Infection Prevention & Control Information

Area hospitals have been documenting an increased number of patients with C. difficile induced diarrhea. In some of these organisms CDC has confirmed a gene mutation, which produces a toxin variant strain of Clostridium difficile. These organisms are more likely to be more pathogenic (disease producing.) Hospitals are taking more aggressive actions to identify patients with C. difficile induced diarrhea in order to limit its' spread. Hospitals, considering the continuum of care, will provide information on patients with C. difficile diarrhea being considered for admission to your Facility.

The information being provided on the Website reflects an effort to prevent the establishment of strains of C. difficile in LTC. Admission Questionnaires, Educational support, Outlines, Policies and Procedures and Surveillance tools are available thru Brookside Laboratory's Certified Infection Control Practitioner. Culture positive infections and Medical information, for your potential admissions/re-admissions, can be obtained from the Hospital(s).

What Long Term Care Facilities need to know about Clostridium difficile and the emerging toxin variant strains of C. difficile.

Clostridium difficile infection represents one of the most common hospital-acquired (nosocomial) infections around the world. In the United States alone, it causes approximately three million cases of diarrhea and colitis per year. This bacterium is primarily acquired in Health-Care facilities following treatment with broad-spectrum antibiotics that target a wide variety of bacteria. C. difficile is the most frequent cause of outbreaks of diarrhea in hospitalized patients.

Antibiotic-associated colitis, also called antibiotic-associated enterocolitis. Clindamycin is the antibiotic that usually comes mind in relationship to C. difficile, but any antibiotic can cause this infection. Because of their wide spread use, b road-spectrum penicillins and cephalosporins are the most common causes of antibiotic-induced diarrhea (AAD). 

Clostridium difficile is normally found in the large intestine of 5% of healthy adults, but people can also become colonized with this bacterium while they are in a hospital or nursing home. In a healthy person, endogenous (normal bacteria) compete with each other for food and "space" along the inner intestinal wall. When antibiotics are given, most of these resident bacteria are killed. With less "competition," the normally harmless C. difficile grows rapidly producing toxins that damage the inner wall of the intestines causing inflammation and diarrhea. The disease and its' symptoms are the result of the toxins, not the bacterium itself. Clostridium difficile toxin is found in the stools of people older than 60 years of age 20 to 100 times more frequently than in the stools of individuals who are 10 to 20 years old. As a result, the elderly are much more prone to developing antibiotic-associated colitis than younger individuals.

Clostridium difficile is a spore-forming, gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B, and it accounts for 15-25% of all episodes of antibiotic-induced diarrhea (AAD). C. difficile spores are heat resistant and can persist in the environment for years. When ingested, they are resistant to gastric acid. Spores convert to the vegetative form in the bowel. This organism is now recognized as the major causative agent of the diarrhea that may occur following antibiotic therapy and colitis (inflammation of the colon).

C. difficile produces a broad range of GI disease varying from asymptomatic carriage to fulminate pseudomembranous colitis (PMC). Relapses after therapy occur in 7% to 20% of cases. Symptoms of antibiotic-associated colitis can begin four to ten days after antibiotic treatment has begun and as long as thirty days after completing the antibiotic. Clostridium difficile, with either "normal toxins" or variant toxin, can be spread from person to person in hospitals and nursing homes. Toxin variant C. difficile is more likely to produce progressive disease with potential complications.

Patients/residents with increased risks for Clostridium difficile -associated disease:

• individuals with antibiotic exposure
• individuals with gastrointestinal surgery/manipulation
• individuals who are fed via a PEG tube
• individuals with serious underlying illness and immunocompromising conditions
• the elderly
• individuals with poor hygiene
• individuals who have been hospitalized for a long period of time.

Differences between colonization with C. difficile and C. difficile -associated disease

Clostridium difficile colonization:

• patients/residents exhibit no clinical symptoms
• patients/residents test positive for Clostridium difficile organism and/or its toxin
• is much more common than Clostridium difficile -associated disease

Early Symptoms of Clostridium difficile -associated disease:

• loss of appetite
• nausea
• abdominal pain/tenderness
• increased frequency of stools, and watery diarrhea
• patients/residents test positive for the Clostridium difficile organism and/or toxin*

* Clostridium difficile toxin is very unstable. The toxin degrades at room temperature and may be undetectable within 2 hours after collection of a stool specimen. When specimens are not tested promptly, or kept refrigerated until testing can be done, false-negative results can occur.

Symptoms of Progressive Disease:

• nausea, vomiting and large amounts of watery diarrhea
• high fever (104 to105° F/40 to 40.5°C)
• Leukocytosis (elevated WBC counts maybe has high as 40.0)
• Pseudomembranous enterocolitis

Complications from Clostridium difficile - associated disease:

• severe dehydration and electrolyte imbalance
• hypotension (low blood pressure)
• edema (fluid accumulation in deep skin/tissue)
• toxic megacolon (enlargement of the large intestine)
• perforation (tears) in the wall of the large intestine
• sepsis
• Death (has been reported)

Routes of transmission:

Clostridium difficile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with fecal matter may serve as a reservoir for the Clostridium difficile spores. Unlike the toxins that are fragile, the spores of C. difficile can be environmentally stable for years. Transfer of the spores to patients/residents is mainly via the hands of healthcare personnel who have touched a contaminated surface or article.

