Anyone aware of changes to C. diff Treatment?

[AnotherSheep]

Hey all, long time lurker and fellow fighter in the trenches. I have a question for my first post. Hospitalist in a small town is swearing that there is new data showing IV vanc is as effective as PO for colitis and C. diff. It's starting to spread and I have seen another physician sight this in his note while we are giving IV to a patient with C. diff. I have expressed my surprise and eagerness to learn about this study but have yet to be informed where I can find this new information..... Inexplicably when I have confronted these cases the physician coincidentally changed their mind the next day and switched to PO vanc.

Perhaps living under a rock in BFE has kept me from the latest and greatest. Can Anyone inform me of these new studies so I can replace everything I know about vanco pharmacology/kinetics?!

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[CetiAlphaFive]

Hey all, long time lurker and fellow fighter in the trenches. I have a question for my first post. Hospitalist in a small town is swearing that there is new data showing IV vanc is as effective as PO for colitis and C. diff. It's starting to spread and I have seen another physician sight this in his note while we are giving IV to a patient with C. diff. I have expressed my surprise and eagerness to learn about this study but have yet to be informed where I can find this new information..... Inexplicably when I have confronted these cases the physician coincidentally changed their mind the next day and switched to PO vanc.

Perhaps living under a rock in BFE has kept me from the latest and greatest. Can Anyone inform me of these new studies so I can replace everything I know about vanco pharmacology/kinetics?!

Cite*
Why would anyone do IV over PO? This makes no sense and sounds like a housework question.

 

[owlegrad]

Even if it was “as effective” (no), why would anyone prefer that?

I presume this whole discussion is framed by the information that even PO Vanco is no longer the preferred treatment for C Diff?

 

[AnotherSheep]

Cite*
Why would anyone do IV over PO? This makes no sense and sounds like a housework question.

My bad, shouldn’t SDN and work. As to your question, it isn’t uncommon here to unnecessarily use IV when PO will do just fine. I’ve also heard before that we have to use IV or our patients will be upset that we are only giving them a pill.

Allow me to be clear that I don’t endorse these beliefs or practices, but it is what some of us are up against in rural healthcare.

 

[confettiflyer]

Are they shooting for vanc troughs of 5, too? lol

 

[rxkrafted]

they did update the guidelines last year but this is definitely not it lol... i would probably scan through all the patients that hospitalist rounds on daily just to look for potential errors.

 

[PharmDBro2017]

New Treatment Guidelines for Clostridium Difficile

The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) have released updated guidelines for Clostridium difficile infections.

www.pharmacytimes.com

 

[RxPreceptor]

Location, location, location...PO

 

[zelman]

Hey all, long time lurker and fellow fighter in the trenches. I have a question for my first post. Hospitalist in a small town is swearing that there is new data showing IV vanc is as effective as PO for colitis and C. diff. It's starting to spread and I have seen another physician sight this in his note while we are giving IV to a patient with C. diff. I have expressed my surprise and eagerness to learn about this study but have yet to be informed where I can find this new information..... Inexplicably when I have confronted these cases the physician coincidentally changed their mind the next day and switched to PO vanc.

Perhaps living under a rock in BFE has kept me from the latest and greatest. Can Anyone inform me of these new studies so I can replace everything I know about vanco pharmacology/kinetics?!

Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for...

www.idsociety.org

They are mistaken. Maybe they got confused by the enema dose/volume?

 

[El Trombopag]

We used to make PO vancomycin from IV vancomycin stock vials, does that count?

 

[Xarelto-10]

I am aware that po Vanc is 1’st line and not flagyl, unless po Vanc is not available.

But IV doesn’t make sense unless pt became septic but still you have to address both and give drugs in the appropriate route.

 

[El Trombopag]

Clipped from the updated 2018/19 IDSA guidelines (free access).

XXIX. What are the best treatments of an initial CDI episode to ensure resolution of symptoms and sustained resolution 1 month after treatment?

