· 4th Ge Hong gave stool suspension
· 16th Li Shizhen – gave yellow soup
· Transfaunation – used by Vets in 17th century
· Eiseman in 1958 treated C diff with FMT
· Intestinal homeostasis
· Human Microbiome project – 3phase project for 10 years Map out microbes in body
· 500 to 1500 species in any given person and 3.3 million microbial genes in the body
· Bacteroidetes, firmicutes, actinobacteria and proteobacteria
· Bacteria produce SCFA that inhibits shiga toxin, ecoli etc
· Recurrent CD is 20%.
· WCE – 62-67% sensitivity and specifity
· Detection of ampulla on WCE is only 10%
Mortality is 15-20 thousand a year
Can occur in IBD pt, compromised, post partum and even normal healthy pt
NAP1/BI/027 3 toxins. Toxin 1 10 x and Toxin B is 23 x and binary toxin
Other RF are more than 65 and increases by 2% per year after 65.
More common in Winter, PPI or antacid use, organ transplant, HIV, chemotherapy, TF, chronic liver disease, ESRD and peripartum
Risk occurs even 3 months after stopping antibiotic
Neonates are often colonized with Cdiff and 3% of healthy people are colonized
Colonizer pts – why do they not get it? We dont know why
Horse manure smell with C diff.
Can get leukamoid reaction
Can have extra intestinal manifestation like joint pain etc
Fulminant is when megacolon more than 6 cm, 50% mortality, low Albumin is BAD sign (less than 2.5), age usually more than 70,
Recurrent C diff is 20% and third recurrence is 40 % and then 60%
Do PCR assay.
Do NOT check for C diff cure. Go clinically.
Other antibiotics include nitazoximide
Flagyl can cause neuropathy and cellebellar disorders
Efficacy of flagyl and vanco is same.
Recurrent C diff, tapering dose of vanco 125 mg qid, then bid thenqd then every other day. Or pulse dosing.
Fidaxomicin : great support from pharm
FMT : First done in in Ge Hong in 4th century, 16th century Li Shizhen and called it yellow soup. In modern times 1958 – Eiseman 4 pt.
Dsorders associated with altered intestinal flora are gallstones, CRC, HE, etc (look up) including NASH, obesity, MS, chronic fatigue syndrome, atherosclerosis, IBS, IBD, type 2 DM
FMT success rate for CDAD is 90%
WHY is FMT effective? Bacteroides species is most important in repopulating gut in 2 studies.
RePOOPulate !!Synthetic stool mixture. new virulate strain ribotype 078 of CD.
Do not FMT in immunocompromised pts.
Make sure donor does not eat nuts if recipient is allergic to it. (give a badge I GAVE A SHIT)
FMT is investigational study Make sure that is on consent and that is the only requirement from FDA.
C diff, Rx strategy. Mild flagyl, moderate vanco, and severe Flagyl IV plus Vanco 500 qid. Score based on age more than 65, Cr more than 2 and WBC more than 2