning sensation in the chest area are not unimportant characteristic signs of tuberculosis. The infiltrative form of tuberculosis is mostly asymptomatic or with the least signs.

Manifestations in the early stages

As already mentioned, if the form of tuberculosis is initial (mild), then the disease is almost asymptomatic. The patient may absolutely not feel any changes and complications in the body. A person should be concerned about symptoms such as: dizziness, apathy, sleep disturbance, pallor of the skin, blush on the cheeks, noticeable weight loss, decreased appetite and body temperature that does not exceed 37 degrees.

If a person has found one or more of the above symptoms, you should consult a doctor and go through the necessary procedures.Any suspicion should be a cause for concern.

Manifestations at the last stage

In the advanced late stage, the disease is practically ineradicable, therefore, this ailment should not be brought to a critical state. There are many symptoms of tuberculosis at the last stage, in some ways they are similar to symptoms in the early stages, but they are more pronounced. A person has a strong and persistent cough, profuse sweating, severe weakness, rapid weight loss with the usual lifestyle, fever and hemoptysis.

It should be noted that the last symptom indicates that Koch’s bacillus (tubercle bacillus) has affected the human immune system and has developed to such an extent that the organ that has become a habitat is affected to the stage of decomposition. This usually happens during the incubation period, which lasts from 7 to 12 weeks.

Manifestations of upper respiratory tract infection

Signs of infection can occur in different respiratory tracts. To recognize the disease in time, you should know its symptoms.At the beginning of the development of tuberculosis, the patient develops dryness and soreness in the nose and oropharynx, and he also cannot swallow food normally. In addition, severe shortness of breath and a hoarse cough are present.

After a while, a strong chill appears, the body temperature rises, and breathing becomes difficult. After another period, the voice changes and hemoptysis begins. At the same time, patients lose a lot of weight, since they cannot fully eat due to pain.

Tuberculosis of the larynx is manifested by improper mobility of the vocal cords and leads to hoarseness, respiratory failure, tickling, voice changes.

When the throat is affected, there is severe pain, a sensation of a foreign body in the pharynx, salivation increases, swelling, rashes and redness of the pharyngeal mucosa appear. If we are talking about tuberculosis of the nose, then all the symptoms are very similar to the usual sinusitis: itching, burning, crusts in the nose, frequent bleeding, congestion, pain, the presence of mucopurulent discharge.

Symptoms may be persistent, come and go, or progress slowly (low-grade tuberculosis).Rapid progress is also common, when a person can die from the manifestations of the disease in a few weeks.

Signs of extrapulmonary tuberculosis

Most often, people are faced with pulmonary tuberculosis, but the disease can also affect other vital organs of a person: intestines, stomach, eyes, brain, genitourinary system, bones and even skin.

It is possible to suspect the presence of incipient extrapulmonary tuberculosis with prolonged disease of organs that cannot be treated.To make an accurate diagnosis, the patient is referred for consultation to specialists and the necessary blood, urine and procedures tests are prescribed.

It should be noted that extrapulmonary tuberculosis is curable, but in case of correct and timely treatment. This treatment should be carried out exclusively under the supervision of the attending physician.

Infection of the gastrointestinal tract

Most often, the disease affects the following organs in the gastrointestinal tract: parts of the small intestine, stomach and cecum. In this case, the intestinal walls become inflamed.The development of the disease is possible after eating infected foods, such as milk. The patient has pain in the abdominal cavity, diarrhea or constipation, intestinal colic, and bloating are possible.

Infection of the nervous system

Damage to the brain and spinal cord is one of the most dangerous forms of tuberculosis. Most often, an infection in the lungs contributes to the development of the disease.

For this reason, tuberculous meningitis is considered a complication of pulmonary tuberculosis.The central nervous system is also affected. At the same time, the patient has apathy, irritability, a constant feeling of fatigue and severe headaches.

Bone-articular lesions

The spine, cervical regions and large tubular bones are most often affected. Tuberculosis of the scapula, knee, hip joint and bone marrow is all the result of the spread of infection from any other focus in the body. This form may not remind of itself for a long time, and manifest itself as a spontaneous fracture.As a result, muscle atrophy and dysfunction of the pubic symphysis can occur.

Skin lesions also exist. Tuberculosis of the skin is the result of the active spread of infection from any focus in the body. The disease develops when a person’s skin comes into contact with the causative agent of the disease.

