As a nurse working in acute medical ward for elderly, I work closely with patients with C. difficile infection. I have noticed the effect of C. difficile infection in elderly can be fatal.
C. difficile is a gram positive anaerobic bacillus. They colonise in the oxygen deficient areas of the body. That can cause life threatening conditions, including diarrhoea, colitis and septicaemia and resulting death. C. difficile infection can cause serious illness and a significant cause of patient morbidity and mortality. It is a major cause of hospital acquired diarrhoea. C. difficile infection can cause serious illness and hospital outbreaks .It can cause significant financial burden on NHS. It is estimated that the increased length of hospital stay itself can cause an excess of around £4,000 per patient. The number of death certificates mentioning C. difficile infection in England and Wales fell by 29% between 2007 and 2008 ,after increasing every year since records began in 1999(National Statistics,2008).
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According to Weston (2007), Clostridium difficile was first identified in 1935s, but until the late 1970s it was not identified as the cause of pseudo membranous colitis following antibiotic therapy. C. difficile infection is more common in elderly (over the age of 65). People who have a long stay in health care settings, those who have recently had gastrointestinal surgery and those who have a serious underlying illness that compromises their immune system are also at high risk to get C. difficile infection. In-patients are also at high risk if there are hospital outbreaks. Poor infection controls are also an important risk factor.
Antibiotics are considered as the most important cause for C. difficile infection. Any antibiotic can cause C. difficile infection, but Broad spectrum cephalosporins, broad spectrum penicillin and clindamycin are most frequently implicated. The second most commonly named antibiotic is Co amoxiclav (Health Protection Agency, 2008). The use of proton pump inhibitors such as lansoprazole, omeprazole and pantoprazole are also potential risk factor for C. difficile infection (Leonard et al., 2007). The disruption of normal harmless bacteria in the gut, because of antibiotic therapy also allows the C. difficile to multiply to greater number. The bacteria start to produce toxins. The antacids suppress the gastric acid secretion and as a result, C. difficile bacteria, including the spores are less likely destroyed. The reason for community associated C. difficile infection was unclear but it is become clear that the reasons for the majority of the infections are associated with antibiotic prescriptions or hospitalisation (Wilcox et al., 2008).
The transmission is through faecal-oral route. The infected patients acquire the organisms directly from other patients with diarrhoea. The route of transmission may be direct, via the hands of health care workers or via the hands of patients or via the environment. Asymptomatic people who are colonised with C. difficile are also can be able to transmit the disease. About 3% is the colonisation rate in healthy adults, but this increases to nearly 20 % in older people especially in chronic care wards. The spore form of C. difficile can survive in the environment for five months or more on hard surfaces. It is considered that the primary route of transmission of C. difficile infection via healthcare workers hand.
Clinical features and pathogenesis
The most important clinical feature is sudden onset of offensive smelling diarrhoea during a course of antibiotic or who had antibiotics with in the previous two months. Patients may pass soft or watery stool more than twice daily or in more severe cases more than 20 times accompanied by severe abdominal cramps (Weston, 2007). Abdominal distension, fever and dehydration may also be present in more severe cases. Unless C. difficile is diagnosed, the patients can be miss- diagnosed with irritable bowel syndrome. C. difficile infection is a major health problem worldwide that leads to increased morbidity and mortality. Healthy adults carry around 500 species of bacteria in the colon, 90% of which are harmless (Weston, 2007). C. difficile colitis results from the disruption of normal colonic flora and C. difficile colonises in the oxygen deficient areas of intestine. The spores are able to replicate and produce toxins that can lead to mucosal damage and inflammation. In a healthy adult the normal colonic flora inhibit the growth and colonisation by C. difficile. The antibiotic therapy may disrupt the normal flora and allow the C. difficile to colonise very rapidly. After colonisation the organism’s produces two protein exotoxins( Toxin A, an enterotoxin and Toxin B , a cytotoxin) in to the colonic lumen. These are responsible for diarrhoea and colitis. Toxin A binds to the receptors in the intestine and cause extensive tissue damage, inflammation and oedema. Both toxins posses cytotoxic activity against cultured cells by same mechanisms but they differ in cytotoxic potency, toxin B is generally 1000 times more potent than toxin A and to play a major role in activating inflammatory repose (Weston, 2007). Toxin B is more important than toxin A in the pathogenesis of C. difficile infection in man.
