C. diff Infections

The Latest on C. difficile Infections

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George T. is a 68-year-old man who comes into your office with a bad cough that turns out to be pneumonia. You prescribe antibiotics according to protocol. One month later, he returns for a routine office visit and blood work. Two days after his visit, he develops severe diarrhea. You suspect that he might have a C. difficile infection initiated by his recent course of antibiotics, but he hasn’t been in the hospital, so what’s the source?

According to a new Vital Signs report[1] from the Centers for Disease Control and Prevention (CDC), Clostridium difficile (C. diff) infection (CDI) is a safety concern in all types of medical facilities, not just hospitals. C. diff  is a bacterium that attacks the gut and causes severe diarrhea, weight loss, and other intestinal diseases after protective bacteria in the gut flora have been wiped out by antibiotics. To make the problem even more pervasive, C. diff can spread from person to person on contaminated equipment, examination tables, lab coats, and on the hands of healthcare workers and visitors. This is likely what happened to George when your nursing assistant forgot to put on gloves as she drew George’s blood after treating a patient with C. diff.

Unlike other healthcare-associated infections, the incidence and mortality associated with CDI have climbed to historic highs over the past decade—only recently leveling off. CDI is linked to about 14,000 U.S. deaths every year.[1] Those most at risk are people who take antibiotics and also receive care in any medical setting. Almost half of infections occur in people younger than 65 years, but more than 90% of deaths occur in people 65 and older.

Previously released estimates suggest that the number of U.S. hospital stays related to CDI adds at least $1 billion in extra costs to the healthcare system. However, hospitals represent only one source of the infection. The Vital Signs report suggests that while 94% of CDI cases are related to medical care, only 25% of patients with CDI infections are first symptomatic in the hospital. In fact, most infected patients are initially exposed to C. diff  while living in a nursing home or while being treated at a medical office or clinic. According to the CDC, half of C. diff  infections diagnosed within hospitals were already present at the time of admission, usually after getting care in other facilities. The other half were related to care given in the hospital where the infection was diagnosed.

So what can you do? Well, hand washing—a cheap and easy way to prevent many healthcare-related infections—“may not be sufficient,” according to the CDC. However, hand washing is still superior to hand sterilizers, because proper hand-washing techniques should include vigorous scrubbing and rinsing—which may help remove bacterial spores from the hands.[2]

But the report outlines other ways to slow the spread of C. diff:

  • Prescribe and use antibiotics carefully. About 50% of all antibiotics given are not needed, unnecessarily raising the risk of CDI.
    • Test for C. diff  when patients have diarrhea while on antibiotics or within several months of taking them. Once culture results are available, check whether the prescribed antibiotics are correct and necessary.
    • Order a C. diff  test (preferably a nucleic acid test) if the patient has had three or more unformed stools within 24 hours.
    • Be aware of infection rates in your facility or practice, and follow infection control recommendations with every patient. This includes isolating patients who test positive for CDI and wearing gloves and gowns to treat them.
    • Isolate patients with C. diff  immediately.
  • Wear gloves and gowns when treating patients with C. diff, even during short visits. Hand sanitizer does not kill C. diff, and hand washing may not be sufficient.
  • Clean room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with C. diff  has been treated.
  • When a patient transfers, notify the new facility if the patient has a CDI.

There is high quality evidence for treating CDI with antibiotics such as metronidazole, vancomycin, or fidaxomicin. However, there continues to be controversy as to the role of probiotics—live bacteria and yeasts, believed to replenish nonpathogenic microorganisms to gastrointestinal (GI) flora that has become altered by antibiotic therapy. They are widely marketed to consumers in the form of capsules, powders, fermented milks, and yogurts. The bulk of the scientific evidence suggests that probiotics may be a useful adjunct to antibiotics in treating CDI and that Saccharomyces boulardii—a yeast probiotic—may prevent recurrences of CDI.[3] There are no data to suggest that probiotics are effective without antibiotics. Of note is that probiotics are not recommended in the 2010 SHEA/IDSA guidelines for treating C diff.[4]

When antibiotic treatment has not been successful, there is one more radical—but effective—therapy known as fecal bacteriotherapy.[5,6] The procedure involves the insertion of strained, diluted feces harvested from someone with a healthy gut into the sick person’s large intestine, in hopes of replacing the devastated colony of bacteria with a fresh, robust one. A recently published case series reported that among 70 adults with CDI who had already received up to 12 courses of antibiotics, 66 of them (94%) reported complete resolution of their symptoms three months after transplantation (94%).[7] Despite the ‘ick factor,’ and a lack of standardized protocol, the procedure is becoming more available throughout the United States as a treatment of last resort.

 

Jill Shuman, MS, ELS
Published March 28, 2012

 

References

  1. Making health care safer: stopping C. difficile infections. Centers for Disease Control and Prevention Website. http://www.cdc.gov/vitalsigns/HAI/index.html Updated March 6, 2012. Accessed  March 7, 2012.
  2. Oughton MT, Loo VG, Dendukuri N, et al. Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile. Infect Control Hosp Epidemiol. 2009:30(10):939-944.
  3. Pillai A, Nelson R. Probiotics for treatment of Clostridium difficile-associated colitis in adults.  Cochrane Database Syst Rev. 2008:(1):CD004611.
  4. Cohen SH, Gerding DN, Johnson S, et al.  Clinical practice guidelines for Clostridium difficile infection in adults:  2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431-455.
  5. Floch MH. Fecal bacteriotherapy, fecal transplant, and the microbiome. J Clin Gastroenterol. 2010;44(8):529-530.
  6. Butler M, Bliss D, Drekonja D, et al. Effectiveness of Early Diagnosis, Prevention, and Treatment of Clostridium difficile Infection. Rockville, MD: Agency for Healthcare Research and Quality; 2011. AHRQ Publication No. 11(12)-EHC051-EF.
  7. Mattila E, Uusitalo-Seppälä R, Wuorela M, et al.  Fecal transplantation, through colonoscopy, is effective therapy for recurrent clostridium difficile infection. Gastroenterology. 2012;142(3):490-496.