Hospital Associated Infections: “C. Diff”
Posted by: Deborah Caputo Rosen
What do Harvard Magazine and AARP: The Magazine have in common? In the past five months both have published articles about “Superbugs”. “Superbugs” are those microorganisms that have developed resistance to commonly- used antimicrobial medications. “Superbugs” are dangerous and difficult to treat.
The Centers for Disease Control and Prevention (CDC) has been in the news providing guidance on the prevention and science of Ebola infection. But Ebola, although terrifying to many, has sickened only a handful of Americans, and only one person has died in this country of Ebola.
Scarier than Ebola is that on any given day about 1 in 25 hospitalized patients has at least one healthcare-associated infection (HAI). In 2011 there were 722,000 HAIs in hospitals. About 75,000 people died from these infections¹.
What does this mean? It means that people are admitted into hospitals without infections but develop an infection during their hospital stay.
Some of the types of infections patients and healthcare workers need to be vigilant about include: catheter-associated urinary tract infections, central-line associated bloodstream infections, ventilator-associated pneumonia, surgical site infections and hospital-onset Clostridium difficile infections (CDI or “C. diff” infection).
Why do patients acquire infections in the hospital? Let’s use C. diff as our example. In 2012, 107,700 cases of C. diff were reported in acute care hospitals². Often, these cases are preventable.
C. diff is the most common cause for infectious diarrhea in hospitals. Long-term care (LTC) facilities may be at even greater risk. In 2003, 2% of patients discharged to long-term care carried a diagnosis of C. diff infection.
There are people who carry C. diff without symptoms. These bacteria produce spores that are shed in feces. The spores can persist for 5 months on hard surfaces that have not been adequately cleaned. They are transferred on the hands of healthcare workers and are not adequately removed with alcohol-based hand rubs. Alcohol-based rubs do not kill the spores. Using them alone, without soap and water washing, merely spreads spores around on the hands but does not completely remove them.
C. diff spores are dormant in the colon until the normal bacterial environment is disrupted. The usual culprit is an antibiotic. Antibiotics can kill harmless C. diff spores. When that happens, C. diff transforms into a form that inflames and damages the colon, causing colitis of varying severity.
C. diff requires both exposure to antimicrobial agents and new acquisition of the organism. This occurs by transferring fecal spores to the mouth, usually by touching contaminated surfaces. Symptoms begin soon after infection; with watery diarrhea 3 or more times per day, cramping pain and tenderness, and fever. If unrecognized and untreated, the symptoms worsen.
The mortality rate for CDI varies. Some patients may recover without therapy other than discontinuation of antibiotics. That is the appropriate first step. Although it may seem counter- intuitive, additional antimicrobial agents are usually prescribed. Elderly patients who are frail and who do not respond to the first or second medications frequently used to treat the infection and supportive therapy for dehydration may become seriously ill, with a mortality rate as high as 25%.³
CDI recurs at least once in 50% of people, either because the first infection was incompletely treated or because of a new exposure. Highest risk groups include the elderly, those taking antibiotics and those with long and/or frequent hospitalizations. Virtually every antibiotic can increase the risk. The risk of acquiring the infection increases with time and can be as high as 40% with prolonged hospitalization. This is due to exposure to healthcare workers’ hands as they care for infected patients, touch contaminated surfaces and experience failures of correct hand washing technique.
Breaking the cycle requires proper hand hygiene, environmental decontamination and a hospital program of antibiotic use monitoring (“antibiotic stewardship”).
Know, Ask, Speak
Wilson-Stronks advises all patients and their care companions to keep in mind the Wilson-Stronks patient safety mantra of “Know-Ask-Speak” to decrease risk of healthcare acquired infections, including C. difficile. When you or a patient you love enters the hospital….
- What C. diff is.
- What the symptoms are.
- How it is transmitted.
- How to properly wash your own hands and when to do so.
- Whether you/the patient has been taking or is now being given antibiotics.
- Whether you/the patient has had a long or recurrent hospital or LTC stay.
- If you/the patient is older than 60 years, has had a compromised immune symptom, or recent gastrointestinal surgery.
- Why antibiotics are being prescribed?
- Whether and what tests will guide antibiotic selection?
- Whether the symptoms could be C. diff?
- How the C. diff will be treated?
- If your room has a patient with C. diff in it?
- Whether disposable equipment can be used?
- Request that providers wash their hands with soap and water in front of you, reminding them that alcohol rubs do not kill C. diff spores.
- Learn how equipment, including BP cuffs, portable commodes and rectal thermometers are disinfected.
- Learn how surfaces, including floors, bedrails, bedside tables, call buttons and bathrooms are cleaned.
- Tell your nurse and doctor if you have cramping pain or watery diarrhea, especially if you are taking an antibiotic.
- If you become infected with C. diff: learn if you will be in a private room or with another patient with C. diff, if contact isolation precautions will be observed, if visitors should follow such precautions.
- Learn what the likelihood of recurrence is and how to reach help if you have symptoms after discharge.
³Cohen S, Gerding N, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431-455.