October 11th, 2008- For over 30 years, we have known that Clostridium difficile, or C. difficile, is the main cause of infectious diseases among hospital patients. This frequently occurs after a patient has been treated with antibiotics. Until 2001 – 2001, these infections did not constitute a serious risk and were generally cured within a few days. However, after 2001 – 2002, a new strain of C. difficile that was more virulent and resistant to treatment began to appear throughout Quebec, Canada, and the United States. Infections caused by this new strain have severe complications and sometimes result in death. C. difficile is responsible for the epidemic that struck North America and spread to Europe in 2005.
Where is C. difficile found?
The C. difficile bacteria are usually found in soil, hospitals, old age care centers and child care facilities. The active form of the bacteria responsible for the most severe infections lives in the patient’s intestines. These are commonly known as communal germs and are mainly found in the digestive tract. They do not necessarily cause illness.
Between 3% and 5% of adults are colonized, or carriers of the bacteria, and are referred to as “healthy carriers.” The percentage of carriers among newborn infants and children under the age of two is much higher; reaching up to 70% of newborns. Unfortunately, the cause of this higher rate is unknown.
Once outside the intestines, the bacteria produce spores that allow it to survive weeks, even months, in the environment. When a hospital room is occupied by a C. difficile carrier – whether simply a carrier or an infected patient – it becomes contaminated within twenty-four hours. Spores are found everywhere in the hospital environment: bedding, furniture, flat surfaces, door handles, phones, arm bands of medical instruments used to measure blood pressure etc. etc. The spores are resistant to heat as well as most disinfectants and detergents, except bleach.
How does one become infected?
Not all hospital patients are necessarily infected by C. difficile. However, any patient can be colonized by the bacteria and become a healthy carrier who, in turn, spreads the spores to his immediate environment. Patients can spread spores even after being discharged from the hospital. This also occurs with visitors and health care workers. The latter have become the main vehicle for spreading bacteria throughout the hospital.
In the last four years, C. difficile infections have occurred not only in hospitals, but outside the health care environment as well. The onset of epidemics in health care establishments results in the spread of C. difficile to the general population. Consequently, infections can strike patients who had not been hospitalized in the previous weeks or months.
Hands are the main source of contamination because they become contaminated on contact. The spores are then transmitted from the hands to the mouth. Once ingested, they go directly to the stomach were they resist digestive juices and, in turn, reach the intestines where they become active bacteria.
Only high risk patients are likely to develop an infection. Such patients are more vulnerable because of:
- Their age: newborns, young children, and people over 65 years of age whose immune system has been weakened.
- Their illness: cancer, diabetes, etc.
- Their treatment: radiology of chemotherapy treatments that tend to weaken the immune system.
Antibiotics are the most frequent catalyst. By modifying the patient’s intestinal flora, they facilitate the development of the bacteria. Certain antibiotics such as fluoroquinolones (Cipro, Floxin) are the most common culprits.
What are the symptoms of C. difficile?
Diarrhea is the most common symptom. Diarrhea occurs whenever a patient experiences liquid stool three times within a 24-hour period. The stool is usually high in volume, and has a distinctive odor that competent health care workers can easily recognize. Lab tests of the stool can quickly confirm the initial diagnosis. Tests should be carried out as quickly as possible after the onset of symptoms or after antibiotic treatment. We now have at our disposal fast, reliable tests that can detect toxins in stool within one hour. It is important that the testing facilities are readily available in hospital laboratories, and that there is sufficient staff to carry out these tests at all times; 24 hours a day, seven days a week. As soon as the diagnosis is confirmed, the patient should be isolated or quarantined in a private room so as not to contaminate other patients.
Mucous colitis is the most severe form of infectious C. difficile. Diarrhea is accompanied by fever and abdominal cramps. Sometimes blood or mucous is found in the stool. An emergency ablation of the intestine (total or partial) may be necessary.
Another extremely and potentially deadly complication is toxic mega colon. Toxic shock causes the intestine to dilate and the stomach to distend. An emergency ablation of the intestine (colectomy) is required.
How to prevent C. difficile related infections
Prevention and control measures are essentially the same as for other NI’s (see text on prevention and control of NI’s). However, these measures need to take into account the specific risk factors associated with C. difficile: C. difficile is spread by bacterial spores that contaminate the environment. Patients become infected when they touch contaminated surfaces.
These spores are resistant to disinfectants and detergents (with the previously noted exception of bleach). The following measures are required:
- Hands must be thoroughly washed with water and an alcohol based solution.
- Rooms of infected or colonized patients must be disinfected and cleaned with bleach on a daily basis. Disposable tissues should be used in order to avoid transporting spores from one place to another. Bleach must be left on any given surface for at least ten minutes to be effective. Surfaces can be rinsed after 10 minutes.
- Patients should frequently wash their hands throughout the day because they are often in contact with contaminated objects or surfaces. It is especially wash hands after eating or going to the bathroom.
As with all NI’s, patients and / or their visitors and families must actively participate in the fight against infection.
- They need to remind health care workers to wash their hands and put on gloves before touching patients.
- They must see that rules for hygiene and for proper maintenance of hospital rooms are followed. Management should be immediately informed of any infractions. The purpose of this is not to lay blame or cause conflict, but to improve patient safety. Health care workers must also accept and apply these measures when performing their duties.
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