{"version":"1.0.0","segments":[{"startTime":0.18,"endTime":3.2,"body":"[intro music]"},{"startTime":3.2,"endTime":5.6,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.2,"endTime":5.6,"body":"to Harrison's Podclass,"},{"startTime":5.6,"endTime":8.9,"body":"where we discuss important"},{"startTime":5.6,"endTime":8.9,"body":"concepts in internal medicine."},{"startTime":8.9,"endTime":9.89,"body":"I'm Cathy Handy."},{"startTime":9.89,"endTime":11.733,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.89,"endTime":11.733,"body":"Wiener and we're coming to you"},{"startTime":11.733,"endTime":13.74,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.81,"endTime":17.993,"body":"[Dr. Handy] Welcome to episode 55,"},{"startTime":17.993,"endTime":20.37,"body":"a 78-year-old with diarrhea."},{"startTime":20.37,"endTime":23.72,"body":"[Dr. Wiener] Hi Cathy, today's"},{"startTime":20.37,"endTime":23.72,"body":"case is a 78-year-old woman"},{"startTime":23.72,"endTime":26.0,"body":"who presents to the"},{"startTime":23.72,"endTime":26.0,"body":"hospital from a nursing home"},{"startTime":26.0,"endTime":28.17,"body":"with complaints of diarrhea."},{"startTime":28.17,"endTime":30.34,"body":"She's been in the nursing"},{"startTime":28.17,"endTime":30.34,"body":"home for the past five years,"},{"startTime":30.34,"endTime":32.5,"body":"following a stroke, which"},{"startTime":30.34,"endTime":32.5,"body":"left her with a residual"},{"startTime":32.5,"endTime":34.66,"body":"right sided hemiplegia."},{"startTime":34.66,"endTime":37.26,"body":"Earlier this month, she"},{"startTime":34.66,"endTime":37.26,"body":"had presumed pyelonephritis"},{"startTime":37.26,"endTime":39.45,"body":"due to E. coli growing in her urine,"},{"startTime":39.45,"endTime":42.63,"body":"and she was treated with"},{"startTime":39.45,"endTime":42.63,"body":"ceftriaxone for 10 days."},{"startTime":42.63,"endTime":45.65,"body":"She completed the treatment"},{"startTime":42.63,"endTime":45.65,"body":"about four days ago."},{"startTime":45.65,"endTime":48.44,"body":"Yesterday, she developed"},{"startTime":45.65,"endTime":48.44,"body":"diffuse abdominal pain"},{"startTime":48.44,"endTime":49.87,"body":"and over the past 24 hours"},{"startTime":49.87,"endTime":51.55,"body":"she has had worsening abdominal pain"},{"startTime":51.55,"endTime":53.61,"body":"and abdominal distension."},{"startTime":53.61,"endTime":56.56,"body":"Despite only tolerating"},{"startTime":53.61,"endTime":56.56,"body":"minimal liquid intake,"},{"startTime":56.56,"endTime":59.64,"body":"she has had eight bowel"},{"startTime":56.56,"endTime":59.64,"body":"movements in the last day."},{"startTime":59.64,"endTime":62.01,"body":"The staff noted the"},{"startTime":59.64,"endTime":62.01,"body":"bowel movements are loose"},{"startTime":62.01,"endTime":64.44,"body":"and they've become a"},{"startTime":62.01,"endTime":64.44,"body":"little bit blood-tinged."},{"startTime":64.44,"endTime":66.42,"body":"So any thoughts at this point?"},{"startTime":66.42,"endTime":67.48,"body":"[Dr. Handy] A nursing home patient"},{"startTime":67.48,"endTime":69.368,"body":"with functional limitations is at risk of"},{"startTime":69.368,"endTime":71.251,"body":"a host of disorders ranging from"},{"startTime":71.251,"endTime":73.46,"body":"infections to vascular events."