Clostridium difficile

Clostridium difficile

General Information

Clostridium difficile [klo–strid–ee–um  dif–uh–seel] (C. difficile) is the most common cause of healthcare-associated diarrhea. It is a spore-forming, Gram-positive anaerobic (does not grow in the presence of oxygen) bacillus that produces two exotoxins: toxin A and toxin B. It causes inflammation of the colon, known as colitis. People who have other illnesses or conditions requiring prolonged use of antibiotics and the elderly are at greater risk of acquiring this disease. The bacteria are found in the feces. People can become infected if they touch items or surfaces that are contaminated with feces and then touch their mouth or mucous membranes. C. difficile infections (CDI) can cause pseudomembranous colitis (PMC), toxic megacolon, perforations of the colon, sepsis, and death. 

Significance

  • U.S. hospitals treat 165,000 cases of hospital-acquired, hospital-onset C. difficile per year, which add $1.3 billion in excess costs and cause 9,000 deaths.
  • In terms of hospital-acquired, post-discharge C. difficile (up to four weeks), there are 50,000 cases annually leading to 3,000 deaths.
  • In nursing homes, there are 263,000 cases of C. difficile per year, associated with $2.2 billion in excess costs and 16,500 deaths per year. Source: CDC

Symptoms

Symptoms include watery diarrhea (at least three bowel movements per day for two or more days), fever, loss of appetite, nausea, abdominal pain/tenderness.

Transmission

C. difficile is shed in feces. Most patients remain asymptomatic after infection. Normally this pathogen has complicated nutritional requirements (fastidious) in its vegetative state. It can form spores when growth conditions are unfavorable, which enables the pathogen to persist in the environment for extended periods of time (e.g., in soil and on dry surfaces).Any surface, device, or material (e.g., toilets, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the C. difficile spores.  Environmental surfaces may serve as a source of infection for patients. It was shown that direct exposure to contaminated patient-care items (e.g., rectal thermometers) and high-touch surfaces in patients’ bathrooms (e.g., light switch) have been implicated as a source of infection. Spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. Risk factors for acquiring infection include exposure to antibiotics, gastrointestinal procedures and surgery, and advanced age.

Treatment

In about 20% of patients, CDI will resolve within 2-3 days of discontinuing the antibiotic to which the patient was previously exposed. The infection can usually be treated with an appropriate course (about 10 days) of antibiotics, including metronidazole, vancomycin (administered orally), or recently approved fidaxomicin. After treatment, repeat C. difficile testing is not recommended if the patients’ symptoms have resolved, as patients may remain colonized.

 

Guidelines and Recommendations

SHEA-IDSA Guidelines (2010)

CDC (2003)

B.  Environmental Cleaning and Disinfection

Recommendations

19.  Identification and removal of environmental sources of C. difficile, including replacement of electronic rectal thermometers with disposables, can reduce the incidence of CDI (B-II).

20.  Use chlorine-containing cleaning agents or other sporicidal agents to address environmental contamination in areas associated with increased rates of CDI (B-II).

21.  Routine environmental screening for C. difficile is not recommended (C-III).

 

Source:  Cohen et al. Clinical Practice Guidelines for Clostridium difficile. Infection control and hospital epidemiology may 2010, vol. 31, no. 5

 

VI. Special Pathogens

G. Because no EPA-registered products is specific for inactivating C. difficile spores, use hypochlorite-based products for  disinfection of environmental surfaces in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of C. difficile. (Category II)

H. No recommendation is offered regarding the use of specific EPA-registered hospital

Disinfectants with respect to environmental control of C. difficile. (Unresolved issue)

 

Source: CDC. Sehulster L, Chinn RYW. Guidelines for environmental infection control in healthcare facilities. MMWR 2003;52(RR10);1–42.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

General Prevention Guidelines

Measures for Healthcare Workers, Patients, and Visitors

  • Healthcare workers and visitors must use gloves and gowns on entry to a room.
  • Emphasize compliance with the practice of hand hygiene.
  • In a setting in which there is an outbreak or an increased rate, instruct visitors and healthcare workers to wash hands with soap and water after caring for or contacting patients.
  • Accommodate patients in a private room with contact precautions. If single rooms are not available, cohort patients, providing a dedicated commode for each patient.
  • Maintain contact precautions for the duration of diarrhea.

Cleaning and Disinfection:

Proper cleaning and disinfection are critical in reducing the risk of C. difficile transmission.

It is recommended to use a sporicidal agent to address environmental contamination in areas associated with increased rates of CDI or in outbreak situations.

Recent studies demonstrated that increasing the frequency of patient room cleaning and disinfection significantly impacted C. difficile rates.

Important Studies:

  1. 1) Kundrapu et al. Daily Disinfection of High-Touch Surfaces in Isolation Rooms to Reduce Contamination of Healthcare Workers’ Hands.  Infect Control Hosp Epidemiol 2012;33(10):1039-1042.
  • Study Conclusion: In a randomized nonblinded trial, we demonstrated that daily disinfection of high-touch surfaces in rooms of patients with Clostridium difficile infection and methicillin-resistant Staphylococcus aureus colonization reduced acquisition of the pathogens on hands after contacting high-touch surfaces and reduced contamination of hands of healthcare workers caring for the patients.
  • 2) Orenstein et al.  A Targeted Strategy to Wipe Out Clostridium difficile. Infect Control Hosp Epidemiol 2012: 32(11): 1137-1139.
    • Study Conclusion: This study evaluated daily cleaning with germicidal bleach wipes on wards with a high incidence of hospital-acquired Clostridium difficile infection (CDI). The intervention reduced hospital-acquired CDI incidence by 85%, from 24.2 to 3.6 cases per 10,000 patient-days, and prolonged the median time between hospital-acquired CDI cases from 8 to 80 days.

    Table 1. HICPAC Categorization Scheme for Recommendations

    Category IA

    A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms.

    Category IB

    A strong recommendation supported by low-quality evidence suggesting net clinical benefits or harms, or an accepted practice (e.g., aseptic technique) supported by low to very low-quality evidence.

    Category IC

    A strong recommendation required by state or federal regulation.

    Category II

    A weak recommendation supported by any quality evidence suggesting a tradeoff between clinical benefits and harms.

    Recommendation for further research

    An unresolved issue for which there is low to very low-quality evidence with uncertain trade-offs between benefits and harms.

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

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