Empiric Therapy and <i>C Difficile</i> Infection

Peter Salgo, MD: Before we leave this whole topic, I want to go back to something that I think is important. My residents ask about this all the time. Now I can tell them that I’ve spoken to the experts about this. I’ve got somebody in the ICU [intensive care unit]. They are not particularly sick, from a diarrheal perspective, but are in the ICU for some other reason. But we see a white count of 23,000. Maybe there’s been a little loose stool, but they’re also on tube feeds and/or something else. They go, “What’s the harm? We’ll just start with a little vancomycin.” You’re telling me to get the test. Empiric therapy for Clostridium difficile [C. diff] no longer makes the guidelines?

Dale N. Gerding, MD: I think that’s generally true. The increase in empiric therapy in C. diff, or in suspected C. diff, really resulted from the emergence of the string of events. In Pittsburgh and Montreal, there were huge outbreaks. In Pittsburgh, for example, they did 16 colectomies in the first year of the outbreak.

Peter Salgo, MD: Sixteen?

Dale N. Gerding, MD: Sixteen colectomies. I think I had seen 1 colectomy in 25 years of experience with C. diff at that time. But as a result of that, because this was such a fulminant disease process in some of these patients, empiric therapy became almost standard. In Montreal, if you had diarrhea, 1 stool, vancomycin was started, the stool specimen was sent off, and you were isolated immediately. This kind of empiric management became very prevalent because of the severity of the disease. We’re not seeing as many of these really fulminant severe cases as we did in the past. And with the new guideline, we’re going to try to back off a little on the urgency to start treatment. The other thing that’s happened is we now have rapid diagnostics that give you same-day answers. If you can get the answer in the same day, this will avoid unnecessary isolation and unnecessary treatment.

Peter Salgo, MD: I was going to go there, because I think that’s critical. It used to be that we’d have to wait on them. Now we can get an answer back fairly quickly.

Darrell S. Pardi, MD: If you can get stool.

Peter Salgo, MD: If you can get stool.

Darrell S. Pardi, MD: If your ICU patient is on a ventilator, is bed bound, has abdominal distension and an ileus, and has a white count of 25,000 or 30,000, you may have to wait a while to get a stool sample. That person might still benefit from empiric therapy.

Peter Salgo, MD: But again, as you implied, it’s always dependent on the clinical presentation.

Darrell S. Pardi, MD: Right.

Peter Salgo, MD: Sick people need more aggressive therapy sooner. In somebody who’s not clinically toxic and maybe doesn’t have that much stool, but has a white count, or you’re worried about it, you should test before you go ahead and start empiric therapy. Is that fair? So, guidelines work for that?

Yoav Golan, MD: In our pathway, as I mentioned, the only other situation in which we recommend empiric therapy is when you have very high certainty that the patient has C. diff, even if the patient is not terribly sick. When someone is in the hospital and he or she suddenly has explosive unexplained diarrhea and a bump in their white cell count, we’ll often order a KUB [kidneys, ureters, bladder] x-ray—a plain x-ray that shows dilation of the clone. In those patients, we’re OK with starting empiric therapy. It’s only used in a small fraction of patients.

Peter Salgo, MD: Sick people, treat. Everybody else, test. And then, when you treat, treat intelligently. How about that as a summation of this whole thing? The devil is in the details now, isn’t it?

Transcript edited for clarity.