},{"startTime":73.46,"endTime":75.27,"body":"So in this case, I'd be worried about"},{"startTime":75.27,"endTime":77.18,"body":"a recurrent urinary tract infection"},{"startTime":77.18,"endTime":79.65,"body":"because you mentioned she"},{"startTime":77.18,"endTime":79.65,"body":"had a history of that."},{"startTime":79.65,"endTime":81.56,"body":"I'm also thinking about acute abdomen"},{"startTime":81.56,"endTime":83.16,"body":"due to a vascular cause,"},{"startTime":83.16,"endTime":85.952,"body":"remember that you mentioned"},{"startTime":83.16,"endTime":85.952,"body":"she's already had a stroke."},{"startTime":85.952,"endTime":88.203,"body":"And I also am thinking"},{"startTime":85.952,"endTime":88.203,"body":"about C. diff infection"},{"startTime":88.203,"endTime":90.353,"body":"given her most recent"},{"startTime":88.203,"endTime":90.353,"body":"course of antibiotics,"},{"startTime":90.353,"endTime":92.12,"body":"which would put her at risk of that."},{"startTime":92.12,"endTime":93.69,"body":"Can you give me more history?"},{"startTime":93.69,"endTime":96.265,"body":"[Dr. Wiener] Sure. Her past"},{"startTime":93.69,"endTime":96.265,"body":"medical history is significant"},{"startTime":96.265,"endTime":98.09,"body":"for cerebrovascular disease,"},{"startTime":98.09,"endTime":100.4,"body":"intermittent atrial fibrillation,"},{"startTime":100.4,"endTime":103.128,"body":"coronary artery disease"},{"startTime":100.4,"endTime":103.128,"body":"requiring an angioplasty"},{"startTime":103.128,"endTime":107.25,"body":"five years ago, hypertension"},{"startTime":103.128,"endTime":107.25,"body":"and hyperlipidemia."},{"startTime":107.25,"endTime":109.99,"body":"Six months ago, she was"},{"startTime":107.25,"endTime":109.99,"body":"treated with oral metronidazole"},{"startTime":109.99,"endTime":112.9,"body":"for a documented C. difficile infection."},{"startTime":112.9,"endTime":115.87,"body":"Her medications include"},{"startTime":112.9,"endTime":115.87,"body":"warfarin, atorvastatin"},{"startTime":115.87,"endTime":117.01,"body":"and losartan."},{"startTime":117.01,"endTime":118.89,"body":"[Dr. Handy] Okay, well now"},{"startTime":117.01,"endTime":118.89,"body":"with the bloody diarrhea"},{"startTime":118.89,"endTime":121.36,"body":"and the abdominal complaints"},{"startTime":118.89,"endTime":121.36,"body":"of the possibilities"},{"startTime":121.36,"endTime":123.5,"body":"that I mentioned, I would move C. diff"},{"startTime":123.5,"endTime":127.46,"body":"and an abdominal vascular event"},{"startTime":123.5,"endTime":127.46,"body":"higher on my differential."},{"startTime":127.46,"endTime":130.027,"body":"C. diff moves up higher"},{"startTime":127.46,"endTime":130.027,"body":"because of her prior history"},{"startTime":130.027,"endTime":132.34,"body":"as well as antibiotic exposure"},{"startTime":132.34,"endTime":134.37,"body":"and the vascular event moves higher"},{"startTime":134.37,"endTime":136.97,"body":"given her history of"},{"startTime":134.37,"endTime":136.97,"body":"significant vascular disease"},{"startTime":136.97,"endTime":140.29,"body":"and atrial fibrillation that"},{"startTime":136.97,"endTime":140.29,"body":"you mentioned she has now."},{"startTime":140.29,"endTime":142.473,"body":"What about her physical"},{"startTime":140.29,"endTime":142.473,"body":"exam? What does that show?"