Treatment of Clostridium difficile -associated disease:

In 23% of patients, Clostridium difficile -associated disease will resolve within 2to 3 days of discontinuing the antibiotic to which the patient was previously exposed. The infection can usually be treated with an appropriate course (about 10 days) of antibiotics including Metronidazole (Flagyl) or Vancomycin administered orally. Anti-diarrheal medications should be avoided. Some studies indicate that persons susceptible to antibiotic-associated diarrhea can prevent the modification of intestinal micro-flora by drinking fermented milk or eating yogurt with live cultures or taking lactobacillus pills. After treatment, repeat Clostridium difficile testing is not recommended if the individual's symptoms have resolved. Asymptomatic colonization may remain. Untreated, the disease has a high mortality rate.

Long Term Care:

Proactive Approaches to Clostridium difficile -associated disease, with or without the presence of a toxin variant strain, should include:

Establish cooperative communications between any and all referring Facilities

Provide diagnoses of communicable disease and positive culture reports with "Sentinel organisms" (MRSA, VRE or C. difficile) when transferring a resident to another Facility.

Obtain the same information noted above, from the transferring Facility, prior to accepting the admission of any patient

Establish guidelines for the prudent use of antibiotics. Leadership, by the Medical Director, is essential for the successful implementation of any guidelines.

Conduct prospective IC surveillance for potential cases of C. difficile disease. R esidents who have significant diarrhea with abdominal pain and fever should have the following tests: Stool for C. difficile and a Complete Blood Count (CBC) with differential. Contact Precautions maybe instituted pending test results.

Establish a written Facility Isolation Policy and Procedure for Residents with Known or Suspected Diseases requiring Contact Precautions

Use soap and water for hand hygiene when caring for patients with Clostridium difficile-associated disease. Alcohol-based hand sanitizers maybe less effective against spore-forming bacteria.

Implement policies and procedures that ensure adequate cleaning and disinfect ion of environmental surfaces and reusable devices; this includes areas contaminated with feces and surfaces that are touched frequently. (See: CDC: Guidelines for Environmental Infection Control in Health-Care Facilities ) An EPA-registered hospital disinfectant is used for general cleaning of resident care areas.

Daily cleaning of rooms, when residents are on Contact Precautions for active C. difficile diarrhea, including furniture is mandatory. After routine cleaning of these rooms, mattresses, side rails, over bed tables, call lights and cords, light switches and all bathroom surfaces are wiped with a disposable cloth containing chlorine. Any surface, visible soiled with fecal matter is cleaned immediately.

NB. At the present time, there are no EPA-registered products with specific claims for inactivating Clostridium difficile spores, but there are a number of registered products that contain hypochlorite (bleach). Consult the label instructions for proper and safe use conditions.

References:

1. The Centers for Disease Control and Prevention at: http://www.cdc.gov
2. The Centers for Disease Control and Prevention also has general information about C. difficile and more information about Infection Control of Gastrointestinal Infections at: www.cdc.gov/ncidod/hip/infect/gi.htm
3. CDC. Guideline for Environmental Infection Control in Health-Care Facilities, 2003 Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) at: http://www.cdc.gov/ncidod/hip/enviro/guide.htm
4. CDC. Guidelines for hand hygiene in health-care settings . MMWR 2002;51 (RR16):1-45. at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm
5. Control of Gastrointestinal Infections at: www.cdc.gov/ncidod/hip/infect/gi.htm
6. Gastrointestinal Infections e xcerpted from : Guidelines for Infection Control in Healthcare Personnel, 1998 at: http://www.cdc.gov/ncidod/hip/INFECT/gi_excerpt.htm
7. Feature Article The Significance of Testing for C. difficile Toxin A/B
   Update on Clostridium difficile Disease and New Atypical A-/B+ Isolates http://www.wampolelabs.com/LT1_featurearticle.htm#top
8. Can Tube Feeding Cause Diarrhea from C. difficile? American Family Physician March 15, 1999 by Richard Sadovsky at: http://www.findarticles.com/p/articles/mi_m3225/is_6_59/ai_54129398
9. Web antibiotics at: http://www.blinn.edu/natscience/phillips/antibiotics.htm
10. Gerding DN, Johnson S, Peterson LR, Mulligan ME, Silva J. SHEA Position Paper: Clostridium difficile -associated diarrhea and colitis. Infect Control Hosp Epidemiology 995;16:459-77 at: http://www.shea- online.org/assets/files/position_papers/Cldiff95.pdf
11. Simor AE, Bradley SF, Strausbaugh LJ, Crossley K, Nicolle LE. SHEA Position Paper: Clostridium difficile in long-term-care facilities for the elderly. Infect Control Hosp Epidemiology 2002;23:696-703.
12. Johnson S, Gerding DN. Clostridium difficile -associated diarrhea. Clin Infect Dis 1998;26:1027-36.
13. Boone N, Eagan JA, Gillern P, Armstrong D, Sepkowitz KA. Evaluation of an interdisciplinary re-isolation policy for patients with previous Clostridium difficile diarrhea. Am J Infect Control 1998;26:584-7.

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