Guideline Updates in the Management of C. Difficile

MAY 01, 2018
MD Magazine Staff

Peter Salgo, MD: We did talk about the guideline update that’s just come out. Why don’t we compare this guideline update against where we were? What’s the significance of it? How is this landscape changing?

Dale N. Gerding, MD: Well, the significance is that it’s taken us forever to get this new guideline written, largely because of a lot of contentious issues around the diagnosis and how to treat patients. But the new guidelines are different from the old guidelines. They now have pediatric-specific recommendations in them, which we did not have before. Also, the quality of the recommendations and the quality of the evidence will be provided for the recommendations under what’s called GRADE. The 2 important major changes, I think, are in how a diagnosis is recommended to be done and what the newer treatment recommendations are. We no longer give metronidazole as a first-line therapy.

Peter Salgo, MD: OK. Are the recommendations for antibiotic stewardship in these guidelines or is that something else?

Dale N. Gerding, MD: They are, as part of the preventive strategy. I think we’ve now formalized antimicrobial stewardship as the methodology for trying to get people to use antibiotics more appropriately.

Peter Salgo, MD: You can’t just blast away and hope for the best?

Dale N. Gerding, MD: Well, you can, but it won’t be good for Clostridium difficile [C. diff].

Peter Salgo, MD: What’s interesting to me about that is that this is one of the very few cases where it’s not good for society, and it’s also not good for the individual patient. They coalesce right at this point.

Dale N. Gerding, MD: Exactly. We used to say that overuse of antibiotics leads to resistance, but that never came back to bite the physician who prescribed the antibiotic. C. diff is close enough to the time of that antibiotic administration that the patient will associate that antibiotic use with getting C. diff. I think this is one of the important factors for trying to reduce and promote the appropriate use of antimicrobials.

Yoav Golan, MD: That’s going to help in a much bigger scope than just with C. diff. We have seen the emergence of resistance. When you want to change your antibiotic prescribing habits, thinking about C. diff, thinking about resistance emergence, in general, there are really 2 things that you have to think about. One is reducing the load of antibiotic use, in general. It’s not always that antibiotics are being used and are not needed to benefit the patient. But, very often, antibiotics are being prescribed for far too long. There used to be this recommendation that if your doctor gave you an antibiotic regimen, you should always make sure that you completed the regimen. But doctors really don’t know for how long to treat, so they overtreat. There are really 2 factors. One is how much antibiotic you are using, and the second one, which is far more complicated, is what antibiotics do you use when you need to use an antibiotic. It’s important for people to understand that these people are really sick and are suspected of having an infection. They need to be treated adequately. If you avoid using some antibiotics, you’re going to use other antibiotics. Just make sure that the other antibiotics that you’re using are….

Peter Salgo, MD: We’re going to move on, but I’m going to share a story with you. My little girl had a sore throat. My wife took her to a doctor. They said, “We don’t think it’s strep, but just in case, here are some antibiotics.” I took the antibiotics and I put them in the fridge. I said, just as you did, “We’re not going there. When the culture comes back, I’ll let you know.” And, of course, it wasn’t. It was a viral syndrome.

Transcript edited for clarity.

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