According to lab test reports there are 100 different types of c difficile stains. The most recognised epidemic types is ribotype 027.The most important feature of ribotype 027 is hypertoxin production, 10 to 20 times more toxin than other stains. The C. difficile infection caused by ribotype 027 are more likely to be severe with increased complications such as renal impairment, severe colonic dilatation and sepsis (Freeman et al., 2007).The clinical features include increased severity of illness, failure to respond to antibiotics ,abdominal distension. Raised CRP and rising WCC particularly in patients who may have appeared to respond to antibiotics and deterioration in condition and appears to have higher mortality rate.
Laboratory studies of stool sample will help to detect c difficile infection. Stool culture will help to detect the presence of difficile with toxin production. Stool enzyme immunoassay (ELISA)will detect both of the toxins ( A or B). For toxin B Stool cytotoxicity assay will be positive.Endoscopy may demonstrate ,but it is the least sensitive for diagnosing C. difficile as compared to stool assays., Sigmoidoscopy alone may not reveal any abnormality if the disease is confined to the right colon. Colonoscopy is more useful. Because of the risk of perforation Sigmoidoscopy and Colonoscopy is contraindicated in patients with colitis (Weston, 2007).
The treatment of C. difficile infection depends on the severity of the illness. At my work place, the patient is closely monitored and isolated. A stool chart is maintained using Bristol Stool Chart. All antibiotics that are not required are stopped. This will help the normal bacteria to thrive again in the gut. If any patient develops C. difficile infection at my work place, we conduct a thorough investigation for the causes and we notify the antibiotic management team to review the patient. The team will review the patient in the ward (rounds Wed/Fri.) or via the phone. There will be a root cause analysis to find why the patient developed C. difficile infection? In some patients fluid and electrolyte replacement and nutrition review may also be necessary. In mild cases of C. difficile infection, patients are monitored for 48 hrs before starting antibiotics. In severe cases, antibiotics may need to be administered immediately. Metronidazole and Vancomycin are the two preliminary antibiotics used in the treatment of the infection (Weston, 2007). Usually a 7 to 10 day of therapy is required. Oral metronidazole 400mgs eight hourly for seven to ten days is the first line of treatment. It is contraindicated in women who are pregnant or who are breast feeding. The most recognised side effects of the metronidazole are an unpleasant metallic taste, nausea, vomiting, diarrhoea, abdominal pain, headache, pruritus, rashes, dizziness and reversible neutropenia.
Vancomycin is known to cause the spread of vancomycin resistant bacteria. Vancomycin is used for severe, life threatening cases of C. difficile infection. It is also used for patients unable to tolerate metronidazole and failed treatment with metronidazole. Vancomycin is expensive. Oral vancomycin is not completely absorbed or metabolized in the gut and is excreted in the stool unchanged. This is ideal in the treatment of C. difficile infection. The recommended oral vancomycin doses for adults are either 125mg or 500mg four times daily. The use of a rectal vancomycin enema (500mg diluted in 1000ml of 0.9% sodium chloride injection) is also an alternative. A recurrence of symptomatic disease with re infection occurs in 5-20% cases. Management of repeated relapses is more difficult. The options include slow tapering of vancomycin or metronidazole over a period of six weeks and vancomycin combined with rifampicin for seven days. There are also case reports of successful treatments with intravenous immunoglobulin which contains antibodies to c difficile toxins. The studies shows oral administration of limited bacteria or yeast helps to reconstitute the gut flora and there is a potential to prevent infection.The ability of these organisms to colonize and also to prevent and treat the c.difficile is unclear. (Department Of Health, 2009). Surgery may be needed for small number of cases especially if C. difficile infection progress to fulminant colitis and perforation. Loperamide (anti diarrhoea drug) is contraindicated for C. difficile infection because this will slow down the clearing of toxic bacteria (Weston, 2007).
