Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
Management of C-difficile Infection (CDI)
3 Plays4 years ago
In this episode of Critical Matters, we will discuss the evidence-based management of severe and fulminant Clostridioides difficile infection(CDI) in the intensive care unit.
Our guest is Dr. Max W. Adelman, a member of the Division of Infectious Diseases and the Department of Medicine, at Emory University School of Medicine in Atlanta.
Additional Resources:
Critical Care Management of the Patient with Clostridioides difficile: https://pubmed.ncbi.nlm.nih.gov/33156122/
CDI Guidelines from IIDSA: https://www.idsociety.org/practice-guideline/clostridium-difficile/
Systematic Review with Meta-Analysis: Fecal Microbiota Transplantation for Severe or Fulminant Clostridioides difficile: https://link.springer.com/article/10.1007/s10620-021-06908-4
Books Mentioned in this Episode:
The Hot Zone: The Terrifying True Story of the Origins of the Ebola Virus by Richard Preston: https://www.amazon.com/Hot-Zone
The Great Influenza: The Story of the Deadliest Pandemic in History by John M. Barry: https://www.amazon.com/Great-Influenza
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Guest Introduction: Dr. Max Adelman
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
00:00:32
Speaker
The coscritoides, formerly Clostridium difficile infection, also known as CDI or C. diff, is a common and potentially lethal hospital-acquired infection.
00:00:41
Speaker
Today, we will discuss evidence-based management of severe and fulminant CDI in the intensive care unit.
00:00:47
Speaker
Our guest is Dr. Max Adelman.
00:00:49
Speaker
Dr. Adelman is a member of the Division of Infectious Diseases Department of Medicine at Emory University School of Medicine in Atlanta.
00:00:56
Speaker
Dr. Adelman is the lead author of a recent concise definitive review on the topic in critical care medicine.
00:01:02
Speaker
Max, welcome to Critical Matters.
00:01:05
Speaker
Thanks so much for having me.
00:01:06
Speaker
Happy to be here.
C. diff Name Change Discussion
00:01:07
Speaker
As we were discussing before we started recording, it's refreshing to talk about an infection that starts with a C and is not COVID, at least in the last year.
00:01:16
Speaker
But I found that as we were preparing for the podcast that the memo didn't get to me, I guess, but they changed the name once again of this disease.
00:01:25
Speaker
Can you tell us a little bit about that before we start?
00:01:28
Speaker
Yeah, absolutely.
00:01:29
Speaker
I think the...
00:01:32
Speaker
the taxonomists are getting their hands on a lot of different infections.
00:01:36
Speaker
So there might be a lot of infectious diseases that we know well, whose names are changing, but I think we all grew up knowing the C. diff is clostridium difficile, but it's actually changed to clostridioides, but still at least it begins with a C. So we can still keep calling it C. diff and not get too confused.
00:01:56
Speaker
And that works.
00:01:58
Speaker
I agree.
00:01:58
Speaker
C. diff is what everybody refers to it.
00:02:01
Speaker
And, uh,
00:02:02
Speaker
I find this a very important topic to cover for many reasons that you'll cover in the epidemiology, but also I think it's a great example of how something that is very frequent, very common in our practice still has layers of depth and still present sometimes with some challenges that might go a little bit out of what most people consider ordinary.
C. diff as a Hospital-Acquired Infection
00:02:24
Speaker
So Max, maybe we could start at the epidemiology
00:02:28
Speaker
and how does C. diff stack up within other hospital-acquired infections to begin with?
00:02:35
Speaker
Yeah, that's a great question.
00:02:36
Speaker
So C. diff is the most common hospital-acquired infection.
00:02:42
Speaker
We think there are about a half million cases of C. diff in the United States per year, and about half of them are hospital-acquired.
00:02:51
Speaker
So a good chunk actually start out in the community.
00:02:56
Speaker
And that rate has been increasing in the past several years, but still about at least half and probably even more than that are hospital acquired.
00:03:03
Speaker
So really something important that all hospitalists and certainly all intensivists should feel pretty comfortable with and pretty comfortable taking care of these patients because we certainly see a lot of them and it's more common than really any other hospital acquired infection.
00:03:21
Speaker
And it's very interesting that in many ICUs,
00:03:24
Speaker
when teams are looking at performance improvement and quality measures, hospital-acquired infections in the form of VAPs, in the form of CAUTIs and CLABSIs are very commonly targeted, yet C. diff, despite being the most common one, is only a problem when they have big outbreaks.
00:03:43
Speaker
But it seems that this is something that we should probably be having our hand on at all times just based on the frequency.
00:03:49
Speaker
Yeah, I absolutely agree.
00:03:51
Speaker
And I think with...
00:03:54
Speaker
things like VAP and CAUTI, it's kind of easy to identify the inciting factor, you know, either being the endotracheal tube or the urinary catheter.
00:04:05
Speaker
And it's a little bit harder to take away the antibiotics from some of these folks who need them.
00:04:09
Speaker
And that really, as we'll get to, is the most important risk factor for C. diff.
00:04:13
Speaker
So I think unlike some of those other hospital-acquired infections, it's a little bit harder to kind of
00:04:19
Speaker
pinpoint one specific thing that we can work on.
00:04:22
Speaker
And certainly antimicrobial stewardship is very important, but it's a little bit harder to change that in a lot of these critically ill patients.
00:04:30
Speaker
So I certainly understand that.
00:04:32
Speaker
Absolutely.
ICU vs. General Hospital C. diff Infections
00:04:33
Speaker
I wanted to ask you, Max, if you could maybe make some comments on the difference between a C. diff infection that requires care in the ICU versus C. diff infections that occur in patients who are in the ICU.
00:04:48
Speaker
from an epidemiology, but also outcomes perspective?
00:04:52
Speaker
Yeah, I think they're, you know, they're potentially two somewhat different diseases.
00:04:58
Speaker
A lot of us think about the patients who come in, who come into the ICU with C. diff and they're very sick with shock, fulminant colitis.
00:05:09
Speaker
And it's pretty easy to identify these patients.
00:05:13
Speaker
I think in many cases, um,
00:05:15
Speaker
And that's going to be about 5% to 15% of folks who are hospitalized with C. diff will end up in the ICU.
00:05:23
Speaker
On the other hand, it's the patients who are already in the ICU and they develop diarrhea.
00:05:31
Speaker
And like so many of our ICU patients do because of whatever reason, really, it's actually pretty infrequent that these patients have C. diff.
00:05:41
Speaker
Diarrhea is pretty common, as everyone knows, in the ICU, and really only a minority, about 10 or 15 percent of patients with diarrhea in the ICU have C. diff, so it can be pretty hard to identify.
00:05:52
Speaker
And certainly the outcomes are really driven by how critically ill these folks are.
00:05:59
Speaker
And a lot of the patients who come into the ICU with C. diff are very sick, and at least 20 to 30 percent of those folks go on to die, so it certainly carries a lot of morbidity and mortality.
Recurring C. diff and Patient Readmission
00:06:12
Speaker
And I think that's an important aspect to reemphasize that despite C. diff being very common as a hospital acquired infection, in those cases that are the ones we're going to be discussing today that result in an ICU admission, the morbidity and mortality is quite significant.
