“C difficile infection – what ED docs need to know” From EM Quick Hits 54 With Links From From The ISDA On C. Difficile Infection

In addition to today’s resource, I have reviewed and link to*

*Note to myself: I didn’t find this resource that helpful.

  • Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Clinical Infectious Diseases, Volume 73, Issue 5, 1 September 2021, Pages e1029–e1044, https://doi.org/10.1093/cid/ciab549
    Published: 14 June 2021

Today, I review and link to the show notes from C difficile infection – what ED docs need to know from EM Quick Hits 52.*

*Helman, A. Ostrow, O. Long, B. McLaren, J. Mullally, J.  Petrosoniak, A. Morgenstern J. EM Quick Hits 54 – Button Battery Ingestion, C. difficile, ECG in Tox, Bed Bugs, Fibrinogen in Trauma, Cold Air for Croup. Emergency Medicine Cases. January, 2024. https://emergencymedicinecases.com/em-quick-hits-january-2024/Accessed January 25, 2024.

All that follows is from the above resource.

C difficile infection – what ED docs need to know (19:15 – 26:30)

Clostridioides difficile is an anaerobic Gram-positive, spore-forming, enterotoxin-producing bacterium that causes watery diarrhea. About 10% of patients presenting to the ED with diarrhea have c difficile infection (CDI).

Risk factors  for CDI may include:

  • Antibiotic use: Fluoroquinolones, beta-lactam and beta-lactamase inhibitors, third- and fourth-generation cephalosporins, carbapenems, and clindamycin. Even a single dose can cause c diff.
  • Health care exposure.
  • Patient health factors including inflammatory bowel disease, HIV, recent GI surgery, tube feedings, malnutrition, obesity, female sex, low albumin, and older age.
  • PPI use is also considered a risk factor, but this is controversial due to poor data.
  • Up to 40% of patients with CDI don’t have a prior antibiotic risk factor, and up to 18% have no prior healthcare exposure.

Suspect CDI in the following patient presentations:

  • Ill-appearing patient with diffuse, watery stools and recent antibiotic use and/or hospitalization.
    • Abdominal pain (6-90%), fever (21-50%), bloody stools (5-21%) and watery diarrhea (55-84%). Diarrhea is often not an isolated symptom; nausea and vomiting can occur in up to 30%.
  • Patients with acute onset of 3 or more unformed stools without explanation.
  • Patients with GI symptoms plus constitutional symptoms, as well as a pertinent history of antibiotic use, comorbid conditions, and/or recent healthcare visits.

CDI testing centers on detection of the organism itself or the production of toxin A or B. Culture is not as feasible in the ED. The most common tests in the ED include toxin assay and nucleic acid amplification.

  • Toxin assay is specific but has a sensitivity of only 50%-60%.
  • NAAT is very sensitive, but it can’t distinguish infection from asymptomatic colonization, so only order the test if the patient has symptoms.
  • IDSA guidelines emphasize using a two or three step algorithm based on laboratory capabilities and institution.


Treatment of c. difficile diarrhea depends on illness severity:

  • Non-severe
    • First episode: vancomycin 125 mg 4x per day for 10 days or fidaxomicin 200 mg 2x per day for 10 days. If these aren’t available, use metronidazole 500 mg 3x per day.
  • Severe CDI includes WBC > 15,000 or creatinine > 1.5 mg/dl.
    • Use vancomycin or fidaxomicin as above.
  • Fulminant CDI includes signs of shock, vasopressor requirement, elevated lactate, or toxic megacolon (peritonitis, severe pain or tenderness, distension, and guarding. Imaging will show a significantly dilated diameter of the colon > 6 cm).
    • Speak with GI and surgery early and use enteral vancomycin 500 mg 4x per day. This can be given orally and rectally. If ileus is present use vancomycin rectally.
  • Recurrent infection is defined by 3 or more CDI episodes.
    • If previously treated with oral metronidazole should be treated with oral vancomycin or fidaxomicin.
  • Prevent the spread by washing hands with soap and water with these patients; the alcohol-based sanitizer does not kill the spores.



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