},{"startTime":142.473,"endTime":145.23,"body":"Is she febrile or do you"},{"startTime":142.473,"endTime":145.23,"body":"have any recent labs?"},{"startTime":145.23,"endTime":146.87,"body":"[Dr. Wiener] Okay. So"},{"startTime":145.23,"endTime":146.87,"body":"on physical examination,"},{"startTime":146.87,"endTime":148.42,"body":"she appears uncomfortable"},{"startTime":148.42,"endTime":152.27,"body":"and has a temperature of"},{"startTime":148.42,"endTime":152.27,"body":"101.2 degrees Fahrenheit."},{"startTime":152.27,"endTime":154.52,"body":"Her blood pressure is 98 over 60,"},{"startTime":154.52,"endTime":158.354,"body":"her heart rate is irregularly"},{"startTime":154.52,"endTime":158.354,"body":"irregular at 115 per minute."},{"startTime":158.354,"endTime":159.86,"body":"Her abdomen appears distended"},{"startTime":159.86,"endTime":162.938,"body":"and tympanitic with diffuse"},{"startTime":159.86,"endTime":162.938,"body":"tenderness to palpation."},{"startTime":162.938,"endTime":165.4,"body":"There are no new neurologic defects"},{"startTime":165.4,"endTime":167.47,"body":"and no new skin rashes."},{"startTime":167.47,"endTime":169.903,"body":"An abdominal X-ray shows"},{"startTime":167.47,"endTime":169.903,"body":"distension of the colon"},{"startTime":169.903,"endTime":171.344,"body":"with ileus."},{"startTime":171.344,"endTime":176.03,"body":"Her initial lab exam shows"},{"startTime":171.344,"endTime":176.03,"body":"a white cell count of 27,200"},{"startTime":176.03,"endTime":179.95,"body":"with 92% neutrophils and 3% band forms."},{"startTime":179.95,"endTime":182.21,"body":"Her hemoglobin is 11.5,"},{"startTime":182.21,"endTime":185.22,"body":"one month ago her hemoglobin was 10.1."},{"startTime":185.22,"endTime":188.76,"body":"Her urinalysis shows no white"},{"startTime":185.22,"endTime":188.76,"body":"blood cells or bacteria."},{"startTime":188.76,"endTime":191.23,"body":"[Dr. Handy] The fever and"},{"startTime":188.76,"endTime":191.23,"body":"leukocytosis is pushing me more"},{"startTime":191.23,"endTime":193.69,"body":"towards C. difficile infection."},{"startTime":193.69,"endTime":196.29,"body":"Her urine has no white"},{"startTime":193.69,"endTime":196.29,"body":"blood cells and no bacteria,"},{"startTime":196.29,"endTime":199.26,"body":"so recurrent pyelonephritis"},{"startTime":196.29,"endTime":199.26,"body":"would be less likely."},{"startTime":199.26,"endTime":201.36,"body":"[Dr. Wiener] Okay, so"},{"startTime":199.26,"endTime":201.36,"body":"let's get to the question."},{"startTime":201.36,"endTime":202.667,"body":"The question asks,"},{"startTime":202.667,"endTime":206.17,"body":"which of the following findings"},{"startTime":202.667,"endTime":206.17,"body":"is least likely to be found"},{"startTime":206.17,"endTime":208.27,"body":"in C. difficile infection?"},{"startTime":208.27,"endTime":209.44,"body":"And the options are,"},{"startTime":209.44,"endTime":211.64,"body":"A. bloody diarrhea;"},{"startTime":211.64,"endTime":213.33,"body":"B. fever;"},{"startTime":213.33,"endTime":215.12,"body":"C. ileus;"},{"startTime":215.12,"endTime":217.09,"body":"D. leukocytosis;"},{"startTime":217.09,"endTime":219.68,"body":"and E. recurrence after therapy."},{"startTime":219.68,"endTime":221.23,"body":"Remember, she has all of these,"},{"startTime":221.23,"endTime":222.93,"body":"but which one is the least likely"},{"startTime":222.93,"endTime":225.31,"body":"if this truly is C. difficile infection?"