00:06:29
Speaker
Yep.
00:06:30
Speaker
Absolutely.
00:06:31
Speaker
The other question I had along this topic relates to readmissions.
00:06:36
Speaker
Obviously, a big topic in value-based care for hospitalized patients.
00:06:42
Speaker
Could you tell us a little bit about readmissions within the context of C. diff?
00:06:46
Speaker
Yeah, readmissions are very common and certainly common in a lot of our patients who are in the ICU.
00:06:55
Speaker
Among patients who survived their initial hospitalization with C. diff, about a quarter of them are readmitted in the month.
00:07:03
Speaker
And, um,
00:07:05
Speaker
I think in the majority of those readmissions are due to CDI recurrence.
00:07:08
Speaker
So even if we feel like someone is getting better from their C. diff, they've made it out of the ICU, they've made it out of the hospital.
00:07:16
Speaker
I think it's really important to remember that these are still really critically, you know, these patients are chronically ill and they have high
00:07:27
Speaker
high potential for readmission and other negative outcomes.
00:07:30
Speaker
So there are still patients who really need to be watched closely and could get very sick again.
00:07:39
Speaker
I want to go into the discussion of risk factors.
00:07:42
Speaker
And you obviously mentioned the single most important one earlier with antibiotics, but maybe we can dive in that a little bit deeper, Max.
00:07:49
Speaker
So if we can start talking about risk factors from the perspective of antibiotics and what do we know
00:07:54
Speaker
about the different types of antibiotics or the different factors that actually increase risk for patients developing C. diff and why?
Antibiotics and C. diff Risk
00:08:03
Speaker
Absolutely.
00:08:04
Speaker
I think this is a really important topic for C. diff and certainly near and dear to my heart as an infectious diseases doctor.
00:08:12
Speaker
I think we all kind of have this association with fluoroquinolones and clindamycin as conferring the highest risk for C. diff.
00:08:24
Speaker
Those antibiotics certainly carry high risk, but those risks were shown mainly in studies of outpatients with C. diff.
00:08:34
Speaker
Other studies have looked at risk among hospitalized patients.
00:08:38
Speaker
And really, the antibiotic class that rises to the top is cephalosporins, mainly third and fourth generation cephalosporins.
00:08:47
Speaker
That's going to be ceftriaxone and cefepine mainly.
00:08:53
Speaker
So really in hospitalized patients, a lot of our hospitalized patients are on those antibiotics and those really seem to confer the highest risk.
00:09:00
Speaker
Certainly other antibiotics like beta-lactam combinations such as peptazo, carbapenems confer high risk as well.
00:09:10
Speaker
And really the main reason these antibiotics drive risk is because they have the largest impact on the gut microbiome.
00:09:19
Speaker
So we know that
00:09:21
Speaker
C. diff can colonize the microbiome of patients, especially once they're hospitalized, and then killing off other gut commensals allows the C. diff to kind of take over the intestinal microbiome and ultimately allows it to establish infection and cause clinical disease.
00:09:44
Speaker
So really, these antibiotics are the main drivers behind C. diff and
00:09:50
Speaker
you know, a lot of our hospitalized patients and critically ill patients certainly need antibiotics, and they can obviously be life-saving, as we all know, but it's important to remember this potential outcome and the mechanism by which that happens.
00:10:06
Speaker
Would it be fair, Max, to say that there is a class effect?
00:10:10
Speaker
So you mentioned some of the cephalosporins, for example, that obviously are associated with a higher risk.
00:10:16
Speaker
There's also a
00:10:18
Speaker
spectrum effect.
00:10:19
Speaker
So the broader the antibiotic, the most likely it is to be associated with C. diff.
00:10:26
Speaker
And finally, I guess you mentioned there's also probably a dose response, right?
00:10:31
Speaker
The longer you are, the higher number of antibiotics, the more likely.
00:10:34
Speaker
Would that be a good way to think about it?
00:10:37
Speaker
Absolutely.
00:10:37
Speaker
I think those are all really excellent points.
00:10:41
Speaker
And really, if you remember the mechanism that the way we develop C. diff is by killing off
00:10:47
Speaker
the other gut microbiomes that kind of crowd out the C. diff, the more antibiotics you give, the broader they are, and the longer you give them for, the more likely you are to kill off the rest of the gut microbiome that's really preventing the C. diff from taking over.
00:11:04
Speaker
So we know from other studies, it's been well demonstrated that
00:11:09
Speaker
giving broad spectrum antibiotics when a narrow spectrum antibiotic would be just fine increases your risk for C. diff.
00:11:16
Speaker
So for example, if you start a patient on vancomycin and cefepime when they have septic shock, and then a few days later, the blood cultures come back with a pan-susceptible E. coli, we know that at that point, the best way to lower risk for C. diff is by narrowing
00:11:37
Speaker
the antibiotics to the narrowest antibiotic possible.
00:11:39
Speaker
So perhaps something like ceftriaxone in that case would be better than, for example, continuing the cefepime because the cefepime is going to have more effect on the gut microbiome and kill off more of the bacteria that can crowd out the C. diff.
00:11:55
Speaker
So certainly I think minimizing antibiotics in, you know, however you can, whether that's narrow spectrum or less duration is helpful for lowering C. diff risk.
00:12:07
Speaker
And the effect that you described, Max, is a very important reminder for clinicians of the importance of deescalating.
00:12:16
Speaker
A lot of times because of inertia or because we want to be on the safe side, we tend to keep antibiotics a little bit longer, broad, despite having positive or negative cultures that could help us deescalate.
00:12:28
Speaker
And this is a specific and very clear example of how you might be harming a patient by having that behavior.
00:12:36
Speaker
Yeah, absolutely.
00:12:37
Speaker
I mean, this is, I think, one of the biggest clinical decisions that intensivists and infectious diseases doctors really have to make on a day-to-day basis.
00:12:47
Speaker
And it can certainly be difficult when you're faced with a critically ill patient.
00:12:52
Speaker
But I think really re-examining every day whether the patient needs the broad-spectrum antibiotics or not is really the best thing to do for them.
00:13:01
Speaker
And
00:13:02
Speaker
we know it can lower their risk of many adverse outcomes.
00:13:05
Speaker
And C. diff is really one concrete example of how we can help patients by narrowing their antibiotics and really thinking about that on a day-to-day basis.
00:13:15
Speaker
Max, so we talked about one end of the spectrum, which is really the use of broad-spectrum antibiotics, which is very common in the ICU.
00:13:25
Speaker
Could you comment of the risk of C. diff in patients that might be undergoing surgery and are receiving
00:13:31
Speaker
pre-op antibiotics.
00:13:33
Speaker
Is there any thoughts on how to manage that best, and is that something that could increase their risk?
00:13:39
Speaker
So certainly even narrow-spectrum perioperative antibiotics have been clearly shown to increase risk for C. diff.
00:13:50
Speaker
Certainly not as much as broad-spectrum antibiotics for longer duration, but
00:13:55
Speaker
Even, you know, every dose of antibiotics is going to increase a patient's risk.
