David H. Wesorick, MD; Vineet Chopra, MD, MSc
Disclosures: Dr. Chopra reports grants from the Agency for Healthcare Research and Quality. Dr. Wesorick has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.
Recent guidelines recommend either oral vancomycin or fidaxomicin as first-line treatment for mild to severe C difficile treatment. Metronidazole is now considered second-line therapy based on a few randomized controlled trials showing it to be inferior to vancomycin.
Fulminant C difficile infection (e.g., hypotension or shock, ileus, megacolon) should be treated with a combination of high-dose oral or enteral vancomycin and intravenous metronidazole. If ileus is present, vancomycin enemas should also be given to maximize delivery of the drug to the colon.
Surgery is indicated for treatment of colonic perforation and may also be helpful in cases of toxic megacolon, acute abdomen, septic shock due to C difficile infection, or failure of medical therapy.
Recurrent disease should be treated with the standard 10-day course of vancomycin (if metronidazole was used for the incident episode), an extended, tapering course of vancomycin (if a 10-day course of vancomycin was used for the incident episode), or a 10-day course of fidaxomicin. Gastroenterology or infectious disease consultation should be considered for recurrent disease.
Fecal microbiota transplantation is recommended for patients who have more than 2 recurrences.
These results demonstrate that the optimal CHA2DS2-VASc score threshold for anticoagulation is highly dependent on the ischemic stroke rate in untreated persons. This rate has varied widely among studies.
These data challenge the broad applicability of currently recommended CHA2DS2-VASc score cutoffs for anticoagulation and suggest that more precise and reproducible estimates of stroke rates in untreated patients are needed.
An editorial points out that the variability of stroke rates across 4 cohorts suggests that different patient populations may have different optimal CHA2DS2-VASc anticoagulation thresholds, and that future strategies may need to allow for more individualized thresholds.
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Wesorick DH, Chopra V. Annals for Hospitalists - 16 October 2018. Ann Intern Med. ;169:HO1. doi: 10.7326/AFHO201810160
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Published: Ann Intern Med. 2018;169(8):HO1.
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