Prevention & Control
Preventing the spread of C. difficile can be challenging as hospitals tend to have an increasing population of elderly, debilitated and susceptible persons, which naturally increases the number susceptible hosts within the environment.
Isolation should be implemented in conjunction with the infection prevention and control measures to minimise the risk of spread to other vulnerable groups. Private room/side room is recommended, especially for patients who are fecally incontinent. Cohort symptomatic C. difficile associated disease patients only with other symptomatic C. difficile infected patients, to minimise environmental contamination. Patients with C. difficile infection may be moved to other rooms or bays when the diarrhoea ceases (no diarrhoea at least 48 hours) (Department Of Health, 2009 and Health Protection Agency, 2009).
Hand washing & Barrier nursing
Contact precautions should be used for C. difficile infected patients with diarrhoea. Proper hand washing is essential. Alcohol-based hand gels are not effective in reducing the spread of the organism and are not recommended. Disposable gloves and aprons should be worn when caring for the patients. It is recommended that not to share the equipments between the patients. It is a good practice to inform healthcare workers and visitors that a patient is on contact precautions, such as labelling the door of the room, without disturbing patient’s privacy. Last year we (My work place) spent £1,280.32 for soap, alcohol, gel and moisturiser.
The environment of a patient with C. difficile infection should be cleaned thoroughly at least twice per day. An approved hospital disinfectant-detergent should be used for all environmental cleaning. Terminal cleaning (stage cleaning) of ward area is essential after the discharge or transfer or death of a patient with C. difficile infection. (My ward)
Decontamination of equipment
Do not share equipments among patients to prevent cross infection. Commodes and bedpans are heavily contaminated with spores and are considered as vehicles of cross infection in C. difficile outbreaks. It is ideal that symptomatic patients have their own commodes or toilet facilities. Proper disinfection must be essential.
Transfer of Patients
Transfer of patients with C. difficile infection or disease to another ward, unit, or to the long term care facility must be informed prior to the transfer that the patient has C. difficile infection. Same notice must accompany transfer of patients with C. difficile infection to a long term care facility (Department Of Health, 2009). It is not necessary to have absence of diarrhoea or negative stool cultures before the transfer of a C. difficile patient to a long term care facility. On the patients discharge, we need to notify the primary care physician (My ward).
Since the outbreaks C. difficile in hospitals and long term care facilities, rectal thermometers are restricted to use. For the routine use Electronic tympanic thermometers are recommended (Department Of Health, 2009)
Ward should conduct training programmes to the health care staff. Ensure that patient / family information leaflets are given out.
Anti microbial management team
It is the responsibility of the hospital trust to develop anti microbial management team. That should consist of a consultant microbiologist, pharmacist and prescriber. The trust also needs to develop restrictive antibiotic guidelines. These guidelines specifically need to address to avoid the use of broad spectrum cephalosporin, broad spectrum penicillin and clindamycin especially in elderly and minimise the use of fluroquinolones, carbapenems,that we follow in my work place. It is also a good practice to have an infection control link nurse to each and every ward. It is their responsibility to do proper training for staffs and auditing the clinical area.
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Outbreaks of C. difficile infection in Long Term Care Facilities
An outbreak of C. difficile infection is defined as three or more cases of symptomatic C. difficile infection mainly in the same area of the hospital ward within a period of seven days. Infected patients should be placed in isolation room or cohorted. Patient(s) can be removed from precautions if there is no diarrhoea .There is no need to wait for negative stool culture to remove the patent from precautions. An education program regarding C. difficile infection and its transmission and prevention should be conducted to all health care workers. Need to highlight the use of gloves and aprons and moreover proper hand washing. The health care facility need to monitor for any significant episodes of C. difficile infection, and then need to liaise with local health department for further assistance (Walker K et al., 1993).