00:14:00
Speaker
So most patients, I think, will be fine and certainly benefit from perioperative antibiotics, but it will increase C. diff risk.
00:14:08
Speaker
So probably something important to think about for the subset of patients who are at higher risk for C. diff, whether they've already had a few recurrences or they have other risk factors.
00:14:20
Speaker
It might not necessarily change your risk.
00:14:24
Speaker
your perioperative antibiotic prescribing practices, but it might make you think about whether they need that, you know, that extra dose that you sometimes keep on just to be on the safe side.
00:14:34
Speaker
Certainly, I think that's something worth thinking about in patients who are at higher risk.
PPIs and C. diff Risk in ICU vs. Outpatient
00:14:40
Speaker
Before we talk a little bit about patient characteristics that are associated with higher risk or worse disease, could you comment on gastric acid suppression by PPIs?
00:14:50
Speaker
That's been a common
00:14:52
Speaker
commonly cited a risk factor, and some people have argued against GI prophylaxis with PPIs because of this.
00:14:59
Speaker
What's the current state of evidence?
00:15:02
Speaker
It's a really good question, and I think another question that's really important for patients in the ICU.
00:15:09
Speaker
So PPIs have been associated with C. diff for about 10 years now.
00:15:14
Speaker
A lot of the early studies that showed this increased risk of C. diff
00:15:20
Speaker
were conducted in the community.
00:15:22
Speaker
And this led to an FDA warning for PPIs.
00:15:26
Speaker
But more recent data, and there was a really good meta-analysis that looked at randomized clinical trials of use of PPIs in the ICU for other indications, such as bleeding prophylaxis.
00:15:41
Speaker
And they did a secondary analysis of C. diff risk and actually found that in these RCTs, PPIs didn't include
00:15:49
Speaker
increased risk of C. diff.
00:15:51
Speaker
So I think for me, that's pretty strong evidence that, you know, perhaps in the outpatient setting where patients are on PPIs for weeks or months or kind of indefinitely, that might increase their C. diff risk, but really probably isn't a big factor in, you know, the days to weeks we're looking at when patients are in the ICU.
00:16:12
Speaker
So I don't think it should be a major factor in deciding whether to prescribe a PPI for an ICU patient or not.
00:16:19
Speaker
Excellent.
00:16:20
Speaker
And that is a change a little bit, like you said, of more relevant perhaps and newer evidence to suggest that the impact might not be as severe as we thought.
00:16:30
Speaker
But like you said, super important and relevant to what we do in the ICU since we prescribe PPIs to our mechanically ventilated patients on a very frequent basis.
00:16:40
Speaker
Yes, absolutely.
00:16:41
Speaker
The last aspect of risk factors, if you could share with us a little bit on your thoughts on
00:16:46
Speaker
patient characteristics in terms of contracting C. diff, but also are there any patient characteristics that are associated with a more likely severe or fulminant case of C. diff?
00:16:59
Speaker
Yeah, the patient characteristics that really are associated with both contracting C. diff and worse outcomes from C. diff, unfortunately, they really look like the patient characteristics
00:17:12
Speaker
for most of our folks who end up in the ICU, especially the medical ICU.
00:17:18
Speaker
So these are patients with diabetes, chronic kidney disease, malignancy.
00:17:24
Speaker
These are all risk factors for development of C. diff.
00:17:29
Speaker
Some studies have indicated that age is a risk factor, and I've
00:17:33
Speaker
think it still might be.
00:17:35
Speaker
One good study that I looked at from about a year or two ago didn't find any difference in age between ICU patients with and without C. diff.
00:17:43
Speaker
So I think the jury may still be out, but I wouldn't be surprised if age was an independent risk factor for C. diff acquisition.
00:17:52
Speaker
And then really, in addition to the risk factors I already mentioned, I think another big risk factor that is a little bit unique to C. diff is
00:18:02
Speaker
C. diff specifically is IBD.
00:18:04
Speaker
So patients with IBD we know are certainly at significantly increased risk for adverse outcomes once they develop C. diff.
00:18:14
Speaker
Excellent.
00:18:14
Speaker
But to move on to the next section, it seems that the really take-home message here is that the one factor that has the highest impact on developing C. diff and happens to be the factor that we have control over is the use of antibiotics.
00:18:30
Speaker
So judicious
00:18:31
Speaker
use of antibiotics, good stewardship with antibiotics is probably the single most important aspect of care that the intensivist can control in trying to decrease the risk of their patients contracting C. diff.
00:18:45
Speaker
Yeah, I definitely agree, and I really like how you put that.
00:18:47
Speaker
It's not only the most important factor, but really our one modifiable risk factor.
00:18:53
Speaker
So really important to consider antibiotics every day and whether they can be discontinued or narrowed.
00:19:00
Speaker
Excellent.
00:19:01
Speaker
Let's talk a little bit before we go into the clinical presentation of fulminant C. diff and what does that entail, but how do we make the diagnosis?
Complexities of C. diff Testing
00:19:11
Speaker
And that, again, seems quite simple, but yet sometimes can be difficult.
00:19:16
Speaker
So can you tell us a little bit of the types of tests and then how do we utilize them at the bedside and how do they perform?
00:19:24
Speaker
I totally agree that this, like many things in medicine and many infectious diseases diagnoses, it seems like it should be relatively simple, but frequently isn't.
00:19:35
Speaker
I think the key thing to know about the tests for C. diff, and we can talk in a little bit about who best to use them on, but there's really
00:19:48
Speaker
two things you want to ensure.
00:19:50
Speaker
First, you want to see if there's actually C. diff present.
00:19:55
Speaker
And we know that for other infections such as VAP or CAUTI, as we've discussed before, that just having the organism present in either an endotracheal aspirate or urinary culture, that doesn't mean that they're causing disease.
00:20:10
Speaker
But certainly they have to be there before they can cause disease.
00:20:14
Speaker
So the first step in testing for C. diff, you want to see if the C. diff organism is actually there.
00:20:20
Speaker
So there are two main ways to do that.
00:20:23
Speaker
The first is a nucleic acid amplification test or a PCR for toxin encoding genes.
00:20:32
Speaker
So if this is positive in this dual sample, that'll tell you that the C. diff is actually present.
00:20:38
Speaker
Similarly, you can perform
00:20:41
Speaker
a test for glutamate dehydrogenase, which is an enzyme that's produced by C. diff.
00:20:47
Speaker
So if that's positive, that also tells you that the C. diff is there.
00:20:51
Speaker
So if one of those tests is positive, you know that the patient has the C. diff organism, but that doesn't tell you if it's causing disease.
00:21:00
Speaker
So the Infectious Diseases Society of America and many other places recommend that if you have a positive either nucleic acid amplification test
00:21:10
Speaker
or a glutamate dehydrogenase enzyme, you then go on to test for production of a toxin, which is required to have clinical disease.
00:21:22
Speaker
So really, most places are requiring or suggesting this two-step process.
00:21:27
Speaker
First, you see if the organism is there.