1. Either vancomycin or fidaxomicin is recommended over metronidazole for an initial episode of CDI. The dosage is vancomycin 125 mg orally 4 times per day or fidaxomicin 200 mg twice daily for 10 days (strong recommendation, high quality of evidence) (Table 1).
2. In settings where access to vancomycin or fidaxomicin is limited, we suggest using metronidazole for an initial episode of nonsevere CDI only (weak recommendation, high quality of evidence). The suggested dosage is metronidazole 500 mg orally 3 times per day for 10 days. Avoid repeated or prolonged courses due to risk of cumulative and potentially irreversible neurotoxicity (strong recommendation, moderate quality of evidence). (See Treatment section for definition of CDI severity.)

XXX. What are the best treatments of fulminant CDI?

1. For fulminant CDI*, vancomycin administered orally is the regimen of choice (strong recommendation, moderate quality of evidence). If ileus is present, vancomycin can also be administered per rectum (weak recommendation, low quality of evidence). The vancomycin dosage is 500 mg orally 4 times per day and 500 mg in approximately 100 mL normal saline per rectum every 6 hours as a retention enema. Intravenously administered metronidazole should be administered together with oral or rectal vancomycin, particularly if ileus is present (strong recommendation, moderate quality of evidence). The metronidazole dosage is 500 mg intravenously every 8 hours.*
   • *Fulminant CDI, previously referred to as severe, complicated CDI, may be characterized by hypotension or shock, ileus, or megacolon.
2. If surgical management is necessary for severely ill patients, perform subtotal colectomy with preservation of the rectum (strong recommendation, moderate quality of evidence). Diverting loop ileostomy with colonic lavage followed by antegrade vancomycin flushes is an alternative approach that may lead to improved outcomes (weak recommendation, low quality of evidence).

XXXI. What are the best treatments for recurrent CDI?

1. Treat a first recurrence of CDI with oral vancomycin as a tapered and pulsed regimen rather than a second standard 10-day course of vancomycin (weak recommendation, low quality of evidence), OR
2. Treat a first recurrence of CDI with a 10-day course of fidaxomicin rather than a standard 10-day course of vancomycin (weak recommendation, moderate quality of evidence), OR
3. Treat a first recurrence of CDI with a standard 10-day course of vancomycin rather than a second course of metronidazole if metronidazole was used for the primary episode (weak recommendation, low quality of evidence).
4. Antibiotic treatment options for patients with >1 recurrence of CDI include oral vancomycin therapy using a tapered and pulsed regimen (weak recommendation, low quality of evidence), a standard course of oral vancomycin followed by rifaximin (weak recommendation, low quality of evidence), or fidaxomicin (weak recommendation, low quality of evidence).
5. Fecal microbiota transplantation is recommended for patients with multiple recurrences of CDI who have failed appropriate antibiotic treatments (strong recommendation, moderate quality of evidence).
6. There are insufficient data at this time to recommend extending the length of anti–C. difficile treatment beyond the recommended treatment course or restarting an anti–C. difficile agent empirically for patients who require continued antibiotic therapy directed against the underlying infection or who require retreatment with antibiotics shortly after completion of CDI treatment, respectively (no recommendation).

 

[VA Hopeful Dr]

Even if it was “as effective” (no), why would anyone prefer that?

I presume this whole discussion is framed by the information that even PO Vanco is no longer the preferred treatment for C Diff?

Do what now? Isn't PO vanc now first line as of last year?

 

[owlegrad]

Do what now? Isn't PO vanc now first line as of last year?

Well, I am glad I got called out! I had it exactly backwards...I thought metronidazole was the preferred treatment. I have no idea where I got that idea.

wuh wuh

 

[CetiAlphaFive]

IDSA just needs to nut up and make Jamba-Deuce the 1st line tx

 

[spacecowgirl]

No. No. No. What is the MOA in which this makes sense?

 

[spacecowgirl]

Also shoot me before you give me a colectomy for CDI. First they come for your colon, then God knows.

 

[Rockinacoustic]

I would have told them to send me the study else I'm changing it to PO Vanc.

 

[AnotherSheep]

I'm getting the sense that some of you feel I was trying to side with these physicians. That is not the case, and I am not able to justify their beliefs or theories with any science or data, because I too know it goes against everything I have ever been taught or practiced. As for just changing the order, that doesn't always happen in a small town hospital like where I work. Decades behind in policies and procedures that allow for autonomy of pharmacists that would be common elsewhere. Hoping it changes with the changing of the guard.