Tuberculosis of the lymph nodes

Damage to the lymph nodes is also dangerous. In the early stages of the disease, inflammation of the lymph nodes is observed, without pain and an increase in body temperature. The progress of the inflammatory process leads to the so-called melting of the lymph nodes and the development of fistulas.The risk of infection is very high. This leads to the fact that infected people pose a great epidemiological danger to others. Tuberculosis of the respiratory tract and inflammation of the pleura can become a complication of tuberculosis of the lymph nodes.

Infection of the genitourinary system

The most vulnerable organ of the genitourinary system is the kidneys. It is the kidneys that are most often affected. The inflammatory process gradually destroys the organ, which can lead to kidney failure and complete organ loss.

Damage to the bladder, adrenal glands, urethra and ureters is mainly due to renal tuberculosis.The defeat of the organs of the genitourinary system leads to their deformation and disrupts the process of the urinary tract, and also disrupts sexual functions.

This applies to both male and female organs. In men, tuberculosis affects the prostate gland, prostate, testicles and vas deferens. In women – the ovaries, uterus, fallopian tubes.

Tuberculosis of the eye

Tuberculosis of the eye is a fairly common phenomenon. Mycobacterium can infect absolutely any part of the eye.There is tuberculous allergic eye disease, but metastatic tuberculosis is the most common. It is extremely difficult to diagnose this disease. Most often, it is detected by excluding other diseases.

Asymptomatic course of the disease

For a long time, pulmonary tuberculosis may be completely asymptomatic or there may be several mild symptoms. Disseminated tuberculosis mainly manifests itself as a consequence of pneumonia, but most often, the disease is latent (latent form) and does not manifest itself.In this case, the disease can be detected by chance, during standard annual examinations: during X-rays, fluorography, Mantoux test.

Symptoms of a dangerous illness can often be confused with the symptoms of bronchitis, pneumonia or ARVI that are common to people. In this case, the main sign to pay attention to is the presence of symptoms for a long time or the lack of improvement after treatment.

Outward appearance of the patient

Patients with tuberculosis outwardly have an emaciated appearance, as they greatly lose weight.They also have a pale skin, sharp facial features. Despite the pale face, there is always a blush on the cheeks of such people.

Manifestations of tuberculosis in infants

If an adult can recognize and understand the disease himself, how can one detect a serious illness in infants? The characteristic primary signs of tuberculosis in infants and newborns are fever, impaired or complete lack of appetite, shortness of breath.There may also be other symptoms in the child, depending on the organ affected. For example, the liver and spleen may be enlarged, since it is these organs that are involved in filtering tuberculosis bacteria. In addition, an infected baby does not gain weight well. Therefore, it is very important to monitor the behavior of infants and young children in order to detect infection in the early stages.

Signs of recovery

There is a clinical recovery from tuberculosis. This value means the complete disappearance of active changes in the body, which can be determined by various research methods.Since this disease is infectious, the time factor is of great importance in determining recovery.

In case of tuberculous lesion of the lungs, recovery is observed in 4-5 percent of the cured, and in the rest of the patients, pathomorphological changes in the body remain. In this case, residual changes may be insignificant: scars, foci. But in some patients, fibrotic changes can still be observed.

When recovering, it is important to take into account the form of the disease, the characteristics of the course of the disease, existing complications, methods of treatment, body reactions and much more.It is also important to ensure that a relapse does not occur, because the risk of re-emergence of the infection is very high. To do this, it is necessary to pass the examination of internal organs and samples for mycobacterium tuberculosis in time. The main signs of clinical recovery from tuberculosis are: the absence of signs of tuberculosis, the absence of X-ray signs of activity of Koch’s bacillus bacteria, persistent bacillary sputum, normal functioning of the internal organs, respiratory organs, circulatory system, central nervous system, restoration of the patient’s ability to work.To ensure complete recovery from tuberculosis, it is important to note the clinical persistence of treatment outcomes.

More fresh and relevant health information on our Telegram channel. Subscribe: https://t.me/foodandhealthru

More than 3 years of experience as an infectious disease specialist.

Has a patent on “A method for predicting a high risk of the formation of chronic pathology of the adeno-tonsillar system in frequently ill children.” And also the author of publications in the journals of the Higher Attestation Commission.

Source

Symptoms of tuberculosis

Medical expert article

The clinical symptoms of pulmonary tuberculosis are diverse, but the disease has no specific signs. This is especially important to take into account in modern conditions, characterized by an unfavorable environmental situation, the frequent use of various vaccines, serums and antibiotics, as well as changes in the properties of the causative agent of tuberculosis.

In this case, it is necessary to keep in mind three circumstances:

Inquiry and physical examination only allow suspecting tuberculosis.For timely clarification of the diagnosis, special research methods are required: immunological, microbiological, radiation, endoscopic and morphological. They are of decisive importance in the diagnosis and differential diagnosis of tuberculosis, in assessing the course of the disease and the results of treatment.

