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Clostridium difficile in community settings

Key learning points:

 - The nature of Clostridium difficile bacteria

 - Symptoms and management of the infection 

 - How healthcare professionals can reduce and prevent infection in the community

Clostridium difficile (C.difficile) is a Gram positive, spore-forming anaerobic bacillus (see Figure 1) and is the most common cause of infectious healthcare-associated diarrhoea.1 Moreover, it is a major cause of morbidity and mortality among patients receiving care in both hospital and community settings. 

Some healthy adults and babies are known to have small numbers of C.difficile bacteria living in their gut which are generally harmless as toxins are not being produced. C.difficile infection (CDI) occurs when powerful toxic spores are produced. These spores are able to survive in the environment for extended periods of time if they are not removed by effective decontamination. However, this also presents significant problems as these spores are resistant to cleaning with detergent and other decontamination processes.2

Patients with CDI usually present with foul-smelling, watery diarrhoea. Some may also experience abdominal pain, fever, nausea and vomiting. In severe cases, pseudomembranous colitis and toxic megacolon can occur which can ultimately result in death.3 

Unfortunately, many patients are known to have repeated CDIs. Such recurrences are usually either due to relapse or re-infection. Relapse can occurs by germination of residual C.difficile spores which have not been killed and remain in the colon after treatment. Patients can also remain susceptible to infection after treatment (see at risk groups) and can become re-infected with a different strain.4 This can have a significant effect on community settings as patients are often discharged from hospital following treatment, then go on to relapse later. Consequently there is an urgent need to appraise the impact of CDI in the community, and the multidisciplinary team must be aware of the potential consequence if CDI is not recognised and treated in a timely manner. 5

Causes of CDI

There are a number of reasons why CDI occurs. The use of antimicrobial agents is the main causative factor. If a person is taking antibiotics for a specific infection such as a wound infection, these antibiotics have the ability to kill many of the harmless bacteria that live in the gut. As C.difficile cannot be eradicated by all antibiotics and the normal flora that would normally prevent infection has been altered, this therefore may allow the C.difficile bacteria to multiply and subsequently cause infection. The risk of infection can also increase depending on the duration and dose of the antibiotic.6 

Additionally, the prolonged use of proton-pump inhibitors (PPIs) can be a predisposing factor for infection. PPIs are prescribed drugs which target the cells that line the stomach to reduce the production of acid. They are commonly used to treat stomach and duodenum ulcers. However, evidence suggests that this reduction of gastric acid secretion allows C.difficile to be ingested and prevent being destroyed by the acidic gastric pool.7 

CDI can also be spread from person to person by poor infection prevention and control practice, such as inadequate hand hygiene and cleaning and disinfection practices, and inadequate and/or inappropriate use of personal protective equipment.8 

Finally, some studies have shown that C.difficile had been found in food and animals in the United States, Canada and Europe. Such evidence has now raised questions about CDI being a zoonotic potential with regards to possible foodborne transmission to humans through the consumption of contaminated products.9 To date however, there is no direct evidence to prove such transmission.

At-risk groups

There are a range of groups who are at risk of acquiring CDI, which provides an indication as to why CDI can be problematic in community healthcare settings. These include:

 - Elderly patients in healthcare facilities, especially hospitals, long-term care facilities and ambulatory.

 - Individuals who are currently taking, or have recently taken antimicrobial agents.

 - Individuals who are currently taking, or have recently taken proton-pump inhibitors.

 - Individuals who have had recent hospital stays.

 - Individuals who are immuno-compromised.

 - Individuals with general poor physical health or have chronic diseases.6

However, over recent years, exploration into the changing epidemiology of CDI has also found increasing cases of the more unusual host groups in the community including healthy, non-institutionalised individuals, younger people, pregnant women and those who do appear to have been exposed to antimicrobial agents.10 

Preventing the spread of CDI 

C.difficile must be monitored closely so that early detection of individual cases and outbreaks can be achieved thus aiding timely treatment and implementation of infection prevention and control measures. Healthcare professionals should also liase closely with their infection prevention and control team to gain advice and guidance about control and prevention.

Staff must ensure correct hand washing is undertaken according to the World Health Organisation's 'five moments', paying particular attention to moments three (after body fluid exposure risk) and five (after touching patient surroundings) - see Box 1. Alcohol hand rub should not be used when dealing with CDI as it is unlikely to destroy spores.11

Due to the nature of some community healthcare settings, single rooms may not always be available. However, when possible, patients who have CDI should be isolated in a single room with en-suite facilities or be provided with an allocated commode. They should remain there until they are at least 48 hours symptom-free and their bowel movements have returned to the patient's normal pattern.8 If no single rooms are available, risk assessment should identify an alternative appropriate patient placement. If there are other patients with CDI, cohorting is advised. It must be noted however, cohorting may increase the risk of patients becoming re-infected with another strain.

