{"id":2686,"date":"2012-05-07T17:58:32","date_gmt":"2012-05-07T21:58:32","guid":{"rendered":"http:\/\/blogs.nejm.org\/?p=2686"},"modified":"2012-05-07T17:58:32","modified_gmt":"2012-05-07T21:58:32","slug":"difficulties-and-differences-on-c-difficile","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/difficulties-and-differences-on-c-difficile\/2012\/05\/07\/","title":{"rendered":"Difficulties and Differences on C difficile"},"content":{"rendered":"<p>Some things in our field &#8212; diseases, treatments, generalizations, cliches, fads &#8212; have <em>really <\/em>changed since back in the early 1990s, when I started in this business.<\/p>\n<p>Here are a few that quickly come to mind:<\/p>\n<ul>\n<li>&#8220;Double coverage&#8221; of pseudomonas with a beta lactam plus an aminoglycoside was <em>de rigueur<\/em><\/li>\n<li>MRSA was an inpatient concern only<\/li>\n<li>You never saw Lyme disease in the winter or in people who hadn&#8217;t left urban areas<\/li>\n<li><em>Mycobacterium avium<\/em> complex was more of a problem in people with AIDS than in middle-aged, slender women who coughed<\/li>\n<li>Kids still got epiglottitis and meningitis from H flu<\/li>\n<li>Life-threatening colitis from <em>C difficile<\/em> was an exceedingly rare event, and barely ever occurred in otherwise healthy people<\/li>\n<\/ul>\n<p>Yes, C diff has changed <em>a lot<\/em> &#8212; and not for the better. However, one thing that hasn&#8217;t changed about C diff\u00a0<em> <\/em>is the controversy over treatment, something we&#8217;re grappling with now.<\/p>\n<p>Should initial therapy be <a href=\"http:\/\/www.annals.org\/content\/155\/12\/839.abstract\" target=\"_blank\">metronidazole?<\/a> Or vancomycin? Or <a href=\"http:\/\/cid.oxfordjournals.org\/content\/45\/3\/302.long\" target=\"_blank\">vancomycin just for severe cases<\/a>? Or <a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMoa0910812\" target=\"_blank\">fidaxomicin?<\/a> What if cost were no issue?<\/p>\n<p>(Ha.)<\/p>\n<p>How long should you treat, especially when the patient is still on antibiotics?\u00a0What do you do about relapses? Probiotics? Tapering schedules? <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/22155369?dopt=Abstract\" target=\"_blank\">Fecal transplants?<\/a> In severe cases, is <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/21865943\" target=\"_blank\">diverting ileostomy<\/a> an alternative to colectomy?<\/p>\n<p>I don&#8217;t have the answers, just some opinions &#8212; which I&#8217;m happy to share &#8212; but first I&#8217;d be thrilled to get some outside views, if only on the initial therapy question.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Some things in our field &#8212; diseases, treatments, generalizations, cliches, fads &#8212; have really changed since back in the early 1990s, when I started in this business. Here are a few that quickly come to mind: &#8220;Double coverage&#8221; of pseudomonas with a beta lactam plus an aminoglycoside was de rigueur MRSA was an inpatient concern [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5,8,9],"tags":[131,358,613,971],"class_list":["post-2686","post","type-post","status-publish","format-standard","hentry","category-infectious-diseases","category-patient-care","category-policy","tag-c-diff","tag-fidaxomicin","tag-metronidazole","tag-vancomycin"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/2686","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=2686"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/2686\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=2686"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=2686"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=2686"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}