Clostridium Difficile Infection (CDI) is the most common healthcare-associated infection, causing half a million infections and an estimated 29,000 deaths. Protect yourself and your family.
Risk Factors for CDI
Most cases of C. diff occur when you’ve been taking antibiotics.
There are other risk factors: • Being 65 or older • Recent hospitalizations • A weakened immune system • Previous infection with C. diff or known exposure to the germs.
Symptoms of CDI
Symptoms can vary depending on the degree of inflammation in the colon, ranging from mildly loose stools to over twenty episodes of diarrhea per day. Abdominal pain and fever may also manifest.
In severe instances, a C. difficile infection can lead to potentially life-threatening complications such as dehydration due to excessive fluid loss from diarrhea, low blood pressure, toxic megacolon (markedly distended colon requiring surgical intervention), and colon perforation.
Precautions
Healthcare professionals, including nurses and doctors, need to strictly adhere to isolation protocols to prevent the spread of this infection. These protocols involve contact and enteric precautions:
- Hand Hygiene: Healthcare providers and visitors should thoroughly wash their hands with soap and water before and after entering a patient's room, using the restroom, or moving between patients. Handwashing with soap and water is preferred over hand sanitizer for effectiveness.
- Personal Protective Equipment: Healthcare workers and visitors should wear disposable gowns and gloves when interacting with infected patients. Gloves are necessary when handling potentially contaminated materials, while gowns should be worn if there's a risk of fecal soiling. Proper removal of gowns and gloves followed by hand hygiene is crucial before leaving the patient's room.
- Room Placement: Ideally, patients with C. difficile should be isolated in private rooms with dedicated bathrooms. If private rooms are unavailable, patients can be grouped based on their C. difficile status.
- Environmental Cleaning: All surfaces in healthcare settings should be thoroughly disinfected using chlorine bleach products since C. difficile spores can survive on surfaces even after standard cleaning.
Enhanced Barrier Precautions For Nursing Homes:
Enhanced Barrier Precautions (EBPs) involve using personal protective equipment (PPE) to minimize the transmission of multidrug-resistant organisms (MDROs) in nursing home settings. EBPs are implemented during high-contact resident care activities and entail wearing gowns and gloves for residents known to be infected with or colonized by MDROs or those at a heightened risk of acquiring them. This includes residents with wounds, indwelling medical devices, central lines, urinary catheters, feeding tubes, tracheostomies, or ventilators.
MDRO transmission is common in skilled nursing facilities, and can lead to increased healthcare costs, as well as significant resident morbidity and mortality.
Sending Specimen for C Diff Testing
• Do NOT send stool for C. difficile testing without diarrhea (≥ 3 loose bowel movements in 24 hours).
• Do not send stool if there has been recent use of laxatives. Discontinue laxatives and consider testing if diarrhea continues beyond 48 hours and there is no alternative explanation for the diarrhea.
• Testing requires approval from the ID attending on-call.
• Do not send repeat specimens to document “test of cure.” The test can remain positive for weeks after treatment
• Do not repeat testing in patients who have undergone recent fecal microbiota transplantation (FMT) for the same reason (Fecal microbiota transplantation 0r FMT, commonly referred to as stool transplant, is a medical procedure wherein beneficial bacteria from a healthy donor are transferred to the colon of a recipient. The aim is to alter the microbial composition of the recipient's gut, offering potential health advantages. FMT is widely accepted as the preferred treatment for recurrent C. diff infections.)
Antibiotic Therapy for CDI
The Agency for Healthcare Research & Quality (AHRQ) has launched a fresh online initiative, the Safety Program for Enhancing Antibiotic Use, designed to enhance antibiotic usage across acute, long-term, and ambulatory care settings by strengthening antibiotic stewardship programs. The objective is to discontinue antibiotics whenever feasible. Antibiotic usage stands as the foremost risk element for CDI (Clostridioides difficile infection). Specifically, broad-spectrum antibiotics such as clindamycin eliminate a wide range of gut bacteria, many of which play crucial roles in human health.
C diff treatment is based on the severity of symptoms. Below are some treatment guidelines followed by hospitals as recommended by Infectious Disease (ID) doctors. Always follow your hospital policy.
|
Severity |
Clinical Manifestations |
Treatment |
|
Asymptomatic colonization |
Positive C. difficile test without diarrhea, ileus, or colitis |
No treatment necessary |
|
Non-severe |
Positive C. difficile test with diarrhea and no manifestations of severe disease |
Vancomycin 125 mg* every 6 hours PO/NGT for 10 days (pre-approved) |
|
Severe |
Positive C. difficile test with diarrhea and ≥ 1 of the following attributable to CDI · WBC ≥ 15,000 · Serum Cr > 1.5 mg/dL
|
Vancomycin 125 mg* every 6 hours PO/NGT for 10 days (10 days are pre-approved) Consider GI consultation for Fecal Microbiota Transplantation (FMT) in patients without improvement on 5 days of therapy |
|
Fulminant* |
Criteria as above with ≥ 1 of the following attributable to CDI · Hypotension · Toxic megacolon · Lactate ≥ 4 · ICU admission for severe disease
|
Vancomycin 500 mg PO/NGT every 6 hours AND Metronidazole 500 mg IV every 8 hours If unable to tolerate oral therapy can consider Vancomycin retention enema (500 mg in 100 mL Normal Saline every 6 hours) Please consult GI for Fecal Microbiota Transplantation (FMT) Please consult ID and Surgery |
(Note: There is a difference between infected and colonized by C Diff. Those who are infected are 'symptomatic". While those who are colonized are "asymptomatic" but still carry the organism in their system. Always observe handwashing and barrier precautions in both cases.)
Other treatment recommendations:
Avoid use of anti-motility agents in patients with CDI.
Avoid use of binding agents (e.g. cholestyramine) as they can bind oral vancomycin.
If patient is not improving on vancomycin, other causes should be evaluated and/or FMT considered. Fidaxomicin is not to be used as a rescue medication if patient is not improving on vancomycin.
Routine prophylactic use of metronidazole or oral vancomycin is not recommended. There may be specific situations where this is warranted and this should be discussed with ID.
Recurrent CDI
Defined as episode of symptom onset and positive assay result following an episode of positive assay result in previous 2-8 weeks
Resistance to either metronidazole or vancomycin has not been described.
Recurrence occurs in approximately 25% of patients and can be due to failure to eradicate spores or acquisition of a new strain. The risk for recurrence increases with every bout of CDI.
I hope you learned something from this article and please check out the references below for more information about CDI. Thank you.
Please watch the YouTube videos that covers this topic:
Clostridium Difficile Infection Lecture Part 1
Clostridium Difficile Infection Lecture Part 2
References:
https://apic.org/professional-practice/implementation-guides/
https://apic.org/resources/topic-specific-infection-prevention/clostridium-difficile/
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