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Clinical Session: “The New C. Diff

From: The Hospitalist, May 2010

by Jason Carris

JOHN G. BARTLETT, MD, professor of medicine in the Department of Infectious Diseases at Johns Hopkins University School of Medicine in Baltimore, mesmerized a standing-room-only crowd of more than 500 at his lecture about the increase of Clostridium difficile in U.S. hospitals.

C. diff incidence has more than doubled since the mid-1990s, to more than 160 cases per 100,000 patients, and currently outnumbers the annual total of MRSA cases in the U.S., according to Dr. Bartlett, one of the foremost scholars on the subject. For hospitalists encountering patients with questions about the disease and where it comes from, Dr. Bartlett encouraged providers to punt that question: “The fact is, we don’t know most of the time.”

Most patients acquire C. diff during a hospital stay (74%) or a previous hospital stay (21%), and research shows the longer patients stay in the hospital, the more likely they are to acquire the disease.

If your lab does PCR, it’s the best test currently available.
—John G. Bartlett, professor, Department of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore

“It’s embedded in the fabric of hospitals,” Dr. Bartlett said. “The longer you are in the hospital, the more likely you are to get colonized.”

Prevention guidelines include:

  • Hand hygiene;
  • Advocate gloves and gowns;
  • Patients with C. diff should be in single rooms;
  • Maintain precautions until diarrhea resolves; and
  • Clean with chlorine antiseptic.

Dr. Bartlett was excited to share his experience with RT-PCR testing, which he termed the “new, slick, fast” testing option for C. diff. In trials, it has been shown to be 99% sensitive and 98% specific. “If your lab does PCR, it is the best test currently available,” Dr. Bartlett said, although he cautioned that “this test detects the bug, not the toxin.”

Treatment of C. diff disease happens in the colon, and medications must make it there to be effective. The most common treatments, vancomycin and metronidazole, have pluses and minuses, Dr. Bartlett explained. Vancomycin is FDA-approved and unbeaten in clinical trials; however, it is the more expensive choice. Metronidazole is cheaper ($5 per day) and proven to be effective in mild to moderate cases, but is not FDA-approved and is unproven in severe cases.

Dr. Bartlett’s guidelines for C. diff treatment:

  • Mild cases: no treatment;
  • Moderate: metronidazole 250 mg four times a day for 10 to 14 days; and
  • Serious: vancomycin 125 mg four times a day for 10 to 14 days.

“If metro doesn’t work, switch to oral vanco,” Dr. Bartlett said. HM10

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