Healthcare’s Public Enemy: Clostridium Difficile (C-Diff)

 

What is C.Diff?

• A spore-forming, gram-positive anaerobic bacillus
• produces two exotoxins: toxin A and toxin B.
• When a person takes antibiotics, good intestinal bacteria that protect against infection are destroyed for several months.
• During this time, patients can get sick from Clostridium difficile (C.diff).
• This bacteria causes potentially deadly diarrhea, which can be spread in healthcare settings (Tiso, 2012).

History of C.Diff

- First isolated from a healthy infant’s stool sample in 1935.

-The name clostridium difficile was chosen to reflect how difficult it was to culture and isolate.

- In 1978, George and colleagues associated clostridium difficile with human disease and discovered that clostridium difficile was the responsible bug that led to most cases of antibiotic-associated diarrhea (George, et al., 1978) (Bartlett, et al., 1978).

-Clostridium difficile is now one of the most common hospital acquired infections (HAI) in the United States and developed countries. There are an estimated 500,000 cases in the United States each year alone (Rupnick, Wilcox, and Gerding, 2009).

-Costs may exceed one billion annually in the United States alone (Kyne, Hamel, Polavaram, et al., 2002).

-Data from the CDC shows the rate of discharge diagnosis of clostridium difficile infection (CDI) increased from 31 cases per 100,000 persons per year in 1996 to 61 per 100,000 in 2003.\

Morbidity and Mortality

-Morbidity of CDI has increased by as much as 25% each year with a twenty-fold increase in mortality (McDonald, Owings, and Jernigan, 2006) (Johnson, et al., 1989) (Dallal, et al, 2002) (Pepin, Valiquette, and Cossette, 2005).

-Each year approximately 15 – 20,000 people die from CDI in the United States (Rupnick, Wilcox, and Gerding, 2009). The estimate is even higher (29,000) according to a 2011 study (Lessa, et al., 2015).   Information Reference: (Heinlen, & Ballard, 2010)

How does Florida Stack Up?

-CDC (2015) published results from data gathered in 2013 concerning healthcare related infections.

-The State of Florida had a significant decrease in its Standardized Infection Ratio (SIR) by 11% (based on 193 out of 237 Florida hospitals reporting) when compared to the national baseline.

-Among 184 Florida hospitals with enough data to calculate a SIR, 16% had a SIR lower than the national SIR of 0.90.

Transmission

-Sources of infection can be endogenous or exogenous

-Fecal-Oral Route

-Hands of healthcare workers or general public

-Contaminated Surfaces

-Person to person in many settings (primarily) inside hospitals.

-Clostridium spores can survive on environmental surfaces for up to FIVE months (Gerding, Muto, & Owens Jr., 2008)!

Pathogenesis

-Step One: Ingestion of spores from other patients

-Step Two: Germination into growing (vegetative) form

-Step Three: Changes in lower intestinal flora (due to antibiotic use) allows for growth of clostridium difficile in colon

-Step Four: Toxins A and B production leads to colon damage and possible creation of pseudomembrane

Symptoms

Symptoms

Note: you may be colonized with C. Diff., AND asymptomatic.

Mild to Moderate watery diarrhea (>=3 BMs in 24 hours)

Abdominal pain/cramping

Nausea

Fever

Loss of appetite

Pseudomembranous colitis is a potentially fatal complication

Median time between exposure and symptoms: 2-3 days

Risk of developing CDI after exposure ranges from 5-10 days and 10 weeks.

C difficile can cause more than abdominal discomfort The mild to severe diarrhea associated with C difficile infections can lead to dangerous electrolyte and fluid imbalances that can subsequently cause kidney dysfunction or failure. It can progress to pseudomembranous colitis, ileus, toxic megacolon, perforation and peritonitis. Surgical intervention to resect nonfunctional intestine and areas of fulminate infection may be necessary in cases of severe symptoms.

Risk Factors

-Exposure to antimicrobial/antibiotic agents (within 3 months)

-Exposure to healthcare (within 3 months)

-Previous infection with toxogenic strains of C. Diff.

-Age >64 years

-Underlying illness, immunosuppression, HIV/AIDS, Chemotherapy

-Enteral feedings

-GI surgery

-Exposure to any medications altering the intestinal flora

Detection

-Proper sampling and testing

-To sample correctly, sample should:

-Only be collected from watery stool

-Come from a symptomatic patient

-First be a stool sample, followed by a toxogenic culture assay

-Testing should occur within TWO HOURs of collection.

Prevention

Antimicrobial stewardship - poor prescribing practices put patients at risk. 30-50% of antibiotics prescribed in hospitals are unnecessary or incorrect. Prescribe and use antibiotics carefully.

• Once culture results are available, check whether the prescribed antibiotics are correct and    necessary.
• Order a C. difficile test if the patient has had three or more unformed stools within 24 hours.
• Isolate patients with C. difficile immediately.

-Optimizing environmental cleanliness - use contact precautions for patients with known or suspected c-diff infection.

-Private rooms if available. If not, can place c-diff patients together in one room

-Use gloves and gowns when entering rooms and during patient care

-Alcohol-based hand sanitizers do NOT kill the spores. Must use soap and water. Even in using soap and water, the removal of clostridium difficile spores is more challenging than the removal or inactivation of other common pathogens.

