abstract:
Diagnosis and treatment of Clostridium difficile (C. diff) colitis: Review of the literature and a perspective in gynecologic oncology
Highlights
- •Gynecologic cancer patients are at increased risk of C. difficile infection (CDI).
- •Antibiotic use increases the risk of CDI, but the role of chemotherapy is unclear.
- •Depending on prevalence, a multi-step algorithm may improve diagnostic accuracy.
- •CDI treatment and prognosis varies by disease severity and number of prior episodes.
Clostridium difficile
infection (CDI) is a major cause of nosocomial diarrhea with the
potential for significant morbidity and mortality. Colonization in a
susceptible individual, with risk factors such as prior antibiotic use,
advanced age, or medical comorbidities, may result in symptomatic
infection. Although patients with a gynecologic malignancy may be at a
higher risk of developing CDI due to an increased likelihood of having
one or more risk factors, data do not consistently support the idea that
chemotherapy or cancer itself are independently associated with CDI.
For diagnosis of CDI, we recommended using a multi-step approach, with a
highly sensitive initial rapid test such as the enzyme immunoassay
(EIA) for glutamate dehydrogenase (GDH) or nucleic acid amplification
testing (NAAT), followed by confirmatory testing with of the above two
tests or EIA toxin A/B, which has high specificity. Treatment varies
based on the severity of disease. We recommend vancomycin as first-line
therapy for an initial episode of mild/moderate or severe CDI, with
consideration of fidaxomicin for patients at particularly high risk for
recurrence. Rectal vancomycin may play an adjunctive role for some
severe cases, while surgical intervention is indicated for fulminant CDI
if no improvement six or more days after initiating medical therapy.
For non-severe recurrent disease, the initial treatment regimen should
be repeated, while subsequent episodes are more appropriately treated
with a tapered and pulsed dose of vancomycin, fidaxomicin, or fecal
microbiota transplantation.
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