},{"startTime":225.31,"endTime":226.533,"body":"[Dr. Handy] I just mentioned that fever"},{"startTime":226.533,"endTime":229.19,"body":"and leukocytosis are what's making me lean"},{"startTime":229.19,"endTime":231.29,"body":"towards C. difficile infection."},{"startTime":231.29,"endTime":233.22,"body":"Both of those symptoms are quite common."},{"startTime":233.22,"endTime":236.28,"body":"Leukocytosis is probably the"},{"startTime":233.22,"endTime":236.28,"body":"most common and is seen in"},{"startTime":236.28,"endTime":238.38,"body":"about 50% of cases,"},{"startTime":238.38,"endTime":240.95,"body":"fever is seen in about 28% of cases,"},{"startTime":240.95,"endTime":245.16,"body":"and then abdominal pain is"},{"startTime":240.95,"endTime":245.16,"body":"seen in about 22% of cases."},{"startTime":245.16,"endTime":247.56,"body":"Of the symptoms mentioned, bloody diarrhea"},{"startTime":247.56,"endTime":250.804,"body":"is actually not common in"},{"startTime":247.56,"endTime":250.804,"body":"C. difficile infection."},{"startTime":250.804,"endTime":253.25,"body":"In this case, I don't think"},{"startTime":250.804,"endTime":253.25,"body":"she's had much blood loss,"},{"startTime":253.25,"endTime":255.56,"body":"in fact, she seems hemo-concentrated,"},{"startTime":255.56,"endTime":257.47,"body":"likely due to volume depletion,"},{"startTime":257.47,"endTime":258.93,"body":"and the blood-tinged stools"},{"startTime":258.93,"endTime":262.01,"body":"I would suspect are more"},{"startTime":258.93,"endTime":262.01,"body":"likely related to her warfarin."},{"startTime":262.01,"endTime":263.68,"body":"[Dr. Wiener] Okay, well"},{"startTime":262.01,"endTime":263.68,"body":"let's talk a little bit more"},{"startTime":263.68,"endTime":265.41,"body":"about C. difficile infection."},{"startTime":265.41,"endTime":266.73,"body":"How does one get it?"},{"startTime":266.73,"endTime":267.86,"body":"[Dr. Handy] Well, the current thinking is"},{"startTime":267.86,"endTime":270.86,"body":"that it takes three steps"},{"startTime":267.86,"endTime":270.86,"body":"to develop the infection."},{"startTime":270.86,"endTime":274.21,"body":"First, one must acquire the"},{"startTime":270.86,"endTime":274.21,"body":"bacterium in the GI tract."},{"startTime":274.21,"endTime":276.42,"body":"This most frequently"},{"startTime":274.21,"endTime":276.42,"body":"occurs in hospitalized"},{"startTime":276.42,"endTime":278.33,"body":"or institutionalized patients because of"},{"startTime":278.33,"endTime":280.62,"body":"the frequency of C. difficile."},{"startTime":280.62,"endTime":282.22,"body":"Remember, while we are all diligent"},{"startTime":282.22,"endTime":285.092,"body":"about cleaning ourselves with"},{"startTime":282.22,"endTime":285.092,"body":"alcohol-based disinfectants,"},{"startTime":285.092,"endTime":287.75,"body":"these do not eliminate the"},{"startTime":285.092,"endTime":287.75,"body":"spores of C. difficile,"},{"startTime":287.75,"endTime":290.88,"body":"that requires rigorous"},{"startTime":287.75,"endTime":290.88,"body":"handwashing with soap and water."},{"startTime":290.88,"endTime":293.096,"body":"[Dr. Wiener] So you mentioned"},{"startTime":290.88,"endTime":293.096,"body":"it takes three steps."},{"startTime":293.096,"endTime":293.98,"body":"Then what?"