Critical Care Management of the Patient with Clostridioides difficile.
Critical Care Management of the Patient with Clostridioides difficile.
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DOI：
10.1097/ccm.0000000000004739
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发表时间：
2021-01-01
影响因子：
8.8
通讯作者：
Kraft CS
中科院分区：
文献类型：
--
作者：
Adelman MW;Woodworth MH;Shaffer VO;Martin GS;Kraft CS
回顾已发表的危重患者艰难梭菌感染（CDI）管理的临床证据。我们从PubMed文献综述和综述文章的参考书目中获得了相关研究。我们选择了与重症监护临床医生相关的CDI方面的英语研究，包括流行病学，风险因素，诊断，治疗和预防，重点是高质量的临床证据。我们回顾了潜在的相关研究，并提取了有关研究设计、方法、患者选择和相关研究结果的信息。这是一种合成的（即，不系统的回顾。CDI是美国最常见的医疗相关感染。抗生素是最重要的CDI风险因素，在抗生素中，头孢菌素类、克林霉素、碳青霉烯类、氟喹诺酮类和哌拉西林-他唑巴坦类的风险最高。年龄、糖尿病、炎症性肠病和终末期肾病是CDI发生和死亡的危险因素。CDI诊断是基于对适当选择的腹泻患者进行检测，或对肠梗阻患者进行临床怀疑。暴发性疾病（CDI伴低血压、休克、肠梗阻或巨结肠）患者应接受口服万古霉素和静脉注射甲硝唑治疗，如果发生肠梗阻，则应接受直肠万古霉素治疗。对初始治疗无反应的患者应考虑进行粪便微生物群移植（FMT）或手术。适当的感染预防措施可降低CDI风险。强有力的临床证据支持在可能的情况下限制抗生素以降低CDI风险。对于暴发性CDI患者，口服万古霉素可降低死亡率，连续治疗（包括静脉注射甲硝唑）和干预（包括FMT）可能使部分患者受益。关于暴发性CDI的管理，仍存在几个重要问题，包括哪些患者受益于FMT或手术。
To review published clinical evidence on management of Clostridioides difficile infection (CDI) in critically ill patients. We obtained relevant studies from a PubMed literature review and bibliographies of reviewed articles. We selected English-language studies addressing aspects of CDI relevant to critical care clinicians including epidemiology, risk factors, diagnosis, treatment, and prevention, with a focus on high-quality clinical evidence. We reviewed potentially relevant studies and abstracted information on study design, methods, patient selection, and results of relevant studies. This is a synthetic (i.e., not systematic) review. CDI is the most common healthcare-associated infection in the United States. Antibiotics are the most significant CDI risk factor, and among antibiotics, cephalosporins, clindamycin, carbapenems, fluoroquinolones and piperacillin-tazobactam confer the highest risk. Age, diabetes mellitus, inflammatory bowel disease and end-stage renal disease are risk factors for CDI development and mortality. CDI diagnosis is based on testing appropriately selected patients with diarrhea, or on clinical suspicion for patients with ileus. Patients with fulminant disease (CDI with hypotension, shock, ileus, or megacolon) should be treated with oral vancomycin and intravenous metronidazole, as well as rectal vancomycin in case of ileus. Patients who do not respond to initial therapy should be considered for fecal microbiota transplant (FMT) or surgery. Proper infection prevention practices decrease CDI risk. Strong clinical evidence supports limiting antibiotics when possible to decrease CDI risk. For patients with fulminant CDI, oral vancomycin reduces mortality, and adjunctive therapies (including intravenous metronidazole) and interventions (including FMT) may benefit select patients. Several important questions remain regarding fulminant CDI management, including which patients benefit from FMT or surgery.