Case 084: Clostridioides difficile Infection

PATIENT PRESENTATION

Chief Complaint

Weakness and diarrhea after completing antibiotic therapy with levofloxacin for pyelonephritis

History of Present Illness

On day five of the current hospitalization LD complains of severe abdominal pain. She has received three days of fidaxomicin for Clostridioides difficile infection (CDI). The team noted absent bowel sounds and sent the patient for imaging. Abdominal x-ray reveals ileus. The patient’s home medications have not been restarted yet this admission.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. What are the risk factors for LD developing CDI?

   Hint: See Inflammatory Gastrointestinal Infections in PPP

2. How would you categorize CDI based on LD’s signs and symptoms?

   Hint: See Inflammatory Gastrointestinal Infections in PPP

3. What is the recommended therapy for initial episodes of CDI?

   Hint: See Inflammatory Gastrointestinal Infections in PPP

4. What are limitations to the use of fidaxomicin in this patient?

   Hint: See Inflammatory Gastrointestinal Infections in PPP

5. What therapeutic changes do you recommend for LD?

   Hint: See Inflammatory Gastrointestinal Infections in PPP

FOLLOW-UP

What FDA-indicated therapy would provide secondary prevention of CDI for this patient?

Hint: See Inflammatory Gastrointestinal Infections in PPP

CASE SUMMARY

Global Perspective

Recent updates to the management of C. difficile infection have been published both in the United States and Europe. Major changes include recommendations regarding first-line therapy for initial and recurrent CDI. The place in therapy of fidaxomicin is defined. Management of severe or fulminant infection remains the same. Additionally, bezlotoxumab, a monoclonal antibody that binds Clostridioides difficile toxin B, has been approved to decrease the risk of CDI recurrence. Fidaxomicin and bezlotoxumab are costly agents, this along with their benefits need to be considered when recommending therapy.

Key References