Family Medicine, Internal Medicine and Surgery Case 5 (answer)

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Case 05 - Cora, 78 years old

Cora is a 78 y/o 10 days post partial colectomy who has had slow return of bowel function and had moderate debilitation from chronic medical conditions. You have just completed the transfer orders when you are called with fever.

She has received no antibiotics for the past 9 days and there is no indwelling line or foley. She has had 3 loose stools; Stool for C diff is ordered

Questions

1) Is a + C diff test sufficient to confirm a diagnosis of C. difficile disease?

  • What are the risk factors for C diff disease?

Answers

C. difficile is a spore-forming bacillus that causes colitis, manifesting as diarrhea that often recurs and can progress to toxic megacolon, sepsis and death. C. diff can colonize the bowel (up to 50% of healthy neonates, 5 - 10% adults) but the detection of TOXIN is sufficient for diagnosis in setting of clinical signs/symptoms

PCR test used here detects the gene segment that encodes for toxin; highly sensitive and specific

Risk factors for C diff disease are:

  • antimicrobial use (increased risk persists for 3 months after antibiotics are discontinued)
  • medical care (94% of cases are associated with various health-care settings)



Questions


2) What measures can be taken to prevent spread of C diff?

  • When can contact precautions be discontinued?
  • What can YOU do to prevent C diff?

Answers

Measures to prevent spread of C. diff:

  • ANTIMICROBIAL STEWARDSHIP!! Even a single peri-operative antibiotic dose is a risk factor.
  • Contact precautions for patients with proven or suspected C. diff; Wear gloves and gowns when examining patients with C diff. Although hand sanitizer does not kill C. diff spores, its use is NOT associated with increased risk. GLOVE USE is key. Clean hands both before and after donning gloves - and can use either soap and water or hand sanitizer.
  • Thorough cleaning of room and high touch surfaces is essential. A sporicidal product is used for terminal cleaning

Contact precautions are discontinued for C. diff :

  • Once patient is on effective therapy and diarrhea has resolved
  • NO TEST OF CURE IS DONE

Not valid as c diff can persist as colonizer for some time after disease resolves
Risk of transmission is related to diarrhea and associated spore contamination of patient and environment
What YOU can do to prevent C diff -

USE ANTIBIOTICS OPTIMALLY!

  • Avoid use if no infection
  • Identify the pathogen and use narrow spectrum when possible
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