Clostridium difficile

Presented byNate Smith, MD, MPHCarole Yeung, RN CIC

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Outline

• Epidemiology

• Treatment

• Prevention

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What is Clostridium difficile?

• Anaerobic spore-forming bacillus• Present in the soil and environment• Produces two toxins – Toxins A and B• Common cause of antibiotic associated diarrhea

(AAD). 15 – 25 % all episodes of AAD• Health care settings are major reservoirs• 20 – 40% hospital patients colonized• 4 – 20% LTCF residents colonized

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What are C. difficile-associated diseases (CDAD)

• Pseudomembranous colitis (PMC)

• Toxic megacolon

• Perforations of the colon

• Sepsis

• Death (rarely) but increasing!

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CDAD-related deaths - Arkansas

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DE

AT

HS

1999 2000 2001 2002 2003 2004 2005*

*2005 data incomplete

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Symptoms of CDAD

• Watery diarrhea• Fever• Loss of appetite• Abdominal pain• Nausea and vomiting• Severe cases: increase WBC and/or creatinine • Can occur up to 8 weeks after antimicrobial

therapy

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Which patients are at increased risk for CDAD?

• Antibiotic exposure – clindamycin, penicillins, cephalosporins, floroquinolones

• Gastrointestinal surgery

• Length of stay in healthcare settings

• A serious underlying illness

• Immunocompromising conditions

• Advanced age

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C. difficile colonization

• Patient exhibits no clinical symptoms

• Patient tests positive for C. difficile organism and/or its toxin

• More common than CDAD

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C. difficile disease (CDAD)

• Patient exhibits clinical symptoms

• Patient tests positive for C. difficile organism and/or its toxin

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Laboratory Tests for CDAD

• Stool culture

• Antigen detection

• Toxin testing

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C. difficile Transmission

• C. difficile spores are shed in feces

• Any surface, device or material that becomes contaminated with feces may serve as a reservoir

• Transferred by hands of healthcare personnel

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Treatment

• Discontinue antibiotics if feasible

• Metronidazole orally for 10 days

• Vancomycin orally

• Relapses are common

• Repeat testing NOT recommended

• NO antiperistalic agents

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Infection Control Preventive Methods

• Use antibiotics judiciously

• Early diagnosis

• Contact precautions for patients with CDAD

• Hand hygiene

• Environmental cleaning and disinfection

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Contact Precautions

• Private room or cohort

• Gloves

• Gowns

• Dedicated patient care equipment

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Hand Hygiene

Soap and water for at least 15 seconds:

• Wet hands under running water

• Apply soap

• Good friction rub for 15 seconds

• Rinse hands

• Dry well with paper towel

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Cleaning and Disinfection

• Clean/disinfect environmental surfaces and reusable items

• Hospital disinfectant

• 1:10 bleach

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Discontinuing Precautions

• NO diarrhea. NO precautions!

• Repeat testing NOT recommended

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Transfer of Patients

• Notify receiving facility if patient has a history of C. difficile

• Observe for recurrence

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References

• SHEA Position Paper CDAD, ICHE 1995

• SHEA Position Paper C. difficile in LTCF for the elderly, ICHE 2002

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QUESTIONS?