The patient's immediate environment should be cleaned regularly according to local policy. Additionally, any patient care equipment should be single use whenever possible. All other equipment should be cleaned in accordance with manufacturer's guidance and local policy.6 

Personal protective equipment (PPE), namely gloves and aprons, must be used during direct patient care. PPE must be removed immediately following use and hands must be washed using the correct technique.8

Visitors and patients must be provided with adequate and appropriate information about the infection and ensure they understand their role in preventing the spread of infection, with a clear focus on good hand hygiene practice. It is advocated that multiple forms of information and communication methods are used for this purpose such as printed leaflets, face-to-face discussions and hands-on demonstrations.12 

Treatment of CDI

In the first instance, if feasible, discontinuing the offending antimicrobial agent should be undertaken. An important reminder is that the correct use of antimicrobial agents is the single most important factor to prevent the acquisition of CDI and antimicrobial stewardship guidance must be adhered to at all times.8 Additionally, proton pump inhibitors should only be used if there is a clear indication to do so.

Oral metronidazole or vancomycin (with or without metronidazole) are currently used to treat CDI. Due to the current evidence of increasing numbers of vancomycin-resistant bacteria in the intestinal microflora, metronidazole is recommended as a first choice.8 Patients in community settings may require hospitalisation for severe infection.

Finally, more recently, due to the high recurrence rate of CDI, alternative therapies have been investigated over the years. One main therapy is faecal microbial transplantation, otherwise referred to as a faecal transplant.13 Evidence has indicated that faecal transplantation is an effective and safe treatment and could be considered for patients with recurrent CDI.14 

Conclusion

CDI is one of the most common healthcare-associated infections and can have a major impact on patient safety in both acute and community settings. Due to the virulence and changing epidemiology of this infection, it is vital that healthcare professionals understand and recognise risk factors to allow for quick detection and reporting and the implementation of preventative and control measures. 

 

References

1. Madeo M, Owen E, Baruah J. Management of Clostridium difficile infection: using small scale audit to indicate the knowledge of nursing and medical staff in an acute hospital setting. Journal of Infection Prevention 2008;12:12-17.

2. Doan L, Forrest H, Fakis A, Craig J, Claxton L, Khare M. Clinical and cost effectiveness of eight disinfection methods for terminal disinfection of hospital isolation rooms contaminate with Clostridium difficile 027. Journal of Hospital Infection 2012;82:114-121.

3. Wiegand PN, Nathwani D, Wilcox MH, Stephens J, Shelbaya A, Haider S. Clinical and economic burden of Clostridium difficile infection in Europe: a systematic review of healthcare-facility acquired infection. Journal of Hospital Infection 2012;81:1-14.

4. Islam J, Cheek E, Navani V, Rajkumar C, Cohen J, Llewelyn MJ. Influence of cohering patients with Clostridium difficile infection on risk of symptomatic recurrence. Journal of Hospital Infection 2013; in press.

5. Wynne S. Managing C difficile relapses in the community. Nursing Times 2012;108:15-17.

6. Public Health England. Updated guidance on the management and treatment of Clostridium difficile infection. Public Health England 2013.

7. Dalton BR, Lye-Maccannell T, Henderson EA, Maccannell DR, Louie TJ. Proton pump inhibitors increase significantly the risk of Clostridium difficile infection in low-endemicity, non-outbreak hospital. Alimentary Pharmacology & Therapeutics 2009;29:626-634.

8. Health Protection Scotland. Targeted literature review: what are the key infection prevention and control recommendations to inform a Clostridium difficile infection (CDI) cross transmission prevention quality improvement tool. Health Protection Scotland 2012.

9. Gould LH, Limbago B. Clostridium difficile in food and domestic animals: a new foodborne pathogen? Food Safety 2010;51:577-582

10. Rupnik M, Wilcox MH, Gerding DN. (2009). Clostridium difficile infection: new developments in epidemiology and pathogenesis. Nature Reviews 2009;7:526-536.

11. World Health Organisation. WHO Guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. World Health Organisation; 2009.

12. Brodine J, Kellogg A. Clostridium difficile infection: what nurses need to know. Johns Hopkins Nursing:Fall/Winter 2011.

13. Karadsheh Z, Sule S. Fecal transplantation for the treatment of recurrent Clostridium difficile infection. North American Journal of Medical Sciences 2013;5:339-343.

14. MacConnachie AA, Fox R, Kennedy DR, Seaton RA. Faecal transplant for recurrent Clostridium difficile-associated diarrhoea: a UK case series. QJM 2009;102:781-784.