Clostridium Dificile - Essay Example

 Clostridium dificile Clostridium dificile has been a known cause of healthcare associated (nosocomial) diarrhea for about 30 years. It can be acquired in both hospital and community settings. C.difficile exists in the environment and colonizes a small percentage of people without causing any symptoms. C.difficile produces spores that are resistant to destruction by many environmental influences, including a number of chemicals. Spread of C.difficile occurs due to inadequate hand hygiene and environmental cleaning; therefore, proper control is achieved though consistent hand hygiene and thorough cleaning of the patient environment. Based on these rationales, Clostridium dificile is an emerging public health issue especially in European countries. Appropriate diagnosis of C.difficile can be a challenge because an asymptomatic patient may be colonized with the bacteria, while patients who have been successfully treated may still have detectable toxin or organism in their stools. Therefore, to address concerns regarding increased occurrence and severity of C.difficile infections, a working group of clinicians, infection control nurses, laboratory technologists and public health professionals must develop a rationale for surveillance, a case definition, recommendations for rapid kit testing, infection control guidelines and treatment recommendations. The only routinely available mortality statistics on Clostridium difficile are those associated with enterocolitis, the most common illness caused by Clostridium difficile infection. In 2003, there were 1,748 deaths due to enterocolitis out of which 934 had Clostridium difficile as an underlying cause (ICD-10, Office for National Statistics) .Complete information on the number of patients with Clostridium difficile infections in the last five years are not available but reports made under the Health Protection Agency's voluntary reporting scheme (England, Wales and Northern Ireland) show a prevalence of 35,537 and 43,672 in 2003 and 2004 respectively. According to the Case definition a person is diagnosed with C.difficile on the basis of: 1. Acute onset of loose stools (more than three within a 24-hour period) for two days without another etiology (loose stool is defined as that which takes the shape of the container that holds it); and 2. Laboratory confirmation (positive toxin assay or culture with evidence of toxin production); or 3. Diagnosis of typical pseudomembranes on sigmoidoscopy or colonoscopy; or 4. Diagnosis of toxic megacolon. A case of C.difficile is defined as nosocomial if: 1. Symptoms occur at least three or more days after admission; or 2. Symptoms cause admission or re-admission of a patient who was discharged from a health care facility within one month prior to the current admission date. A case of recurrent C.difficile is defined as recurrence of diarrhea within eight weeks of the end of previous effective treatment for C.difficile infection. Clostridium difficile, or C. difficile (a gram-positive anaerobic bacterium), is considered a major causative agent of colitis (inflammation of the colon) and diarrhea that may occur following antibiotic intake (Pothoulakis, 2000). C. difficile infection represents one of the most common hospital (nosocomial) infections globally and is primarily contacted in hospitals and chronic care facilities following broad-spectrum antibiotic therapy). It is the most frequent cause of outbreaks of diarrhea in hospitalized patients. One of the main characteristics of C. difficile-associated colitis is severe inflammation in the colonic tissue (mucosa) associated with destruction of cells of the colon (colonocytes). In initial stages, this disease involves alteration in the constitution of beneficial bacteria found in the colon caused by antibiotic therapy. These alteration mechanisms result in colonization by C. difficile when this bacterium or its spores are present in the environment (especially hospitals and nursing homes). In contrast, individuals treated with antibiotics as outpatients have a much smaller risk of developing C. difficile infection. Laboratory studies show that when C. difficile colonize the gut, they release two potent toxins, toxin A and toxin B, which bind to certain receptors in the lining of the colon and ultimately cause diarrhea and inflammation of the large intestine, or colon (colitis). The laboratory diagnosis of C. difficile infection is indicated by the demonstration of C. difficile toxins in the stool of suspected patients which is done by cytotoxicity assay where the toxins can be easily observed in the microscope. This tissue culture assay is considered the gold standard because of its high sensitivity and specificity. Since there is no correlation between levels of C. difficile toxins in the stool and severity of the disease, the results are reported simply as "positive" or "negative." However, time is a limitation in performing this laboratory test since it requires 24 to 48 hours to read the results. In recent years, several rapid tests which do not even require specialized personnel have been developed (immuno-enzymatic assays) for the detection of C. difficile toxins in the stool. These tests are commercially available in the form of diagnostic kits. Although they are relatively less sensitive and demonstrate lower specificity compared to the laboratory tests, they are very useful in screening of patients and emergency situations where instantaneous intervention is critical. Clinical Features of C.difficile infection include a wide range of conditions that usually develop 4 to 9 days after the beginning of antibiotic intake. It should be noted, however, that some patients develop diarrhea after antibiotics are discontinued and this may lead to diagnostic confusion. Although nearly all antibiotics have been implicated with the disease, the commonest antibiotics associated with C. difficile infection are ampicillin, amoxicillin, cephalosporins, and clindamycin. The infection most commonly manifests as mild colitis, or simple diarrhea that is watery and contains mucus but not blood. Examination by sigmoidoscopy usually reveals normal colonic tissue. General symptoms are commonly absent and diarrhea usually stops when antibiotics are discontinued. C. difficile can also cause non-specific colitis