},{"startTime":293.98,"endTime":296.77,"body":"[Dr. Handy] The second step is"},{"startTime":293.98,"endTime":296.77,"body":"usually exposure to antibiotics"},{"startTime":296.77,"endTime":299.77,"body":"to make the colon"},{"startTime":296.77,"endTime":299.77,"body":"susceptible to the infection."},{"startTime":299.77,"endTime":302.51,"body":"It's thought that the change"},{"startTime":299.77,"endTime":302.51,"body":"in the microbiome as a result"},{"startTime":302.51,"endTime":306.62,"body":"of antibiotic exposure allows"},{"startTime":302.51,"endTime":306.62,"body":"C. difficile to proliferate."},{"startTime":306.62,"endTime":309.61,"body":"Finally, if the strain of"},{"startTime":306.62,"endTime":309.61,"body":"C. difficile is toxigenic"},{"startTime":309.61,"endTime":312.57,"body":"and the patient has"},{"startTime":309.61,"endTime":312.57,"body":"sufficient IgG response"},{"startTime":312.57,"endTime":314.19,"body":"to the toxigenic strain,"},{"startTime":314.19,"endTime":317.13,"body":"the patient won't develop"},{"startTime":314.19,"endTime":317.13,"body":"a symptomatic infection."},{"startTime":317.13,"endTime":319.59,"body":"This scheme is important"},{"startTime":317.13,"endTime":319.59,"body":"to know because it explains"},{"startTime":319.59,"endTime":321.81,"body":"how patients may have asymptomatic disease"},{"startTime":321.81,"endTime":324.611,"body":"with a toxigenic strain or be colonized"},{"startTime":324.611,"endTime":327.21,"body":"with a non-toxigenic"},{"startTime":324.611,"endTime":327.21,"body":"strain of C. difficile."},{"startTime":327.21,"endTime":328.34,"body":"[Dr. Wiener] That's interesting."},{"startTime":328.34,"endTime":330.22,"body":"What about the signs and"},{"startTime":328.34,"endTime":330.22,"body":"the symptoms mentioned"},{"startTime":330.22,"endTime":331.18,"body":"in the question?"},{"startTime":331.18,"endTime":333.9,"body":"You mentioned a couple"},{"startTime":331.18,"endTime":333.9,"body":"already, but can you elaborate?"},{"startTime":333.9,"endTime":335.7,"body":"[Dr. Handy] Yeah, so"},{"startTime":333.9,"endTime":335.7,"body":"C. difficile infection"},{"startTime":335.7,"endTime":337.69,"body":"is a common gastrointestinal illness"},{"startTime":337.69,"endTime":340.71,"body":"that's most commonly associated"},{"startTime":337.69,"endTime":340.71,"body":"with antimicrobial use"},{"startTime":340.71,"endTime":343.572,"body":"and subsequent disruption"},{"startTime":340.71,"endTime":343.572,"body":"of normal colonic flora."},{"startTime":343.572,"endTime":346.62,"body":"When adynamic ileus,"},{"startTime":343.572,"endTime":346.62,"body":"which is seen on X-ray"},{"startTime":346.62,"endTime":348.56,"body":"in about 20% of cases,"},{"startTime":348.56,"endTime":351.38,"body":"when that results in"},{"startTime":348.56,"endTime":351.38,"body":"cessation of stool passage,"},{"startTime":351.38,"endTime":353.53,"body":"the diagnosis of C. difficile infection"},{"startTime":353.53,"endTime":355.41,"body":"is frequently overlooked."},{"startTime":355.41,"endTime":358.75,"body":"A clue to the presence of"},{"startTime":355.41,"endTime":358.75,"body":"unsuspected C. difficile infection"},{"startTime":358.75,"endTime":361.95,"body":"in these patients would be"},{"startTime":358.75,"endTime":361.95,"body":"unexplained leukocytosis"},{"startTime":361.95,"endTime":365.66,"body":"with over 15,000 white"},{"startTime":361.95,"endTime":365.66,"body":"blood cells per microliter."