Study of complaints and anamnesis

When familiarizing with the anamnesis, it is necessary to establish when and how the tuberculosis disease was detected: when contacting a doctor about any complaints or during examination (preventive or about another disease).The patient is asked about the time of onset of symptoms and their dynamics, previous illnesses, injuries, operations. They pay attention to such possible symptoms of tuberculosis as pleurisy and lymphadenitis, identify concomitant diseases: diabetes mellitus, silicosis, gastric ulcer and duodenal ulcer, alcoholism, drug addiction, HIV infection, chronic obstructive pulmonary disease (COPD), bronchial asthma. Clarify whether he received drugs that suppress cellular immunity (glucocorticosteroids, cytostatics, antibodies to tumor necrosis factor).

Information about stay in regions with a high incidence of tuberculosis, in institutions of the penitentiary system, about participation in hostilities, place and living conditions of the patient, about the presence of children in the family is important. The profession and the nature of work, material and living conditions, lifestyle, the presence of bad habits (smoking, alcohol, drugs) are important. The level of the patient’s culture is assessed. Parents of sick children and adolescents are asked about anti-tuberculosis vaccinations and the results of tuberculin tests.It is also necessary to obtain information about the health of family members, possible contact with tuberculosis patients and its duration, about the presence of animals with tuberculosis.

When detecting contact with a patient with tuberculosis, it is important to clarify (request from another medical and prophylactic institution) the form of the disease, bacterial excretion, the presence of resistance of mycobacteria to anti-tuberculosis drugs, the treatment carried out and its success.

Typical symptoms of respiratory tuberculosis: weakness, increased fatigue, loss of appetite, weight loss, fever, sweating.cough, shortness of breath, chest pain, hemoptysis. The severity of the symptoms of tuberculosis varies, they occur in various combinations.

Early manifestations of tuberculosis intoxication can be symptoms of tuberculosis such as weakness, increased fatigue, impaired appetite, weight loss, irritability, decreased performance. Patients often do not associate these symptoms of tuberculosis with the disease, believing that their appearance is due to excessive physical or mental stress.The symptoms of tuberculosis and intoxication require increased attention, especially in persons at risk for tuberculosis. An in-depth examination of such patients can reveal the initial forms of tuberculosis.

With tuberculosis, body temperature can be normal, subfebrile and febrile. It is often characterized by significant lability and can increase after physical or mental stress. Patients usually tolerate an increase in body temperature quite easily and often almost do not feel it.

In case of tuberculosis intoxication in children, the body temperature rises in the afternoon for a short time to 37.3-37.5 ° C. Such rises are observed periodically, sometimes no more than twice a week, and alternate with long intervals of normal temperature. Less commonly, the body temperature remains within 37.0 ° C with a difference between morning and evening temperatures of about one degree.

Stable subfebrile condition with slight temperature fluctuations during the day is not typical for tuberculosis and is more common in chronic nonspecific inflammation in the nasopharynx, paranasal sinuses, biliary tract or genitals.An increase in body temperature to subfebrile may also be due to endocrine disorders, rheumatism, sarcoidosis, lymphogranulomatosis, and kidney cancer.

In rare cases, patients with pulmonary tuberculosis have a perverted type of fever, when the morning temperature exceeds the evening temperature. Such a fever indicates severe intoxication.

Cough very often accompanies inflammatory, tumor and other diseases of the lungs, respiratory tract, pleura, mediastinum.

In the early stages of tuberculosis, cough may be absent, sometimes patients notice intermittent coughing. With the progression of tuberculosis, the cough increases. It can be dry (non-productive) and mucus (productive). A dry paroxysmal cough appears when the bronchus is compressed by enlarged lymph nodes or displaced organs of the mediastinum, for example, in a patient with exudative pleurisy. Especially often dry paroxysmal cough occurs with bronchial tuberculosis.A productive cough appears in patients with pulmonary tuberculosis with destruction of lung tissue, formation of a lymphobronchial fistula, breakthrough of fluid from the pleural cavity into the bronchial tree. Cough with tuberculosis can also be caused by chronic nonspecific bronchitis or bronchiectasis concomitant with tuberculosis.

Sputum in patients with early stages of tuberculosis is often absent or its release is associated with concomitant chronic bronchitis. After the breakdown of the lung tissue, the amount of sputum increases.In uncomplicated pulmonary tuberculosis, the sputum is usually colorless, homogeneous and odorless. The addition of nonspecific inflammation leads to increased coughing and a significant increase in the amount of sputum, which can acquire a purulent character.

