tailieunhanh - Chapter 123. Clostridium difficile–Associated Disease, Including Pseudomembranous Colitis (Part 5)

Recurrent CDAD Overall, ~15–30% of patients experience recurrences of CDAD, either as relapses caused by the original organism or as reinfections following treatment (Table 123-2). Recurrence rates are higher among patients ≥65 years old and among patients who remain in the hospital after the initial episode of CDAD. Patients who have a first recurrence of CDAD have a high rate of second recurrence (33–65%). In the first recurrence, re-treatment with metronidazole is comparable to treatment with vancomycin. Recurrent disease, once thought to be relatively mild, has been documented to pose a significant (11%) risk of serious complications (shock, megacolon,. | Chapter 123. Clostridium difficile-Associated Disease Including Pseudomembranous Colitis Part 5 Recurrent CDAD Overall 15-30 of patients experience recurrences of CDAD either as relapses caused by the original organism or as reinfections following treatment Table 123-2 . Recurrence rates are higher among patients 65 years old and among patients who remain in the hospital after the initial episode of CDAD. Patients who have a first recurrence of CDAD have a high rate of second recurrence 33-65 . In the first recurrence re-treatment with metronidazole is comparable to treatment with vancomycin. Recurrent disease once thought to be relatively mild has been documented to pose a significant 11 risk of serious complications shock megacolon perforation colectomy or death within 30 days . There is no standard treatment for multiple recurrences but long or repeated metronidazole courses should be avoided because of potential neurotoxicity. Approaches include the administration of vancomycin followed by the yeast Saccharomyces boulardii the administration of vancomycin followed by synthetic fecal bacterial enema and the intentional colonization of the patient with a nontoxigenic strain of C. difficile. None of these biotherapeutic approaches has been approved by the FDA for use in the United States. Other strategies include 1 the use of vancomycin in tapering doses or with pulse dosing every other day for 4-6 weeks and 2 sequential treatment with vancomycin 125 mg four times daily followed by rifaximin 400 mg twice daily for 14 days. IV immunoglobulin which has also been used with some success presumably provides antibodies to C. difficile toxins. Fulminant CDAD Fulminant rapidly progressive and severe CDAD presents the most difficult treatment challenge. Patients with fulminant disease often do not have diarrhea and their illness mimics an acute surgical abdomen. Sepsis hypotension fever tachycardia leukocytosis may result from severe CDAD. An acute abdomen with or without