},{"startTime":365.66,"endTime":367.93,"body":"These patients are at high"},{"startTime":365.66,"endTime":367.93,"body":"risk for complications"},{"startTime":367.93,"endTime":369.2,"body":"of C. diff infection,"},{"startTime":369.2,"endTime":372.165,"body":"particularly toxic megacolon and sepsis."},{"startTime":372.165,"endTime":374.92,"body":"[Dr. Wiener] Okay. The question"},{"startTime":372.165,"endTime":374.92,"body":"also asks about recurrences,"},{"startTime":374.92,"endTime":376.11,"body":"that's common, right?"},{"startTime":376.11,"endTime":378.055,"body":"[Dr. Handy] Yeah. It"},{"startTime":376.11,"endTime":378.055,"body":"recurs after treatment in"},{"startTime":378.055,"endTime":381.91,"body":"15 to 30% of cases,"},{"startTime":378.055,"endTime":381.91,"body":"susceptibility to recurrence"},{"startTime":381.91,"endTime":384.55,"body":"of clinical C. diff"},{"startTime":381.91,"endTime":384.55,"body":"infection is likely a result"},{"startTime":384.55,"endTime":387.61,"body":"of continued disruption of"},{"startTime":384.55,"endTime":387.61,"body":"the normal fecal microbiome,"},{"startTime":387.61,"endTime":389.64,"body":"which is caused by the antibiotic used"},{"startTime":389.64,"endTime":391.08,"body":"to treat C. diff infection"},{"startTime":391.08,"endTime":393.83,"body":"and the aforementioned"},{"startTime":391.08,"endTime":393.83,"body":"immune predisposition."},{"startTime":393.83,"endTime":395.78,"body":"I should also mention"},{"startTime":393.83,"endTime":395.78,"body":"that it's not recommended"},{"startTime":395.78,"endTime":397.63,"body":"that you retest patients."},{"startTime":397.63,"endTime":400.39,"body":"You're really looking for"},{"startTime":397.63,"endTime":400.39,"body":"resolution of symptoms as a marker"},{"startTime":400.39,"endTime":401.336,"body":"of improvement."},{"startTime":401.336,"endTime":402.65,"body":"[Dr. Wiener] Okay, great."},{"startTime":402.65,"endTime":405.397,"body":"Well, this is a two part"},{"startTime":402.65,"endTime":405.397,"body":"question because it now asks,"},{"startTime":405.397,"endTime":407.13,"body":"how would you treat this patient?"},{"startTime":407.13,"endTime":408.367,"body":"And the options are,"},{"startTime":408.367,"endTime":410.436,"body":"A. oral metronidazole;"},{"startTime":410.436,"endTime":413.03,"body":"B. intravenous metronidazole;"},{"startTime":413.03,"endTime":416.29,"body":"C. rectal instillation of vancomycin;"},{"startTime":416.29,"endTime":420.36,"body":"D. oral vancomycin and IV metronidazole;"},{"startTime":420.36,"endTime":422.58,"body":"or E. oral vancomycin."},{"startTime":422.58,"endTime":424.75,"body":"[Dr. Handy] Mild cases"},{"startTime":422.58,"endTime":424.75,"body":"of C. diff can be treated"},{"startTime":424.75,"endTime":427.825,"body":"with oral medications,"},{"startTime":424.75,"endTime":427.825,"body":"either oral metronidazole,"},{"startTime":427.825,"endTime":430.57,"body":"vancomycin or fidaxomicin."},{"startTime":430.57,"endTime":433.653,"body":"Oral metronidazole is less"},{"startTime":430.57,"endTime":433.653,"body":"effective than the other options,"},{"startTime":433.653,"endTime":437.03,"body":"and may necessitate a longer"},{"startTime":433.653,"endTime":437.03,"body":"treatment course for response."