Progression of tuberculosis can lead to the development of chronic pulmonary heart disease (CPP) and pulmonary heart failure. In these cases, shortness of breath increases markedly.

A large proportion of smokers among tuberculosis patients determines the prevalence of concomitant COPD, which can affect the frequency and severity of expiratory dyspnea, requires differential diagnosis.

Dyspnea is often the first and main symptom of such complications of pulmonary tuberculosis as spontaneous pneumothorax, atelectasis of the lobe or the whole lung, pulmonary embolism. With the rapid accumulation of a significant amount of exudate in the pleural cavity, severe inspiratory dyspnea may suddenly occur.

In pulmonary tuberculosis, chest pain usually occurs due to the spread of the inflammatory process to the parietal pleura and the occurrence of perifocal) adhesive pleurisy.The pain arises and intensifies with breathing, coughing, and sudden movements. The localization of pain usually corresponds to the projection of the affected part of the lung onto the chest wall. However, with inflammation of the diaphragmatic and mediastinolic pleura, pain radiates to the epigastric region, the neck. shoulder, heart area. Weakening and disappearance of pain in tuberculosis is possible even without regression of the underlying disease.

With dry tuberculous pleurisy, pain occurs gradually and persists for a long time. It increases with coughing and deep breathing, pressure on the chest wall and, depending on the localization of the inflammation, can radiate to the epigastric or lumbar region.This makes diagnosis difficult. In patients with exudative tuberculous pleurisy, chest pain occurs acutely, but decreases with the accumulation of exudate and remains dull until it dissolves.

In cases of acute pericarditis, which sometimes occurs with tuberculosis, the pain is more often dull, unstable. It decreases in a seated position when leaning forward. After the appearance of effusion in the pericardium, the pain subsides, but when it disappears, it may reappear.

Sudden sharp pain in the chest occurs when tuberculosis is complicated by spontaneous pneumothorax.Unlike pain in angina pectoris and myocardial infarction, pain in pneumothorax increases during talking and coughing, and does not radiate to the left arm.

In intercostal neuralgia, pain is limited to the area of ​​the intercostal nerve and increases with pressure on the intercostal space. Unlike pain in tuberculous pleurisy, it intensifies when the body is tilted to the affected side.

With neoplasms of the lung, chest pain is constant and may gradually increase.

Hemoptysis (pulmonary hemorrhage) is more often observed in infiltrative, fibrous-cavernous and cirrhotic pulmonary tuberculosis.Usually, it gradually stops, and after the release of fresh blood, the patient continues to cough up dark clots for several more days. In cases of aspiration of blood and the development of aspiration pneumonia after hemoptysis, an increase in body temperature is possible.

Hemoptysis is also observed in chronic bronchitis, nonspecific inflammatory, tumor and other diseases of the chest organs. Unlike tuberculosis, patients with pneumonia usually have chills and a rise in body temperature first, followed by hemoptysis and stabbing pain in the chest.With a pulmonary infarction, chest pain often appears first, followed by fever and hemoptysis. Prolonged hemoptysis is typical for patients with lung cancer.

Massive pulmonary hemorrhage occurs more often in patients with fibro-cavernous. cirrhotic tuberculosis and gangrene of the lungs.

Physical methods of examination of patients with tuberculosis

Examination

Not only in medical literature, but also in fiction, the external appearance of patients with progressive pulmonary tuberculosis, which is known as habitus phtisicus, is described.Patients are characterized by a lack of body weight, a blush on a pale face, glittering eyes and wide pupils, dystrophic skin changes, a long and narrow chest, dilated intercostal spaces, an acute epigastric angle, lagging (pterygoid) scapula. Such external signs are usually observed in patients with late stages of the tuberculous process. When examining patients with initial manifestations of tuberculosis, sometimes no pathological changes are found at all. However, an inspection is always necessary.It often reveals various important symptoms of tuberculosis and must be carried out in full.

Pay attention to the physical development of the patient, the color of the skin and mucous membranes. Compare the severity of the supraclavicular and subclavian fossa, the symmetry of the right and left halves of the chest, assess their mobility during deep breathing, participation in the act of breathing of auxiliary muscles. Narrowing or widening of the intercostal spaces, postoperative scars, fistulas or scars after healing are noted.On the fingers and toes, attention is paid to the deformation of the terminal phalanges in the form of drumsticks and changes in the shape of the nails (in the form of watch glasses). In children, adolescents and young people, scars on the shoulder are examined after BCG vaccination.