-Preventing contamination of the hands via glove use remains the cornerstone for preventing Clostridium difficile transmission via the hands of healthcare workers; any theoretical benefit from instituting soap and water must be balanced against the potential for decreased compliance resulting from a more complex hand hygiene routine.

-Dedicate or perform cleaning with bleach-based products of any shared medical equipment

ENTERIC CONTACT ISOLATION - Wear gloves and gowns when treating patients with C. difficile, even during short visits. Hand sanitizer does not kill C. difficile, and although hand washing works better, it still may not be sufficient alone, thus the importance of gloves.

-Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices. Use an EPA registered disinfectant with sporicidal claim for surface disinfection. Chlorine bleach may also be appropriately diluted and used. **Standard EPA-registered hospital disinfectants are not effective against c-diff spores

-Hand Hygiene

-NOT JUST FOR CLINICIANS! Visitors to patients should be strongly encouraged to follow the same hand washing procedures as healthcare workers!

-Sing the Happy Birthday Song for 30 seconds thoroughly rubbing and scrubbing each hand with warm, soapy water and thoroughly rinse after. Do not attempt to shut off faucet with bare hands. If capable, use a paper towel to shut off faucet, then dry hands. ("Wash Your Hands", 2013) 

 

• Educating patients and their loved ones on
• C.diff signs and symptoms
• prevention
• treatment
• proper hand hygiene
• Encouraging coworkers to adhere to PPE requirements and reporting those that break infection control protocol.

 

 

 

 

 

 

 

References:

Armstrong, G. D., Pillai, D. R., Louie, T. J., MacDonald, J. A., & Beck, P. L. (2013). A Potential New T

Bartlett, JG., Moon, N., Chang, TW., et al. (1978). Role of clostridium difficile in antibiotic -associated   pseudomembranous colitis. Gastroenterology. 75:778–782

Breacher, S. (2010). Tres difficile. Retrieved from http://www.in.gov/isdh/files/BRECHER_STEPHEN_-  _Indiana_Leadership_Conference.pptClinical Infectious Diseases. (2015). Retrieved from   http://cid.oxfordjournals.org/content/55/suppl_2/S65/F1.expansion.html

Dallal, RM., Harbrecht, BG., Boujoukas, AJ., et al.(2002). Fulminant clostridium difficile: an underappreciated and   increasing cause of death and complications. Ann Surg. 235:363–372.

Gerding, D., Muto, C., & Owens Jr., R. (2008). Clinical Infectious Diseases. Retrieved from   http://cid.oxfordjournals.org/content/46/Supplement_1/S43.full

Hall, I., O'Toole, E.(1935) Intestinal flora in newborn infants with a description of a new pathogenic anaerobe,   Bacillus difficilis. American Journal of Dis Child. 49:390.

Heinlen, L., & Ballard, J. D. (2010). Clostridium difficile Infection. The American Journal of the Medical Sciences, 340(3), 247–252. doi:10.1097/MAJ.0b013e3181e939d8

George, WL., Sutter, VL., Goldstein, EJ. et al. (1978). Aetiology of antimicrobial - agent associated colitis.   Lancet. 1:802–803.

Healthcare associated infections (HAI). (2015). Retrieved from   http://www.cdc.gov/hai/pdfs/stateplans/factsheets/fl.pdf

Ibrahim, S. (2011). Clostridium Difficile. Retrieved from   http://www.dhhr.wv.gov/oeps/disease/.../C_diff-review_Sherif.ppt

Johnson, S., Adelmann, A., Clabots, CR., et al.(1989). Recurrences of clostridium difficile diarrhea not caused by the   original infecting organism. Journal of Infectious Diseases. 159:340–343

Kelly ,CP. LaMont, JT. (2008). Clostridium difficile - more difficult than ever. New England Journal of   Medicine.   359:1932–1940.

Kyne, L., Hamel, MB., Polavaram, R., et al.(2002). Health care costs and mortality associated with   nosocomial diarrhea due to Clostridium difficile. Clinical Infectious Diseases. 34:346–353.

Lessa, F., & Et al. (2015). Burden of Clostridium difficile Infection in the United States — NEJM.   Retrieved from   http://www.nejm.org/doi/full/10.1056/NEJMoa1408913#t=articleResults

McDonald, LC., Owings, M., Jernigan, DB.(2006). Clostridium difficile infection in patients discharged   from US short - stay hospitals. Emergent Infectious Diseases. 12:409–415

Pepin, J., Valiquette, L., Cossette, B.(2005). Mortality attributable to nosocomial clostridium difficile - associated disease during an epidemic caused by a hypervirulent strain in Quebec. Candian Medical Association Journal. 173:1037–1042

Rupnik, M., Wilcox, MH., Gerding, DN. (2009). Clostridium difficile infection: new developments in   epidemiology and pathogenesis. Nature Reviews Microbiology.7:526–536.

Tiso, S. (2012). Lessons learned: clostridium difficile. Retrieved from   http://practicingclinicians.com/dailypost/Infectious-Diseases

Tool for Managing Clostridium difficile Infection.(n.d.). Journal Of Infectious Diseases, 207(10), 1484-1486.

Wash Your Hands. (2013). Retrieved from http://www.cdc.gov/features/handwashing/