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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Identify signs and symptoms of Clostridium difficile infection (CDI).

  • Discuss CDI complications.

  • Evaluate treatment options and develop an optimal patient-specific treatment plan for initial and recurrent CDI including drug, dose, frequency, route of administration, and duration of therapy.

  • Develop a pertinent monitoring plan for a CDI regimen from a therapeutic and toxic standpoint.

  • Discuss novel agents/treatment approaches being developed for CDI treatment.

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PATIENT PRESENTATION

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Chief Complaint

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“I have been having to go to the bathroom a lot more frequently, and my stomach hurts a lot.”

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HPI

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John Quinn, a 73-year-old man, is transferred to your medical team from the MICU after being admitted for urosepsis and hypotension requiring pressor support. Over the past 2 days, he has been complaining of frequent foul-smelling stools. One week prior to being transferred to your team, he was admitted to the hospital complaining of urinary frequency and urgency for 3 days, nausea, vomiting, and left-sided flank pain, as well as lightheadedness and dizziness. In the ED, the patient was noted to be hypotensive (BP 92/63 mm Hg) and tachycardic (HR 112–124), with an elevated lactate level and leukocytosis. He was transferred to the MICU for pressor support and started on an empiric regimen of ceftriaxone 2 g IV daily, levofloxacin 750 mg IV daily, and vancomycin 1 g IV Q 12 H for diagnosed urosepsis. Urine (×2) and blood (×3) cultures were subsequently found to be growing E. coli and enteric gram-negative rods, respectively, and antibiotic coverage was narrowed to ceftriaxone 2 g IV daily on day 5. The patient’s blood pressure was stabilized, and he was transferred to the internal medicine service on day 7 of hospitalization. He is now complaining of new-onset diarrhea and abdominal pain, as described above.

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PMH

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  • Type 2 DM

  • Hyperlipidemia

  • HTN

  • s/p MI 2003

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SH

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Lives at home alone, lifetime smoker (half pack per day for 54 years), drinks alcohol socially

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Medications

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  • Metoprolol XL 100 mg PO once daily

  • Amlodipine 5 mg PO once daily

  • Pravastatin 20 mg PO once daily

  • Omeprazole 20 mg PO once daily

  • Metformin 500 mg PO twice daily

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All

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NKDA

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Physical Examination

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Gen
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Patient is overweight and complains of abdominal discomfort.

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VS
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BP 139/85, P 98, RR 20, T 38.8°C; Ht 5′8″, Wt 87.2 kg

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Skin
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Warm and moist secondary to diaphoresis, no lesions

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HEENT
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PERRLA; EOMI; TMs intact; clear oropharynx, moist oral mucosa

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Neck/Lymph Nodes
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Neck is ...

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