quite reminiscent of other intestinal bacterial infections such as Shigella or Campylobacter. This is a more serious illness than simple antibiotic-associated diarrhea; patients experience watery diarrhea 10 to 20 times a day and lower, crampy abdominal pain which may be associated with low-grade fever, dehydration, and non-specific colitis. Pseudo membranous colitis is the hallmark of full-blown C. difficile-associated colitis. Sigmoidoscopic examination reveals the presence of characteristic plaque-like pseudo membranes, scattered over the colonic tissue. The presence of these plaques is a distinctive indicator of C. difficile infection in patients with diarrhea following antibiotic treatment. Endoscopic findings are useful in diagnosis of pseudo membranous colitis. The most serious manifestation of C. difficile infection is fulminant colitis (severe sudden inflammation of the colon) which is associated with very serious complications and may cause mortality in 3% of patients; mostly those who are elderly and debilitated from other diseases. Patients with this form of the disease experience severe lower abdominal pain, diarrhea, high fever with chills, and rapid heart beat. Prompt management of fulminant colitis is essential because of the high risk of morbidity and mortality presented by it. Surveillance rationale should include determination of the epidemiology of C.difficile cases , including age, sex, hospital/ward, location and predisposing factors (e.g., antibiotics, etc.); incidence trends over time; the attributable morbidity, mortality and cost of C.difficile infections; and provide awareness of the impact of C.difficile, leading to optimal policy, clinical management, infection control practices and research opportunities. Transmission Factors - An important feature of C. difficile-associated diarrhea and colitis is its high prevalence among hospitalized patients. Thus, C. difficile infection is affected mainly by the length of stay at a hospital, and may be associated in some elderly adults with chronic diarrhea, and occasionally other serious or potentially life-threatening consequences. One study demonstrated that 20% of patients admitted to a hospital for various reasons were either positive for C. difficile on admission or acquired the microorganism during hospitalization. . It is not clear what the prevalence of this infection is in asymptomatic patients in hospital settings; however, in at least one study, it has been found in 30 percent of adult patients who develop diarrhea during hospitalization while the remainders were asymptomatic carriers serving as a reservoir of C. difficile infection. While most cases appear to be related to the hospital setting, freestanding hospital-like settings where antibiotics are used may also be important. Community-acquired infection and disease in healthy, ambulatory populations is uncommon. Thus, it is a particularly common cause of health care-associated diarrhea that occurs after 72 hours of hospitalization. The organism and its spores were also demonstrated in the hospital environment, including toilets, telephones, stethoscopes, and hands of healthcare personnel. While patient-to-patient spread and environmental contamination can contribute to cross-infection in C. difficile-associated diarrhea and colitis, antibiotic therapy is the major risk factor for this disease. Thus, restricting antibiotic use only when necessary is the most effective measure of preventing C. difficile infection. The use of multiple antimicrobial agents may put patients at a higher risk of developing disease due to C.difficile. Even short course antimicrobial therapy for indications, such as antimicrobial prophylaxis for surgery, can trigger antibiotic-associated colitis related to C.difficile. In addition, characteristics of C.difficile like virulence, antibiotic resistance, and use of proton pump inhibitors have recently been discussed as risk factors. The route of transmission is not entirely clear, but it is primarily linked to persons infected with the organism, environmental contamination including inanimate objects, and the carriage of the organism on the hands of those persons in contact with contaminated material, objects or environment. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with infected feces may serve as a reservoir for the spores. It is well documented that C. difficile may complicate the course of ulcerative colitis or Crohn's disease and it is responsible for 4 to 12% of diarrhea in AIDS patients. In this case, patients develop the typical symptoms of C. difficile colitis, including diarrhea, abdominal pain, and fever reminiscent of exacerbation of inflammatory bowel disease. The reason can be attributed to frequent hospitalizations and exposure to antibiotics of patients with inflammatory bowel disease or AIDS that places them at increased risk for the infection. Also, patients with compromised immune system , foe example those undergoing chemotherapy, immunosuppressant treatment and those suffering from immune disorders are at an increased risk to contact C.difficile infection. Therapy of C. difficile is directed against eradication of the microorganism from the colonic micro flora. In noncomplicated patients with mild diarrhea, no fever, and modest lower abdominal pain, discontinuation of antibiotics (if possible) is often enough to alleviate symptoms and stop diarrhea. When severe diarrhea is present and in cases of established colitis, the patients should receive the antibiotics, metronidazole or vancomycin, for 10 to 14 days. Approximately 15 to 20% of patients will experience re-appearance of diarrhea and other symptoms weeks or even months after initial therapy has been discontinued. In cases of relapse a repeat course of metronidazole or vancomycin for 10 to 14 days is usually successful. However, a subset of patients continues to relapse whenever antibiotics are discontinued and this represents a therapeutic challenge in which case, the patient may require surgical intervention. Asymptomatic carriers require no intervention. As noted, C.difficile is presumably transmitted by contact; the spores formed by this agent create a means of persistence in the environment from which continued transmission may occur. Principles of prevention and control needs to be focused on strategies that