Palpation

Palpation allows you to determine the degree of skin moisture, its turgor, the severity of the subcutaneous fat layer. Thoroughly palpate the cervical, axillary and inguinal lymph nodes. In inflammatory processes in the lungs with the involvement of the pleura, the lag of the affected half of the chest during breathing, soreness of the pectoral muscles are often noted.In patients with chronic tuberculosis, atrophy of the muscles of the shoulder girdle and chest can be detected. A significant displacement of the mediastinal organs can be determined by palpation by the position of the trachea.

Vocal tremor in patients with pulmonary tuberculosis can be normal, increased or weakened. It is best performed over areas of the compacted lung with infiltrative and cirrhotic tuberculosis, over a large cavity with a wide draining bronchus. The weakening of vocal tremor up to its disappearance is observed in the presence of air or fluid in the pleural cavity, atelectasis, massive pneumonia with obstruction of the bronchus.

Percussion

Percussion reveals relatively gross changes in the lungs and chest in infiltrative or cirrhotic lesions of a lobar nature, pleural fibrosis. An important role is played by percussion in the diagnosis of such urgent conditions as spontaneous pneumothorax, acute exudative pleurisy, lung atelectasis. The presence of a boxed or shortened pulmonary sound allows you to quickly assess the clinical situation and conduct the necessary studies.

Auscultation

Tuberculosis may not be accompanied by a change in the nature of breathing and the appearance of additional noise in the lungs.One of the reasons for this is the obstruction of the bronchi draining the affected area with dense caseous-necrotic masses.

[1], [2], [3], [4], [5], [6], [7], [8]

Source

Self-medication with antibiotics for COVID-19 is dangerous. REMINDER

1 December 2020 13:00

Self-medication with antibiotics for COVID-19 is dangerous. REMINDER

Anna Simakova, the chief infectious disease specialist of the Primorsky Territory, spoke about the consequences of uncontrolled intake of antibacterial drugs.

What are antibiotics and when do they help?

– Antibiotics really radically changed the treatment of not only infectious diseases, but also showed a positive effect in the development of surgery and transplantology, oncology and hematology. Thanks to these drugs, the rate of patient recovery has increased significantly worldwide. However, antibiotics are not suitable for treating the COVID-19 virus. Their use is justified only in the case of bacterial inflammation or complications.

We are now dealing with a viral epidemic, not bacterial, which occurs in winter. Therefore, the unreasonable intake of antibiotics by patients on an outpatient basis is absolutely ineffective and senseless, since it entails an increase in the resistance of the microbial flora to them.

– Doctors say that taking antibiotics without a doctor’s prescription is dangerous. Is it so?

– Now is a difficult period for society. The epidemic and general panic about the development of coronavirus infection have led to an increase in the number of people self-medicating.Doctors sound the alarm for a reason. Firstly, antibiotics do not help to cure an infectious disease, which is COVID-19. The recommendations of the experts of the Ministry of Health clearly state: in case of mild course and in the absence of bacterial inflammation, in the absence of a pronounced inflammatory reaction, the use of antibiotics is not necessary and may even be dangerous, since these drugs have many contraindications.

Secondly, antibiotics do not work for the so-called prevention of possible bacterial complications in viral infections, including coronavirus infection.

Therefore, in any clinical situation, antibiotics should be prescribed only by a doctor who monitors the dynamics of the patient’s condition improvement and is ready to amend the treatment protocol in accordance with the symptomatology. There are clear rules for prescribing antibiotics based on the results of a study of a biomaterial containing a bacterium, as well as analyzes indicating a systemic inflammatory process.

– The authorities are discussing the sale of prescription-only antibiotics.Is this a justified measure?

– There is an increased demand for antimicrobial drugs in many pharmacy organizations in the country. Citizens often buy them for future use, and often take antibiotics on their own “for prevention.”

But uncontrolled antibiotics can make other microorganisms in the oral cavity, gut, that can cause disease, become resistant to them, and it will be extremely difficult for us doctors to treat possible bacterial complications.

The patient may develop resistance to most antibiotics (infectious agents become resistant to these drugs). This means that in an emergency, the usual antibacterial drugs will not help him. On a national scale, this will lead to the fact that entire branches of medicine will suffer: surgery, oncology, hematology, transplantology, traumatology and others – those in which antibiotics are really vital.

90,000 Does an incomplete course of antibiotics lead to the development of antibiotic resistance?

Question: Does an incomplete course of antibiotics lead to the development of antibiotic resistance?

Answer: Numerous studies are being carried out to determine the shortest possible antibiotic treatment needed to kill all bacteria.

The type of antibiotic your doctor prescribes to treat the infection and the length of treatment should be based on the best scientific evidence.