00:21:29
Speaker
And then if it's there, you test for presence of a toxin, which is actually needed to have clinical disease.
00:21:35
Speaker
But certainly, this can be tricky.
00:21:37
Speaker
A lot of patients have
00:21:39
Speaker
presence of the organism, usually identified by a positive nucleic acid amplification test, and then a negative toxin test.
00:21:49
Speaker
That can really indicate either colonization with the organism, or we know that the toxin tests aren't 100% sensitive.
00:21:59
Speaker
So a negative toxin test doesn't necessarily rule out disease, and that's
00:22:04
Speaker
you know, an important place where clinical gestalt and determination is necessary for deciding whether this represents colonization or actually active disease.
00:22:15
Speaker
Would it be fair to say that two strategies or approaches that we could utilize to overcome this lack of sensitivity with a toxin especially and trying to differentiate colonization from ruling out, let's say, an infection would be to
00:22:31
Speaker
testing obviously based on clinical suspicion first.
00:22:34
Speaker
I mean, you don't just test in everybody, right?
00:22:36
Speaker
Because a whole bunch of people are going to be colonized.
00:22:39
Speaker
And B, is there any value in increasing the number of times we test or the number of tests that we do to increase the sensitivity?
00:22:48
Speaker
Those are both really good questions.
00:22:49
Speaker
I think the first part I definitely agree with that we should really only be testing unless patients have alias, which I think those patients really fall into a different camp.
00:23:01
Speaker
But really, patients shouldn't be tested unless they're having at least three loose stools in a 24-hour period.
00:23:08
Speaker
And even patients who are having three loose stools in a 24-hour period, in the ICU especially, there are a lot of reasons for diarrhea.
00:23:17
Speaker
So we should be checking to see if they're on tube feeds or stool softeners or laxatives.
00:23:23
Speaker
And if they are really only testing for C. diff,
00:23:27
Speaker
if you think there's a strong clinical suspicion otherwise.
00:23:30
Speaker
If not, then it probably makes more sense to add fiber, for example, to thicken the stools or to hold the laxatives and then see if the diarrhea persists and only testing for C. diff if it does.
00:23:46
Speaker
The second part, in terms of repeat testing with an initial negative test, I think the
00:23:55
Speaker
nucleic acid amplification tests are sufficiently sensitive, especially in patients who are having copious diarrhea, that if those are negative, it's pretty good at ruling out C. diff in these patients.
00:24:08
Speaker
So I don't think there's a standard recommendation to retest folks who have an initial negative test as long as they are having diarrhea.
00:24:15
Speaker
Okay, that's important.
00:24:17
Speaker
And you did mention ILEAS.
00:24:19
Speaker
So maybe it might be a good time to talk about the patient who has ILEAS.
00:24:23
Speaker
And what do we do then?
00:24:26
Speaker
Yeah, this can certainly be very challenging.
00:24:29
Speaker
I think the key point in diagnosing C. diff in patients with ileus, as most intensivists do, is really just to maintain a high degree of suspicion.
00:24:40
Speaker
It's obviously hard or impossible to collect a stool sample from these patients to know if they have C. diff.
00:24:47
Speaker
So you really just have to put it in the clinical context and really for any hospitalized patient who newly develops ileus, C. diff should be high on the list of potential causes for this.
00:25:01
Speaker
We can use adjuncts such as CT scans to see if there are clinical signs of colitis, for example, although that again, it really isn't particularly specific.
00:25:16
Speaker
But there really aren't many diagnostic tests that are going to help diagnose C. diff in patients with ileus.
00:25:24
Speaker
And in terms of colonoscopy, there's typical findings, but probably not a routine test that we would do to diagnose C. diff, right?
00:25:33
Speaker
It's usually more of an incidental finding as they're working or doing something else.
00:25:36
Speaker
Can you comment on that, Max?
00:25:38
Speaker
Yeah.
00:25:39
Speaker
So colonoscopy isn't recommended in suspected cases of C. diff just for the reasons you mentioned.
00:25:46
Speaker
It's not really helpful in ruling in or out the diagnosis.
00:25:52
Speaker
Pseudomembranous colitis might be present in slightly above half the cases, so not particularly sensitive or specific.
00:25:59
Speaker
It does carry risk of complications, including sedation, colonic perforation.
00:26:06
Speaker
So we don't routinely recommend C. diff, excuse me, FMT in cases of suspected C. diff, but certainly pseudomembranous colitis may be there if
00:26:15
Speaker
the patient is getting a colonoscopy for another reason, or in cases of delivery of FMT, as we'll discuss later, you can certainly see pseudomembronous colitis as well.
00:26:29
Speaker
Excellent.
00:26:30
Speaker
So I would like to spend a little bit of time on the clinical presentation or the clinical spectrum.
00:26:36
Speaker
So obviously you talked about an important number of patients who can be colonized, which are not active infections.
00:26:42
Speaker
There might be even in patients outside of the ICU or people who contract C. diff in the ICU, diarrhea is the main symptom.
00:26:50
Speaker
But could you give us more details of how we start progressing into what some call severe C. diff and then fulminant C. diff and what characterizes or defines those?
00:27:02
Speaker
Absolutely.
00:27:03
Speaker
And these are really important because the different clinical severity is really what's going to drive your treatment decisions.
00:27:13
Speaker
Once you get, as C. diff gets more severe, the first category is severe C. diff, which is defined by either a white count greater than 15,000 or a serum creatinine greater than 1.5.
00:27:27
Speaker
Even beyond that, which is fulminant C. diff, which is really important to intensivists.
00:27:36
Speaker
And that's defined as C. diff with any of hypotension, shock, megacolon,
00:27:42
Speaker
or alias.
00:27:43
Speaker
So these are really the patients that probably most folks are thinking about now, the really critically ill patients who have one of these severe complications from C. diff that really puts them at a quite high risk of mortality.
00:27:59
Speaker
And I believe that it's important to spend a little bit of time and reemphasize the fulminant is, like you mentioned, probably easier to recognize.
00:28:10
Speaker
But
00:28:10
Speaker
A lot of times what I worry about is that patient who's becoming sick, but we haven't really identified them as being as sick, and maybe we might lose our window of intervening.
00:28:21
Speaker
But it seems that as somebody develops C. diff, if they're outside of the ICU or we're evaluating somebody with C. diff, and their white count starts going up and their cranny starts going up, we probably should be paying more attention to those patients as their likelihood to be moving in the wrong direction.
00:28:38
Speaker
Yeah, certainly, you know, as with many infectious diseases, early institution of proper antibiotics and proper adjunctive measures is really helpful in preventing adverse outcomes.
00:28:53
Speaker
So as an infectious diseases doctor, you know, we think a lot about which
00:28:59
Speaker
which antibiotics to institute, but certainly this is another, C. diff is another great example of where multidisciplinary management is really important in terms of fluid resuscitation and collecting, excuse me, correcting electrolyte abnormalities and organ impairment.
00:29:17
Speaker
These patients who are starting to slip into severe fulminant C. diff really deserve to be, um,
00:29:26
Speaker
treated pretty aggressively up front, thinking about antibiotics and adjunctive measures that can perhaps prevent them from developing even more severe disease.