minimize or reduce the likelihood of surface (both patient and environment) contamination with C.difficile in either vegetative or spore form. In addition to Routine Practices (Standard Precautions), contact precautions should be initiated for any patient who is considered to be at risk for CDAD (C.difficile acquired disease) at the onset of symptoms and prior to receipt of C.difficile toxin testing results. Contact precautions may be initiated by the healthcare provider (e.g. physician, nurse) as soon as CDAD is suspected. If the patient is on antibiotic therapy, it should be discontinued at the onset of symptoms if the patient's condition permits (except metronidazole or vancomycin initiated as treatment for CDAD). Necessary contact precautions include: 1) Accommodation: All patients suspected of having CDAD should be placed in a isolated environment with dedicated toileting facilities (private bathroom or individual commode chair), wherever possible. Priority for accommodation should be given to patients with confirmed CDAD. If the patient is in a multi-bed room/unit, signs indicating the precautions to be used should be visibly displayed, a barrier supply cart and a laundry hamper should be easily accessible. 2) Contact Precautions: Signage indicating the precautions to be used should be posted on the door of any room of a suspected or confirmed CDAD patient or cohort of patients. Appropriate personal protective equipment (PPE), i.e. gloves and gown, must be donned by all persons prior to entering the room and discarded appropriately upon exit of the room. If an anteroom exists, it should be designated as either a clean or dirty area for donning or removal/disposal of PPE. For shared equipment, disinfection of all such equipment with hospital-grade disinfectant, approved for use with the equipment, must occur before use with another patient. The rectal route should not be used to record body temperature and all cases of CDAD should be reviewed at the time of diagnosis and regularly thereafter by Infection Prevention and Control to ensure that contact precautions are being used correctly. 3) Hand Hygiene: After removal and appropriate discarding of PPE (gloves and gown), hands should immediately be washed with soap and water for at least 15 seconds. The purpose of hand hygiene is to physically remove C.difficile spores through friction, lather and rinsing. Where sinks for hand washing are not available, alcohol-based waterless hand rub may be used on hands after glove removal; Hand hygiene should not be carried out at a patient sink as this will re-contaminate the healthcare worker's hands. 4)  Environmental Cleaning: All horizontal surfaces in the room and all items within reach of patients with suspected or confirmed CDAD should be cleaned daily with a hospital-grade disinfectant with particular attention to the cleaning of patient-specific items and high touch surfaces including bedside rails, telephone, call bells, light switches, door handles, faucets, etc. Terminal cleaning must occur when a CDAD patient is discharged from a room or upon resolution of CDAD symptoms. In patient-care areas where there is evidence of ongoing transmission of C.difficile, use of hypochlorite-based products for disinfection after the room is cleaned with hospital-grade disinfectant may be considered, in consultation with Infection Prevention and Control. Ensure clear communication with housekeeping/environmental services with respect to : i. Cleaning protocols for C.difficile. Consider developing a checklist for housekeeping/environmental services staff that can be posted on the back of signage that indicates precautions to be used. The checklist can also be posted in a housekeeping closet. ii. When C.difficile cleaning of a specific patient room/isolation area is required. 5)  Visitors: Visitors, including children, who are unable to understand and comply with contact precautions, should not be permitted to enter isolation rooms/areas and those who do should receive instruction from the patient’s nurse on the importance of hand hygiene and how to properly carry this out. If a visitor is providing care for the patient or having significant contact with the patient’s immediate environment, gloves and gown should be worn and instructions regarding correct use of personal protective equipment should be given by the nurse. Information sheets on proper hand hygiene and use of PPE may be helpful and visitors should be prohibited from using the patient’s bathroom or bed linen. 6)  Patient Transfer: Both transportation services and the receiving department must be notified that the patient is on contact precautions prior to transport and transfer of a patient with CDAD to another unit or facility must be accompanied by notice that the patient has CDAD. Infection Prevention and Control should also be notified prior to transfer of patients with CDAD, to enable appropriate accommodation, application of contact precautions and follow-up. 7) Patient Discharge: After discharge, patients with CDAD are not a concern for other family members, as person-to-person transmission within the home setting is rare. Good hand hygiene practices should always be exercised by the discharged patient and family members/staff. Educational tools for patients and family regarding proper hand hygiene should be considered. CONCLUSION: The pathophysiology of Clostridium difficile infections establishes the need for appropriate care and preventive strategies due to its contagious and potentially life threatening consequences. The target groups of patients in question are elderly, debilitated and immuncompromised inpatients who are highly susceptible to contacting infection. Since a nurse is the primary health care professional in the wards and in personal care of the patients, it becomes a professional responsibility to monitor the isolation, transfer and the surroundings of a patient along with the patient’s interaction with others as well as his or her own surroundings. REFERENCES Brooks, SE. “Reduction in the Incidence of Clostridium difficile-associated Diarrhea in an Acute Care Hospital and a Skilled Nursing Facility Following Replacement of Electronic Thermometers with Single-use Disposables,” Infection Control and Hospital Epidemiology 13:98-103; 1992. 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