},{"startTime":437.03,"endTime":439.19,"body":"Metronidazole is really"},{"startTime":437.03,"endTime":439.19,"body":"only recommended now"},{"startTime":439.19,"endTime":442.97,"body":"if vancomycin or fidaxomicin"},{"startTime":439.19,"endTime":442.97,"body":"is not readily accessible."},{"startTime":442.97,"endTime":445.063,"body":"[Dr. Wiener] But she doesn't"},{"startTime":442.97,"endTime":445.063,"body":"have a mild case, does she?"},{"startTime":445.063,"endTime":446.57,"body":"[Dr. Handy] No, she would be classified"},{"startTime":446.57,"endTime":448.2,"body":"as fulminant infection."},{"startTime":448.2,"endTime":449.54,"body":"[Dr. Wiener] How do you define that?"},{"startTime":449.54,"endTime":451.74,"body":"[Dr. Handy] Fulminant C."},{"startTime":449.54,"endTime":451.74,"body":"diff infection is defined"},{"startTime":451.74,"endTime":454.428,"body":"as severe disease, which is leukocytosis"},{"startTime":454.428,"endTime":457.113,"body":"with a white blood cell count over 15,000,"},{"startTime":457.113,"endTime":461.34,"body":"and a creatinine level 1.5"},{"startTime":457.113,"endTime":461.34,"body":"times the premorbid value,"},{"startTime":461.34,"endTime":464.7,"body":"that, plus the presence of"},{"startTime":461.34,"endTime":464.7,"body":"hypotension, shock, ileus"},{"startTime":464.7,"endTime":466.61,"body":"or toxic megacolon would be"},{"startTime":466.61,"endTime":469.43,"body":"how you diagnose fulminant"},{"startTime":466.61,"endTime":469.43,"body":"C. diff infections."},{"startTime":469.43,"endTime":472.14,"body":"[Dr. Wiener] Okay, so her"},{"startTime":469.43,"endTime":472.14,"body":"white cell count is 27,000."},{"startTime":472.14,"endTime":474.55,"body":"So even though we don't"},{"startTime":472.14,"endTime":474.55,"body":"have her serum creatinine,"},{"startTime":474.55,"endTime":476.23,"body":"she meets definition by that alone,"},{"startTime":476.23,"endTime":477.6,"body":"given her clinical symptoms."},{"startTime":477.6,"endTime":479.325,"body":"[Dr. Handy] Exactly"},{"startTime":477.6,"endTime":479.325,"body":"and she also has ileus,"},{"startTime":479.325,"endTime":482.16,"body":"which puts her in the"},{"startTime":479.325,"endTime":482.16,"body":"fulminant infection category."},{"startTime":482.16,"endTime":484.46,"body":"[Dr. Wiener] So what would you"},{"startTime":482.16,"endTime":484.46,"body":"recommend for treatment then?"},{"startTime":484.46,"endTime":485.6,"body":"[Dr. Handy] The medical management"},{"startTime":485.6,"endTime":488.3,"body":"of fulminant C. difficile"},{"startTime":485.6,"endTime":488.3,"body":"infection is suboptimal"},{"startTime":488.3,"endTime":490.293,"body":"because of the difficulty of delivering"},{"startTime":490.293,"endTime":493.413,"body":"oral medications to the colon"},{"startTime":490.293,"endTime":493.413,"body":"in the presence of ileus."},{"startTime":493.413,"endTime":495.59,"body":"The combination of vancomycin,"},{"startTime":495.59,"endTime":499.017,"body":"which is usually given orally"},{"startTime":495.59,"endTime":499.017,"body":"or via nasogastric tube,"},{"startTime":499.017,"endTime":500.83,"body":"or even by retention enema"},{"startTime":500.83,"endTime":503.35,"body":"plus IV metronidazole has been used"},{"startTime":503.35,"endTime":506.21,"body":"with some success in uncontrolled studies."