 

[CetiAlphaFive]

I'm getting the sense that some of you feel I was trying to side with these physicians. That is not the case, and I am not able to justify their beliefs or theories with any science or data, because I too know it goes against everything I have ever been taught or practiced. As for just changing the order, that doesn't always happen in a small town hospital like where I work. Decades behind in policies and procedures that allow for autonomy of pharmacists that would be common elsewhere. Hoping it changes with the changing of the guard.

You have an obligation to advocate for patients.
It sounds like youre doing a decent job of it.

 

[rawlithium]

fidaxomicin or po vancomycin for 10 days is now considered first line. I think I remember in school that fecal transplant had a phenomenal success rate but was last line because how how invasive it was lol.

New Treatment Guidelines for Clostridium Difficile

The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) have released updated guidelines for Clostridium difficile infections.

www.pharmacytimes.com

"Inexplicably when I have confronted these cases the physician coincidentally changed their mind the next day and switched to PO vanc.,"

I feel you on that, my friend. It happens almost every other week where I make a recommendation, get yelled at, and then MD changes it to what I suggested.

 

[BidingMyTime]

I feel you on that, my friend. It happens almost every other week where I make a recommendation, get yelled at, and then MD changes it to what I suggested.

Yes, this is a common happening. Certain doctors have to keep their pride by not admitting the pharmacist was right at the time of the suggestion.

 

[rxkrafted]

I'm getting the sense that some of you feel I was trying to side with these physicians. That is not the case, and I am not able to justify their beliefs or theories with any science or data, because I too know it goes against everything I have ever been taught or practiced. As for just changing the order, that doesn't always happen in a small town hospital like where I work. Decades behind in policies and procedures that allow for autonomy of pharmacists that would be common elsewhere. Hoping it changes with the changing of the guard.

Were there any consults on these patients? I would have tried to get a new order from a different physician because this isn't anything new... or would have asked him for this new information he is so confident about

 

[spacecowgirl]

I'm getting the sense that some of you feel I was trying to side with these physicians. That is not the case, and I am not able to justify their beliefs or theories with any science or data, because I too know it goes against everything I have ever been taught or practiced. As for just changing the order, that doesn't always happen in a small town hospital like where I work. Decades behind in policies and procedures that allow for autonomy of pharmacists that would be common elsewhere. Hoping it changes with the changing of the guard.

No, not at all. Keep fighting the good fight.

 

[AnotherSheep]

Were there any consults on these patients? I would have tried to get a new order from a different physician because this isn't anything new... or would have asked him for this new information he is so confident about

Well, I believe both times they were also using IV Flagyl so there was improvement in the patient. Also, as they are switching to PO vanc the next day, I don't really have a week of failed therapy to rub in their face as proof. As for other physicians, there is but one hospitalist. I have expressed my surprise and interest in this new data, however have not outright demanded he show it to me. In a hospital this small with one hospitalist, I need to be very calculated as to not ruin what relationship currently exists. If he does come through with this groundbreaking study you all will be the first to know 😉

 

[rawlithium]

Hey all, long time lurker and fellow fighter in the trenches. I have a question for my first post. Hospitalist in a small town is swearing that there is new data showing IV vanc is as effective as PO for colitis and C. diff. It's starting to spread and I have seen another physician sight this in his note while we are giving IV to a patient with C. diff. I have expressed my surprise and eagerness to learn about this study but have yet to be informed where I can find this new information..... Inexplicably when I have confronted these cases the physician coincidentally changed their mind the next day and switched to PO vanc.

Perhaps living under a rock in BFE has kept me from the latest and greatest. Can Anyone inform me of these new studies so I can replace everything I know about vanco pharmacology/kinetics?!

I also wanted to add that sometimes if MD tells me something I think is stupid/off-EBM/not going to work, I just tell them I'll get back to them because I'm busy right now and then use that time to google the guidelines or look it up on uptodate, and then print out the section and tell them it's bs. (not necessarily in those words)