00:29:37
Speaker
Max, a heuristic or a pattern that has been ingrained in my clinical mind for years now is intubated patients, ileus, very high Y count, more than 20,000, 30,000, 40,000, like immediately think C. diff.
00:29:54
Speaker
Is there any validity to that?
00:29:56
Speaker
Is that something that is useful, you think?
00:30:00
Speaker
You know, I think that's probably a good mental model.
00:30:04
Speaker
I don't know off the top of my head, or I don't know if there's been evidence to suggest how often patients develop, you know, white counts between 15 to 20,000, 20 to 30.
00:30:15
Speaker
Certainly, the higher, the worse, and the higher is going to make you think more about C. diff.
00:30:21
Speaker
But I think really keeping C. diff high interdifferential for any patient who might meet criteria is going to help missing some cases and is going to prevent any significant morbidity or mortality associated with C. diff.
00:30:37
Speaker
So I think the cases you're describing are certainly the ones that are going to get all of our attention and probably the ones that are going to be
00:30:45
Speaker
most tricky and most likely to have really bad outcomes.
00:30:50
Speaker
So those are certainly good ones to remember.
00:30:52
Speaker
But keeping C. diff pretty high on the differential for even more subtle presentations, I think, will help doctors take really good care of these patients.
00:31:02
Speaker
Excellent.
C. diff Treatment Options
00:31:03
Speaker
So why don't we dive into treatment?
00:31:05
Speaker
And you mentioned, obviously, first step related to antibiotics.
00:31:09
Speaker
And I would imagine that involves what to stop, but also what to start.
00:31:14
Speaker
Right.
00:31:15
Speaker
Right, exactly.
00:31:16
Speaker
So a few things are really important in managing C. diff patients.
00:31:21
Speaker
And we talked before about limiting antibiotics for patients who are at risk of C. diff.
00:31:29
Speaker
Certainly, if patients require systemic antibiotics and develop C. diff, trying to, again, discontinue or narrow the systemic antibiotics is really helpful.
00:31:42
Speaker
You know, that's obviously not always possible in every patient, but certainly something to think about daily.
00:31:48
Speaker
And again, once patients develop C. diff, but once they develop C. diff, the quarterstone antibiotic is really oral vancomycin for everyone.
00:31:58
Speaker
This is
00:32:00
Speaker
very safe, effective, limited systemic absorption, although there are some patients who could develop systemic levels of vancomycin, but in general, quite safe and not associated with many of the adverse outcomes that we think of with IV vancomycin and is really widely available and a great treatment for C. diff.
00:32:22
Speaker
Could you comment on the dosing of oral vancomycin?
00:32:27
Speaker
I know there's a traditional dose of 250, but some people recommend using higher doses.
00:32:33
Speaker
Yeah, I think this hasn't been entirely rigorously studied, so it's a little bit hard to know.
00:32:39
Speaker
There's thought that giving a higher dose of 500 milligrams oral every six hours is
00:32:46
Speaker
could lead to higher intracolonic levels, especially among patients who might have alias.
00:32:52
Speaker
So they're likely to have less drug delivery to the distal colon, where the C. diff is really causing most of the issues.
00:32:59
Speaker
So that's really the thinking behind giving this higher dose of 500 Q6.
00:33:04
Speaker
Some studies indicate that even at lower doses, 250 or 125, you're still getting colonic concentrations of well above the MIC.
00:33:14
Speaker
So there's some thought that you might not need that 500 Q6, but it's still guideline recommended, at least in the United States, and still probably the standard of care to give high-dose vancomycin for patients with severe or fulminant C. diff.
00:33:30
Speaker
And this doesn't apply to patients without severe or fulminant C. diff, but to give them that high dose to make sure they're getting really high intracolonic levels.
00:33:41
Speaker
And those patients with either megacolon or ileus,
00:33:44
Speaker
Are rectal deliveries of vancomycin useful and utilized?
00:33:52
Speaker
Yeah, I think they are still standard of care, again, for the same, thinking of the same reason.
00:33:58
Speaker
We really don't know how much of that oral vancomycin is making it all the way to the distal colon.
00:34:03
Speaker
It seems like even if a little bit is trickling down there, that's probably going to get above the MIC.
00:34:09
Speaker
But without really knowing how much is there,
00:34:12
Speaker
it probably makes sense to give them rectal retention enemas of vancomycin to make sure you're getting the drug right to where it needs to go and killing off the C. diff spores right where they're causing disease.
00:34:23
Speaker
So I think that would still be recommended or is recommended, I should say, for patients with alias or toxic megacolon.
00:34:31
Speaker
And because of the lack of absorption, you could utilize both at the same time.
00:34:36
Speaker
Is that correct?
00:34:38
Speaker
You can.
00:34:39
Speaker
You certainly can.
00:34:39
Speaker
I think there are some cases where patients do develop actually systemic absorption, which I'm not sure is very widely known.
00:34:47
Speaker
And this is really a risk in patients with end-stage renal disease and significant colonic inflammation where they actually are getting some systemic absorption of vancomycin.
00:34:58
Speaker
So I think it's reason to be a little bit cautious in patients, like I said, with ESRD,
00:35:03
Speaker
and they're getting a PO and rectal vancomycin, if they're needing both of those at high doses for a long time, it's probably worth at least thinking about checking a serum vancomycin level to make sure they're not getting much systemic absorption.
00:35:19
Speaker
Again, the risks, you always have to weigh the risks and benefits, but it's at least worth thinking about for patients who are getting long courses of rectal and oral vancomycin, thinking about whether they could be absorbing some systemically.
00:35:33
Speaker
And what's the standard duration?
00:35:35
Speaker
So I guess you start with 10 days is what I have always done, but in some cases you might need to do a little bit longer.
00:35:40
Speaker
Is there any current recommendations on duration?
00:35:44
Speaker
Has this been studied?
00:35:46
Speaker
There really aren't any current recommendations and there really aren't any trials evaluating this.
00:35:51
Speaker
A lot of the data in fulminant C. diff is extrapolated from less severe forms of C. diff.
00:35:59
Speaker
Right now, the standard practice is to kind of start with 10 days and then see how things are going.
00:36:05
Speaker
And certainly, if patients are still having bad disease after 10 days, you can either extend the vancomycin course or consider switching to other antibiotics.
00:36:16
Speaker
I think that's
00:36:18
Speaker
you know, 10 days is probably a good place to start.
00:36:20
Speaker
And then you can kind of take it from there in terms of how the patient's responding and whether they might need more vancomycin or switching to a different agent altogether.
00:36:30
Speaker
Excellent.
00:36:31
Speaker
And Max, could you comment on the role of metronidazole in these patients?
00:36:36
Speaker
Yeah, metronidazole, you know, is unlike vancomycin, it's given IV.
00:36:42
Speaker
So the thinking is that, you know,
00:36:45
Speaker
Actually, I should take a step back.
00:36:46
Speaker
I think, you know, we used to give oral metronidazole for non-severe forms of C. diff.
