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学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense ID pharmacist.

CDI 治療の復習

消化器医師とCDI治療についてdiscussion

 
CDIは5大院内感染の1つであり
重要なので、学生と復習
 
以下は、本日のUp To Date より引用

 

まずは、抗菌薬の中止と接触予防策

The initial step in the treatment of Clostridium difficile infection (CDI) is cessation of the inciting antibiotic as soon as possible. Infection control practices must be implemented, including contact precautions and hand hygiene. Hand hygiene with soap and water may be more effective than alcohol-based hand sanitizers in removing C. difficile spores, since C. difficile spores are resistant to killing by alcohol. Therefore, use of soap and water is favored over alcohol-based hand sanitization in the setting of a CDI outbreak, although thus far no studies have demonstrated superiority of soap and water in non-outbreak settings

 
重症でない場合の初期治療
For initial treatment of nonsevere CDI, we suggest oral metronidazole (Grade 2B). 
 
重症の場合
For treatment of severe CDI, we recommend vancomycin 125 mg four times daily for 10 to 14 days (Grade 1B). For patients with severe disease who do not demonstrate clinical improvement, we suggest treatment with oral vancomycin 500 mg four times daily (Grade 2C); fidaxomicin may be considered in patients who cannot tolerate vancomycin, although more data are needed. 
 
重症で急増悪、治療抵抗性
In critically ill patients with fulminant or refractory disease, we suggest oral vancomycin 500 mg four times daily and intravenous metronidazole 500 mg every eight hours (Grade 2C); fidaxomicin may be considered in patients who cannot tolerate vancomycin, although more data are needed.
 
特殊疾患の場合
For treatment of severe disease in patients with profound ileus, we suggest addition of intracolonic vancomycin (Grade 2C), but there is risk of colonic perforation. Therefore, use of intracolonic vancomycin should be restricted to patients who are not responsive to oral therapy, and the procedure should be performed by personnel with expertise in administering enemas.
 
重症でない再発症例
For treatment of a nonsevere initial recurrence of CDI, we suggest oral metronidazole (Grade 2A). Alternatives include oral vancomycin or fidaxomicin. 
 
2度目の再発
For treatment of a second recurrence of CDI, we suggest intermittent and tapering vancomycin therapy or fidaxomicin (Grade 2B). For treatment of subsequent recurrences of CDI, we suggest administering either fidaxomicin or vancomycin followed by rifaximin (Grade 2C).
 
手術の適応
We recommend urgent surgical evaluation for patients with a white blood cell count ≥20,000 cells/microL and/or a plasma lactate between 2.2 and 4.9 mEq/L (Grade 1B). In addition, surgical intervention should be strongly considered in the setting of peritoneal signs, severe ileus, or toxic megacolon.
 
期待されている治療法
Potential alternative therapies requiring further investigation prior to routine use include new antibiotic agents, binding resins, intravenous immunoglobulin, and fecal bacteriotherapy. 
 
重症度
Guideline parameters for severe CDI include white blood cell count of >15,000 cells/microL, serum albumin <3 g/dL, and/or a serum creatinine level ≥1.5 times the premorbid level
 

Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) ... - PubMed - NCBI

Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. - PubMed - NCBI
 
Probiotics
予防としては、あり
In patients receiving antibiotics who are felt to be at increased risk for CDAD, we suggest coadministration of probiotics for prevention of CDAD (Grade 2B). Factors for consideration include prolonged duration of antibiotic therapy, local incidence of CDAD, and individual patient characteristics.
 
治療としては、なし
We suggest NOT administering adjunctive probiotics for routine treatment of CDAD (Grade 2C). Use of probiotics may be reasonable in patients with recurrent disease that is not severe, as long as there are no significant comorbidities. 
 
菌血症の報告
A small number of case reports describing bacteremia or fungemia attributed to probiotics have been reported; Saccharomyces boulardii and Lactobacillus rhamnosus GG are the most common organisms. In almost all cases, patients who developed bacteremia or fungemia in the setting of probiotic therapy had severe comorbidities, were on immunosuppressive medication, had recent surgical intervention, or had recent prolonged hospitalization
 
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