Conducting education programmes and workshops for health care workers and public to increase the awareness of C. difficile infection can contribute a major role in reducing the number of C. difficile infection cases within the healthcare system. Need special attention to personal hygiene. The primary route transmission is via the hands of healthcare workers and other patients and residents. It is very important to perform proper hand washing and barrier nursing (gloves, gowns). Environmental hygiene is also very important factor in controlling C. difficile infection. Regular and proper cleaning of patient rooms with anti bacterial cleaning agents is essential as C. difficile toxins can stay in the environment for several months.
Changing the way doctors prescribe antibiotic therapy is also an important strategy in control the C. difficile infection. Because C. difficile infection is always associated with the use of antibiotics, It is also recommended to have an antimicrobial management team for each hospital (Department Of Health, 2009).
In cases of recurrent C. difficile infection experts agree that the non antibiotic treatment have a positive impact. The use of toxin binders neutralises the effect of toxin producing stains and to helps the intestinal flora to restore .Tolevamer, developed by Genzyme Corporation is the first non antibiotic treatment approved for C. difficile infection (www.mediscape.com).
Mandatory surveillance of C. difficile infection in the United Kingdom
When looking at surveillance reports, many of the hospitals in the UK have been affected with outbreaks of C. difficile. We can see that the large increase in the number is between 2000 and 2007.It is the responsibility of the hospitals in the UK has to measure and report to the Department of Health. The surveillance should include the number of positive cases, number of severe infections, the number of required surgery cases and number of deaths.
The surveillance of C. difficile infection is taking to get a target for 30% reduction from 2007/2008 numbers by 2010/2011. In 2007-2008, there were 55,498 cases reported across England. In 2008-2009, the cases reported dropped to 36,095. i.e., cases dropped by 35%. Last year our target (My hospital and my community) was 180. The number of cases reported was 171, 98 of which are from hospital (7 cases from my ward).This year, the target is 155.
Social, economic and political issues.
C. difficile infection is expensive to the NHS. The total identifiable increased cost of C. difficile infection causes an excess of £4000 per case. Such high costs can be used to justify expenditure on personnel and/or other control measures to reduce the incidence of this hospital-acquired infection. There are notable outbreaks of c. difficile infection worldwide since 2003.Outbreaks was reported in Montreal, Quebec and Calgary, Alberta, in Canada. Approximately 1400 cases affected, death count 36 – 89.A similar outbreak reported at Stoke Mandeville Hospital in the United Kingdom between 2003 and 2005, in which 33 patients died. In 2007 Maidstone and Tunbridge Wells NHS Trust was heavily criticized by the Commission, have heightened media and made public awareness. In 2009, four deaths reported at Our Lady of Lourdes Hospital in Ireland also thought to have links to Clostridium difficile infection. The prevention and control of C. difficile infection in health care settings is become a global public health challenge.(Health Protection Agency 2009)
C. difficile infection is a major problem in hospitals that is associated with the use of antibiotics. C. difficile infection also recognised as one of the major health care associated infection. It is estimated that C. difficile infection affects between 40000-60000 people in the UK every year. The prevention and control of C. difficile infection is very important.
The three main elements of prevention are:
Need to restricted use of antibiotics;
Strict isolation precautions and barrier nursing when looking after patients with diarrhoea and
Through cleaning of clinical areas.
Poor hand washing is known to play a key role in the spread of infection. Hand washing facilities in the hospitals such as the number of hand washing sinks and their position, and type of taps are also need to be inspected. Hand washing protocols is low in many hospitals. C. difficile infection needs treatment only if it is symptomatic. Most of the people make full recovery and in rare cases the infection can be fatal. Infection control teams need to develop education programmes to improve compliance and regular auditing. It is everybody’s business to participate to prevent and control C. difficile infection with in the health care system. The health care workers need to follow the hospital infection control policy.
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