00:36:53
Speaker
And even now, in the last version of the IDSA guidelines in 2018, vancomycin is recommended first for really all patients with C. diff.
00:37:02
Speaker
So every patient with C. diff should be on oral vancomycin unless there's a really compelling reason not to do so.
00:37:08
Speaker
For patients with severe and fulminant C. diff,
00:37:12
Speaker
The current practice is to add on intravenous metronidazole.
00:37:17
Speaker
And the thinking there is that if the patient has ileus and they might not be getting a lot of vancomycin into their colon, that because the metronidazole is given systemically, you are going to reach high intraclonic levels of metronidazole.
00:37:33
Speaker
So that is certainly standard practice to add on IV metronidazole in addition to the oral vancomycin for severe and fulminant C. diff.
00:37:42
Speaker
And I think certainly what I still do and what I imagine most folks still do, there have been a few recent large retrospective studies that have kind of called this into question and haven't shown that this improves clinical outcomes.
00:37:57
Speaker
So I think this might be changing a little bit in the next few years, but for now, I do think it's still standard of care and probably still recommended to give IV metronodazole in addition to the oral vancomycin for patients with very severe C. diff.
00:38:11
Speaker
So clearly, the oral vancomycin and the IV metronidazole are first-line therapy, what we should be doing in all our patients.
00:38:19
Speaker
Could you comment on some of the drugs that maybe have a much more niched approach for refractory cases or when we should use them that perhaps are not as common?
Advanced Treatments for C. diff
00:38:29
Speaker
And that includes a couple of antibiotics like fidaxamycin and the tegacycline, but also some monoclonal antibodies and IV immunoglobulins.
00:38:41
Speaker
Yeah, so like you said, Sergio, really all patients should be on vancomycin and probably metronidazole.
00:38:49
Speaker
And then if they have ileus or toxic megacolon, they should be given rectal vancomycin as well.
00:38:58
Speaker
Fidoximycin is another antibiotic that's used more widely in Europe.
00:39:03
Speaker
It is available in the United States.
00:39:05
Speaker
Its use has been limited a little bit by its cost, but it does actually in non-severe C. diff have improved outcomes in terms of decreasing recurrence mainly and perhaps mortality and cure improvement as well.
00:39:21
Speaker
So Fidoximycin is certainly something to consider.
00:39:25
Speaker
There haven't been any studies that primarily evaluated it in severe and fulminant C. diff, but there is some hint that it might be at least as good, if not perhaps a little bit better than vancomycin in severe C. diff, although I don't think we can say that definitively at this point.
00:39:40
Speaker
So vancomycin is certainly still the standard of care.
00:39:43
Speaker
But fidoxomycin might be something you consider if the patient isn't responding to vancomycin after a few days and they're not sick enough at that point to necessarily need a fecal microbial transplant or surgery.
00:39:58
Speaker
Tiga cyclin has also made it into the 2018 IDSA guidelines.
00:40:03
Speaker
I don't think I've ever used this or really seen it used.
00:40:06
Speaker
It's a really poorly tolerated antibiotic, and its use was really just based on a few case series.
00:40:12
Speaker
So I don't think there's much of a role for tigacyclin, which is the other antibiotic that people sometimes talk about using for C. diff.
00:40:21
Speaker
Bezlatoximab is a monoclonal antibody against toxin B, which is the main C. diff toxin that really causes disease and is virulent.
00:40:33
Speaker
This, the main benefit of bezotoximab is that it decreases C. diff recurrence.
00:40:40
Speaker
So it might be something to think about for your patients who already have recurrent C. diff or are at high risk of developing recurrence.
00:40:49
Speaker
But it's really not going to be kind of a standalone therapy for C. diff.
00:40:54
Speaker
Similarly, IV immunoglobulin might have some of the same benefits, but really isn't used that much for C. diff and definitely carries risks for ICU patients, including a large volume of administration.
00:41:06
Speaker
So I think the takeaway is that for patients not responding to initial therapy and you don't think they're quite sick enough yet to need FMT or surgery, maybe think about switching to fidoxamizam.
00:41:19
Speaker
Excellent.
00:41:20
Speaker
So let's dive into FMT.
00:41:22
Speaker
We had talked about it here and there, but could you first tell us what does FMT stand for and how does it work and who should we be thinking to use it in?
Fecal Microbiota Transplant for Recurrent C. diff
00:41:35
Speaker
Yeah, thanks.
00:41:35
Speaker
I'm sorry if I didn't define this before, but FMT stands for fecal microbiota transplant.
00:41:42
Speaker
And as we discussed before,
00:41:45
Speaker
The main pathogenesis of C. diff is that the quote-unquote good or commensal gut bacteria are killed off by antibiotics, which allows C. diff to colonize the intestines and then kind of take over and cause disease.
00:42:03
Speaker
FMT really attempts to reverse that process by instilling feces from a healthy donor into a person with C. diff.
00:42:15
Speaker
you can recolonize their intestines with this beneficial commensal bacteria and hopefully crowd out the C. diff spores.
00:42:23
Speaker
And this has been really, really well demonstrated for recurrent or, let's say, refractory C. diff cases, you know, maybe not folks in the ICU, but outpatients who just keep coming back and back with C. diff that really won't go away despite antibiotics.
00:42:40
Speaker
FMT is really clearly indicated for those patients and is really over 90% cure rate.
00:42:45
Speaker
So really the standard of care for those patients.
00:42:49
Speaker
In patients with fulminant or severe disease in the ICU, a few recent studies have shown that FMT may improve outcomes compared to antibiotics alone, including vancomycin.
00:43:06
Speaker
So I think this is a really promising
00:43:09
Speaker
therapy for patients who are sick enough to end up in the ICU.
00:43:13
Speaker
I think there's still a lot we don't know, as you alluded to, specifically which patients to give FMT to.
00:43:20
Speaker
And it seems to be that, you know, this shouldn't be first line, at least not quite yet.
00:43:26
Speaker
And I think there's kind of this window of when patients are
00:43:32
Speaker
haven't yet responded to initial therapy, including usually vancomycin and metronidazole, when they might benefit from FMT.
00:43:39
Speaker
But I think this is really still one of the main questions that needs to be defined in terms of C. diff care is which patients benefit from FMT and when they benefit.
00:43:52
Speaker
Excellent.
00:43:52
Speaker
And I guess that the third weapon we have therapeutically to treat
00:43:59
Speaker
C. diff directly is surgery for those fulminant cases that are not responding.
Surgical Interventions for Severe C. diff
00:44:03
Speaker
Can we first maybe talk about timing of involvement of surgery, timing of surgery, and then what are the types of operations that people have utilized for these patients?
00:44:16
Speaker
Yeah, I really like how you phrased that question, kind of distinguishing the timing of involvement of surgery from timing of surgery itself.
00:44:26
Speaker
And I think, as a lot of your listeners will know, involving surgery early on is usually to the patient's benefit.
00:44:34
Speaker
And the idea is that the surgeons can have some time to prepare for surgery, potentially, if it's needed.
00:44:41
Speaker
But certainly, they can follow serial abdominal exams, get a sense of the patient, and kind of watch their clinical exam evolve over time.
