Cases of Clostridioides difficile (C diff) have increasingly been reported outside of typical settings, and a survey of general practitioners in France found that many cases can be managed without hospitalization.
Clostridioides difficile infections (CDIs) are generally associated with health care facilities, but cases are increasingly being reported in other settings, such as nursing homes or communities. A study published in European Journal of General Practice examined CDI management in the primary care setting in France to characterize patients and describe clinical outcomes.
C diff is often associated with taking antibiotics, and it mostly affects patients with risk factors such as older age or a weakened immune system. It manifests in a range of clinical variations, such as asymptomatic carriage through diarrhea, pseudomembranous colitis, or toxic megacolon.
Patients with CDIs in hospital settings typically face longer hospitalization for treatment. But low-risk patients can also have CDIs, and the study authors stress the importance of identifying and managing this condition in primary care settings to reduce the number of patients who end up in emergency departments with CDIs. Although a selection of antibiotics is approved to treat CDIs, general practitioners (GPs) in France only have access to metronidazole to prescribe to patients with nonsevere infections.
This retrospective observational study aimed to estimate the prevalence and management of CDIs in the primary care setting, and to determine whether hospital specialists are more equipped to handle these cases, through an anonymized online survey of GPs.
Surveys on CDI management were conducted from September 2018 to April 2019, and 41 GPs submitted complete responses. In these cases, 41 patients had confirmed CDIs through either C diff toxin B or A by enzyme-linked immunosorbent assays. Half of those patients had no past medical history, and the most common clinical manifestation was long-lasting diarrhea, which was present in 56%. In the overall group, 63% of patients were either taking or had recently taken antibiotics.
Patients were also stratified into 2 groups: a recovered cohort (n = 25) and a recurrent infection group (n = 16). All patients in the recovered group only had a primary episode of CDI, and they were generally younger with no comorbidities.
In the recovered group, 23 patients were successfully treated with oral metronidazole as single therapy, and data were missing for the 2 remaining patients. In the recurrent infection group, regimens varied. Metronidazole was used in 11 cases, vancomycin in 7 cases, and fidaxomicin in 2 cases. In most recovered group cases, diarrhea ceased within 48 hours of treatment with metronidazole. Laxatives and antidiarrheal agents were associated with relapse.
In the recurrent infection group, GP cooperation with a hospital specialist was seen in 87.5% of cases vs 28% of cases in the recovered group. Seven patients were hospitalized overall, 6 of whom were in the recurrent group to discuss a new therapy option. Just 1 patient in the recovered group was hospitalized, and that was for intravenous rehydration.
These findings suggest that CDIs can be managed on the general practice level, especially since younger patients with mild cases and no comorbidities respond well to metronidazole treatment. Longer duration of diarrhea while on appropriate treatment may be an indicator of potential relapse that warrants further research as a criterion for contacting hospital specialists quickly, the study authors noted.
“Management by GPs in collaboration with hospital specialists helped the majority of patients to avoid unnecessary and costly hospital admissions,” they concluded. “Therefore, work hand-in-hand between GPs and specialists is urged to improve patient care, especially in an era of COVID-19 where hospital overload is detrimental.”
Preventive measures, namely the reasonable use of antibiotics and over-the-counter medications, are also crucial for reducing the potential for CDIs and their subsequent burden on the health care system.
Klezovich-Bénard M, Bouchand F, Rouveix E, Goossens PL, Davido B. Management and characteristics of patients suffering from Clostridiodes difficile infection in primary care. Eur J Gen Pract. 2021;27(1):320-325. doi:10.1080/13814788.2021.1998447