},{"startTime":506.21,"endTime":508.27,"body":"Another option is IV tigecycline"},{"startTime":508.27,"endTime":510.23,"body":"in a small-scale uncontrolled study,"},{"startTime":510.23,"endTime":512.76,"body":"which also potentially"},{"startTime":510.23,"endTime":512.76,"body":"showed some benefit."},{"startTime":512.76,"endTime":515.48,"body":"Surgical colectomy may be"},{"startTime":512.76,"endTime":515.48,"body":"life-saving in these cases,"},{"startTime":515.48,"endTime":518.01,"body":"if there's no response"},{"startTime":515.48,"endTime":518.01,"body":"to medical management,"},{"startTime":518.01,"endTime":520.17,"body":"but if possible colectomy"},{"startTime":518.01,"endTime":520.17,"body":"should be performed"},{"startTime":520.17,"endTime":524.11,"body":"before the serum lactate"},{"startTime":520.17,"endTime":524.11,"body":"level reaches 5 mmol/L."},{"startTime":524.11,"endTime":525.568,"body":"[Dr. Wiener] Okay, so you're recommending"},{"startTime":525.568,"endTime":529.57,"body":"option D. enteral vancomycin"},{"startTime":525.568,"endTime":529.57,"body":"and IV metronidazole."},{"startTime":529.57,"endTime":531.119,"body":"[Dr. Handy] Yes, that's"},{"startTime":529.57,"endTime":531.119,"body":"the correct answer,"},{"startTime":531.119,"endTime":532.32,"body":"and I'd also add to that,"},{"startTime":532.32,"endTime":534.44,"body":"that she needs close"},{"startTime":532.32,"endTime":534.44,"body":"observation to determine"},{"startTime":534.44,"endTime":536.96,"body":"if she needs a surgical intervention."},{"startTime":536.96,"endTime":537.793,"body":"[Dr. Wiener] Okay, great."},{"startTime":537.793,"endTime":540.21,"body":"So the teaching points of this case are"},{"startTime":540.21,"endTime":543.85,"body":"that C. difficile infection"},{"startTime":540.21,"endTime":543.85,"body":"occurs in a susceptible host,"},{"startTime":543.85,"endTime":546.94,"body":"and is usually precipitated"},{"startTime":543.85,"endTime":546.94,"body":"by prior antibiotics."},{"startTime":546.94,"endTime":549.08,"body":"The infection may become severe"},{"startTime":549.08,"endTime":550.75,"body":"and mimic an acute abdomen"},{"startTime":550.75,"endTime":553.58,"body":"when developing fulminant disease."},{"startTime":553.58,"endTime":554.67,"body":"[Dr. Handy] And you can"},{"startTime":553.58,"endTime":554.67,"body":"read more about this"},{"startTime":554.67,"endTime":556.97,"body":"in Harrison's chapter on C. diff infection"},{"startTime":556.97,"endTime":560.4,"body":"and the IDSA guidelines"},{"startTime":556.97,"endTime":560.4,"body":"last published in 2018"},{"startTime":560.4,"endTime":561.614,"body":"on the topic."},{"startTime":561.614,"endTime":564.197,"body":"[outro music]"},{"startTime":565.39,"endTime":568.26,"body":"[Mr. Shanahan] This is Jim"},{"startTime":565.39,"endTime":568.26,"body":"Shanahan, publisher at McGraw Hill."},{"startTime":568.26,"endTime":569.89,"body":"Harrison's Podclass is brought to you"},{"startTime":569.89,"endTime":571.86,"body":"by McGraw Hill's Access Medicine,"},{"startTime":571.86,"endTime":573.36,"body":"the online medical resource"},{"startTime":573.36,"endTime":575.34,"body":"that delivers the latest trusted content"},{"startTime":575.34,"endTime":577.2,"body":"from the best minds in medicine."},{"startTime":577.2,"endTime":579.723,"body":"Go to accessmedicine.com to learn more."}]}