00:44:51
Speaker
I know many surgeons usually aren't happy when you call them in only once the patient has perforated their colon.
00:44:57
Speaker
So probably a good idea to think about getting surgery involved early, at least to see the patient.
00:45:03
Speaker
if the patient is critically ill.
00:45:04
Speaker
So I think probably anyone with ileus or megacolon, or as you mentioned before, you know, really high white counts or severe abdominal pain or lactic acidosis, those are probably all patients who should have a surgical consult.
00:45:18
Speaker
Whether or not they ultimately need surgery is a different question, but probably a good idea to think about calling surgery pretty early in those patients' course.
00:45:27
Speaker
And then
00:45:28
Speaker
when to do surgery specifically.
00:45:30
Speaker
I mean, this is, I think, a really hard question, and I'm certainly not a surgeon, so I can't give personal thoughts or opinions on this.
00:45:39
Speaker
And I imagined if you asked 10 different surgeons, you'd get 10 or 12 or 15 different answers.
00:45:44
Speaker
But I think similar to FMT, there's this idea that there's
00:45:50
Speaker
kind of an optimal surgical window for C. diff.
00:45:54
Speaker
And this is after patients haven't responded to initial treatment.
00:45:58
Speaker
So you certainly want to, unless they're very, very sick, give them a shot to respond to the usual antibiotics we give.
00:46:07
Speaker
But you don't want to let them get too sick.
00:46:09
Speaker
That surgery won't be beneficial and they'll have an unacceptably high surgical mortality.
00:46:14
Speaker
So I think
00:46:17
Speaker
This idea of maybe between day two to seven or so, some studies have suggested that a lactate between 2.2 and 5 is kind of the ideal surgical window.
00:46:33
Speaker
So I think that kind of reflects this clinical sense that the patient is sick and quite sick.
00:46:39
Speaker
but not too sick that they won't even benefit from surgery.
00:46:42
Speaker
And this is really hard to define.
00:46:44
Speaker
And similar to C. diff, I think deserves more, excuse me, similar to FMT, I think deserves more rigorous perspective study.
00:46:53
Speaker
But clearly identifying those patients who are sick and might need surgery early is important to get the team involved.
00:47:02
Speaker
And like you said, this narrow window makes it difficult because if you wait too long,
00:47:08
Speaker
then it's probably surgery that's not going to make a difference.
00:47:11
Speaker
And that's also, I believe, something that our surgeons are not going to be very happy being called at that stage.
00:47:17
Speaker
Right.
00:47:18
Speaker
Exactly.
00:47:18
Speaker
So I think, like you said before, potentially calling surgery early is usually in the patient's benefit.
00:47:26
Speaker
You know, the surgeons are really the ones with the clinical expertise, and they've seen a lot of these cases and know when it might still be in the patient's benefit to intervene.
00:47:37
Speaker
And in terms of the type of surgery, obviously none of us are surgeons, but traditionally people have done total abdominal colectomies, but it seems that now loop biliostomies are a little bit more popular as well.
00:47:50
Speaker
Could you comment on what the data shows on these?
00:47:53
Speaker
Yeah, so like you said, total abdominal colectomy was really the primary surgery that was done until about 10 or so years ago.
00:48:03
Speaker
There was a retrospective study published about 10 years ago that showed that loop ileostomy, where they actually connect the ileum without resecting it, and then that allows you to give integrated vancomycin flushes through the ileostomy.
00:48:24
Speaker
They showed that that had improved mortality compared to total abdominal colectomy.
00:48:30
Speaker
Other studies since then haven't been as definitive as to whether loop ileostomy has a mortality benefit.
00:48:37
Speaker
I think this is a really hard thing to study.
00:48:40
Speaker
Certainly, it would be tough to randomize patients to one of these two interventions, and there's obviously a lot of differences between the patients who you might take for a total colectomy or a loop ileostomy.
00:48:53
Speaker
In talking to some surgeons, it seems that the loop ileostomy allows for much easier subsequent reanastomosis than the total abdominal colectomy.
00:49:05
Speaker
So that seems to be the one that's probably preferred.
00:49:08
Speaker
It's much less invasive and it allows for subsequent reanastomosis.
00:49:13
Speaker
So if the patient can undergo that,
00:49:15
Speaker
That should probably be the procedure of choice.
00:49:18
Speaker
But certainly, I think more important is having an experienced surgeon come evaluate the patient and decide whether surgery is in their best interest.
00:49:27
Speaker
And then if so, which of the two surgical techniques would be best for the patient?
00:49:32
Speaker
Absolutely.
00:49:32
Speaker
And the one thing that also you mentioned, obviously, is when a patient progresses to a point of perforation, it's late.
00:49:40
Speaker
even if they go to surgery at that point, their options are limited and probably they're going to end up with a total abdominal colectomy regardless.
00:49:47
Speaker
Right.
00:49:48
Speaker
If they have complications like perforation or necrosis or large areas of ischemia, at that point, it seems like it would be better to do the total abdominal colectomy, which is another great reason to involve the surgeons earlier, potentially preventing the patient from progressing to that point.
00:50:07
Speaker
Excellent.
00:50:08
Speaker
Well, I think that the last area from the clinical management that I think is worth discussing and emphasizing is prevention.
Prevention Strategies for C. diff
00:50:16
Speaker
And I think especially after a year plus of N95s and a lot of alcohol, it might be good to remind people what prevention looks like in C. diff.
00:50:28
Speaker
Yeah, that's a very, very good point.
00:50:31
Speaker
C. diff prevention looks a little different from COVID prevention, and both very important.
00:50:37
Speaker
Really, the cornerstone of C. diff prevention, as we've talked about before, is limiting antibiotics.
00:50:42
Speaker
But now everyone is expert in doing that.
00:50:45
Speaker
So let's say you've limited antibiotics and your patient still develops C. diff.
00:50:51
Speaker
The main way to prevent C. diff from spreading to other patients in the unit is by the standard infection control practices that we all know and love.
00:51:00
Speaker
So these involve using a single-use gown and gloves, even though some places are getting rid of those for MRSA and certain gram-negative, resisting gram-negative infections.
00:51:13
Speaker
I don't think those will go away for C. diff anytime soon.
00:51:17
Speaker
So certainly using single-use gown and gloves.
00:51:21
Speaker
Single-use stethoscope is really important as well.
00:51:24
Speaker
And then once you leave the patient's room, cleaning with soap and water, because we know that
00:51:30
Speaker
the alcohol-based hand sanitizers really don't do a good job of killing the C. diff spores.
00:51:35
Speaker
It's really crucial to wash with soap and water.
00:51:39
Speaker
So those are really the cornerstones for preventing C. diff and hopefully not having it become an outbreak in your ICU.
00:51:48
Speaker
Excellent.
00:51:49
Speaker
Well, we would like to end, Max, with some questions that are unrelated to the clinical topic.
00:51:55
Speaker
That's a tradition in the podcast.
00:51:58
Speaker
Would that be okay?
Influential Books and Infectious Disease
00:51:59
Speaker
Yeah, absolutely.
