A) What is C. Difficile?

The C. Difficile bacteria (clostridium difficile) are the main cause of infectious nosocomial diarrhea among adult hospital patients. C. Difficile is responsible for 16% to 26% of infectious diarrhea, and for over 90% of pseudo-membranous colitis (PMC).

Since 2002 - 2003, severe nosocomial (ICD) epidemics have struck the USA, Quebec, Great Britain, Belgium, the Netherlands, and more recently, France. These epidemics were caused by a new, virulent strain of C. Difficile characterized by very high production of toxins. Only the toxic strains are pathogenic.

In Quebec, the incidence of ICD's has increased at an alarming rate over the last decade. Since 1992, the number of severe strains has risen sharply. In 2003, for example, 18.2% of patients were afflicted with a severe form of ICD such as septic shock, intestinal perforation, and toxic mega colon. Between 2003 and 2005, 14 000 patients were infected with this strain, and 2000 of them died.

Approximately three percent of healthy adults are carriers of non-toxic C. Difficile. Less that one percent of the adult population carries a toxic strain.

ICD's can be found in the general populace, but the vast majority of them are nosocomial, in other words, infections contracted during a medical procedure.

An ICD is considered nosocomial is a patient gets infected within forty-eight hours of admission, or within four weeks of hospitalization.

B) What are the symptoms?

ICD's are classed in two categories, depending on their severity.

Diarrhea: Doctors should consider the possibility of an ICD if a patient being treated with antibiotics exhibits the following symptoms:
- The patient has liquid diarrhea three times within a day.
- The patient's stool is so voluminous that if fills the receptacle.

Elderly patients may suffer an intestinal occlusion accompanied by fever, abdominal pain, or a sharp increase in white blood cell count.

Pseudo-membranous Colitis (PMC): Pseudo-membranous colitis constitutes 7% to 9% of all ICD's. Symptoms include frequent diarrhea (up to seven times a day), abdominal pain, or hyperleukocytosis (abnormally large increase in the number of white blood cells). An endoscopy of the large intestine needs to be performed whenever a patient suffers diarrhea for no apparent reason, or if the doctor suspects that the patient has an ICD.

The most severe complications of pseudo-membranous colitis are toxic shock, or extreme hypertrophy of the large intestine (mega colon), which could result in perforation. When this occurs, a partial or complete ablation of the large intestine must be performed.

C) Death Rate

The death rate generally varies from 0.6% to 3%, but can reach 35% to 50% if the patient suffers pseudo-membranous colitis with complications. In Quebec, 13.8% of patients died within one month of contracting an ICD.

D) Relapses

Relapses occur within two months of the initial episode in roughly 20% of cases. Patients who have a relapse are at great risk of suffering multiple relapses.

E) Diagnosis

Diagnosis consists primarily of observing symptoms, and performing laboratory tests on the patients stool. Since 1991, refined testing techniques can provide a diagnosis within thirty minutes.

F) Risk Factors

Risk factors include the patient's age (65 years of age or older), gastro-intestinal surgery, or
anything that disrupts the digestive system such as laxatives, antacids, treatment for gastric ulcers, or gastro-intestinal surgery.

How the disease is spread: C. Difficile contamination usually occurs in the oral - intestinal pathway. It is spread by infected patients coming into contact other patients, by the unclean hands of heath-care workers, and by a contaminated environment. Half of the samples (49%) taken from an ICD infected patient's room tested positive for bacteria. Once in the environment, C. Difficile spores are able to survive for weeks, and in some cases, months.

Grouping patients in the same hospital room frequently results in contamination. A patient sharing a room with a C. Difficile carrier will likely get infected within four days.

The frequency of treatment is another factor that favors the spread of bacteria because health-care workers hands are often contaminated due to improper hygiene.

Finally, antibiotics must be prescribed with great caution. The frequent use of antibiotics weakens the patient's resistance to the C. Difficile, thereby favoring the spread of bug

G) Treatment

In 25% of cases where antibiotic treatment can be stopped, the patient recovers within a few days.

If the symptoms persist, or if it is not possible to stop using antibiotics, a more specific treatment is required.

Patients infected with severe strains should be transferred to an intensive care unit. Surgery is required if the patient suffers toxic mega colon, or if the patient's digestive system is perforated.

Treating healthy patients with antibiotics is unnecessary. Antibiotics are useless for eliminating intestinal bacteria.

It is absolutely essential that patients and their families are informed of risks and preventative measures. By providing pertinent information, patients and their loved ones will have a better understanding of the problem, and will therefore be more likely to obey infection control measures.

(H) Prevention and Control Measures

Prevention of C. Difficile related diarrhea is simply a matter if prescribing antibiotics in a sensible manner. The overuse of antibiotics is the major contributor to the development of antibiotic resistant bacteria.

Health-care workers, patients, and visitors need to be informed of the importance of hand-cleanliness. Clearly visible signs to that effect should be posted in all hospital rooms

Infected patients must be isolated in individual rooms. Should there be insufficient space to allow for this, infected patients should be isolated in a special unit.

Basic hygiene measures, in particular hand cleanliness, must be strictly enforced. While liquid alcohol solutions are effective for most bacteria, they do not work for C. Difficile, which requires antiseptic foam. Only methodical washing will eliminate C. Difficile spores.

Small, disposable medical instruments should only be used once and then thrown away. Any given medical instrument such as a stethoscope should only be used on only one infected or colonized patient.

Proper maintenance of hospital rooms and units must be carried out at least once a day. This includes cleaning, rinsing, and disinfection with bleach. In order to be effective, bleach must remain on any given surface for ten minutes.

Patients should only be removed from isolation if they have not experienced diarrhea for 72 hours.

Conclusion: Above all, insufficient prevention and control measures are responsible for the recent C. Difficile epidemic that struck Quebec. During a two-year period, 14,000 patients were infected with the C. Difficile bug, and 2,000 of them died as a result.