00:52:01
Speaker
So the first question relates to books.
00:52:04
Speaker
And is there a book or books that have influenced you the most or that you have gifted most often to others?
00:52:10
Speaker
That's a good question.
00:52:11
Speaker
I've had a little more time to read in this past year with the pandemic.
00:52:16
Speaker
You probably get, I don't know if you've had, you probably get the same response from a lot of the ID doctors you have on the podcast, but
00:52:24
Speaker
I think the book, The Hot Zone, really stuck with me and is timely now.
00:52:28
Speaker
This was about an Ebola outbreak in a primate facility in Virginia in the early 90s.
00:52:37
Speaker
And it was really, really well written and reported and kind of did a great job, I thought, of bridging science and public health and making it accessible for a wide audience.
00:52:46
Speaker
But I think the idea that these infections really are never that far from us in this
00:52:54
Speaker
was kind of a wild idea 20 or 30 years ago when the book was written.
00:52:58
Speaker
And now we've seen it, unfortunately, really play out in the past year, year and a half.
00:53:04
Speaker
So this was a book that really, really stuck with me.
00:53:06
Speaker
And I think, you know, really started my love of infectious diseases and viral infections and really a fascinating book for anyone who hasn't read it.
00:53:15
Speaker
Probably not the escapist literature that some people might be looking for in the COVID era, but definitely a really good, well-written and exciting read.
00:53:24
Speaker
Absolutely.
00:53:25
Speaker
And we will link this in the show notes, but a book that I agree, I had a lot of time or read a lot more during the last 12 months that I've read in a long time, even though I definitely try to dedicate a lot of time to reading, but a book that was recommended to me by another infectious disease colleague that really was quite interesting during, especially during the context of COVID, was a book on the great influenza pandemic from 1918.
00:53:52
Speaker
I think it's by Barry.
00:53:54
Speaker
which also intertwines the whole history of the pandemic with the history of medicine in the United States, the initiation of John Hopkins Medical School and how it became a science in the United States and really a fascinating story.
00:54:09
Speaker
But I'm sure that I had not read the hot zone, but what was remarkable for me was that a pandemic over a hundred years ago, Max had so many dynamics that were exactly the same of what we saw here.
00:54:20
Speaker
And it's just speaks to human behavior, right?
00:54:23
Speaker
That never changes.
00:54:25
Speaker
I totally agree.
00:54:25
Speaker
I think, yeah, as much as we all wish it will change, you know, as a result of COVID, I think when the same thing happens, whenever it does, and hopefully it's, you know, not for at least another hundred years, a lot of the same things will be will happen again.
00:54:40
Speaker
So I think that's a really great point.
Critique of Manifesting Concept
00:54:43
Speaker
The second question relates to beliefs.
00:54:45
Speaker
And is there something that you believe to be true in medicine or in life that most other people or many other people don't believe or don't behave as they believe?
00:54:56
Speaker
That's a really good question about beliefs.
00:54:59
Speaker
Actually, I just came across something today, and I've heard about this a few times recently, including from an unnamed family member, and that's this idea of manifesting.
00:55:11
Speaker
I don't know if you've heard of this, but it seems to be this idea that you can kind of make something come true just by believing in it or thinking about it enough to
00:55:20
Speaker
Like my family member was saying, you know, you could, for example, manifest getting a new job or getting a promotion or something like that.
00:55:29
Speaker
And I know I'm probably preaching to the choir, talking to a group of scientists, but this to me just, you know, seems kind of to go against the
00:55:40
Speaker
the core ideas of, you know, hard work and really working at something to make it happen.
00:55:46
Speaker
And it really doesn't seem to me like it should have any place in our modern society, but I guess it, it kind of just ties into the general anti-science attitude in our, in our population that, you know, I think is a problem and is, you know, been more of a problem in the past few years.
00:56:04
Speaker
And certainly, as you said, you know, might've contributed to, to making this pandemic worse than it had to be.
00:56:10
Speaker
And it's interesting because I often think of maybe the contrary of manifesting in terms of not having ideas lead me to a different way of being or acting, but actually starting with actions that ultimately change the way I think.
00:56:28
Speaker
If you start acting like a leader, all of a sudden you become a leader, right?
00:56:32
Speaker
As you start acting like a scientist and asking the right questions and being very, very, very,
00:56:40
Speaker
very hesitant and accepting things that are apparent initially, you might start becoming more of a scientist.
00:56:47
Speaker
But it is definitely an interesting discussion.
00:56:50
Speaker
And like we mentioned, same dynamic in 1918.
00:56:53
Speaker
The war against science was present there.
00:56:56
Speaker
The war against science is present now.
00:56:59
Speaker
And it just seems to speak to the polarity that we have now in society, but definitely very interesting topics.
Cautious UTI Diagnosis
00:57:06
Speaker
Yep.
00:57:07
Speaker
I like that way you put it of kind of flipping it on its head and start
00:57:10
Speaker
know start with the outcome and then it'll it'll drive your thoughts too so i really like how you put that so the last question max relates to what would you want every intensivist that's listening to you our audience and a fact or quote to know as a departing thought well i'm sorry to to make it too id related um and i certainly don't envy any intensivist you all have an incredibly difficult job but i think
00:57:40
Speaker
For me, the one thing that I really think clinically is important is the diagnosis of urinary tract infection.
00:57:47
Speaker
And for me, this is just a big bugaboo of mine, let's say.
00:57:52
Speaker
And I really think UTI is a diagnosis of exclusion.
00:57:55
Speaker
So sorry to leave it on a very ID-specific note.
00:58:00
Speaker
But if I could take away urine cultures, I probably would.
00:58:04
Speaker
And, you know, UTI is a really hard diagnosis to make.
00:58:08
Speaker
And I think it's usually not what is was driving any any major pathology.
00:58:13
Speaker
So I love it because it came out of out of right field.
00:58:18
Speaker
I wasn't expecting that, but I love it because that would be a great PSA for every hospital to have in the parking lot for all the doctors to see, right?
00:58:26
Speaker
I totally agree.
00:58:27
Speaker
UTI is a diagnosis of exclusion.
00:58:28
Speaker
That could be my tagline.
00:58:30
Speaker
I'd be happy if that was on my gravestone.
00:58:32
Speaker
That's a perfect place to stop.
00:58:33
Speaker
Max, I want to thank you for your time, for sharing your expertise.
00:58:37
Speaker
I look forward to talking more with you, having you back on the podcast, talk about other ID critical care related topics.
00:58:44
Speaker
And also hope we all have the opportunity to see each other soon in conferences and as we emerge from this pandemic to get to interact again in person.
00:58:55
Speaker
Thank you so much, Sergio.
00:58:56
Speaker
I really appreciate it.
00:58:57
Speaker
And that sounds great to me too.
00:58:59
Speaker
Take care.
00:59:00
Speaker
Bye.
00:59:02
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:59:06
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
00:59:12
Speaker
Sound's transforming the way critical care is provided in hospitals across the country.
00:59:16
Speaker
To learn more, visit www.soundphysicians.com.