Clostridium Difficile Infection

Clostridium Difficile Infection (CDI) should be suspected in any hospital patient that develops diarrhoea or any ED patient that presents with diarrhoea following a course of antibiotics (patients who have been taking Proton Pump Inhibitors or chemotherapy are also thought to be at increased risk).

Healthy individuals are usually resistant to CDI probably due to their commensal bowel flora and strong antibody mediated immunity. But interruption of these defense mechanisms with gastric acid suppression, antibiotics, immunosuppresive or cytotoxic drugs can lead to C. Diff colonising the GI tract.

Patients with severe CDI may present with fevers, hypotention, ileum, or peritonitis and have an elevated WCC, and lactate, and low albumin levels.

They produce a profuse, watery/mucoid, foul-smelling stool that may contain blood and pseudomembranes.

Diagnosis:

Clostridium difficile toxin studies (the gold standard is a toxogenic culture, but there are various other tests) are best performed on a liquidy / watery stools ( a positive result in a formed stool only signifies colonisation).
If the patient has an ileus then rectal swabs are useful to send.

Treatment:

Perform frequent clinical assessments. These patients ( particularly if elderly, very young or immunosuppressed ) may crash without warning.
Doctors should be performing serial assessments of WCC, lactate, creatinine and electrolytes.
Current antibiotics of choice is Metronidazole with Vancomycin held back for severe presentations.

  • metronidazole 400 mg (child: 10 mg/kg up to 400 mg) orally or via nasogastric tube, 8- hourly for 10 days.
  • Metronidazole can be given intravenously in patients who cannot tolerate the oral formulation: 500 mg (child: 12.5 mg/kg up to 500 mg) IV, 8-hourly for 10 days
    compendium of Nursing Esoterica 45
    theNursePath.com
  • Vancomycin 125 mg (child: 3 mg/kg up to 125 mg) orally or via nasogastric tube, 6- hourly for 10 days. NOTE: Intravenous vancomycin is not effective against C. difficile.

Avoid and/or stop any therapies with anti peristaltic agents and opiates

Stop therapy with other antibiotics if possible. If this is not possible a prolonged treatment regime is likely to be required.
It may take several days before signs of improvement are evident with a decrease in frequency of diarrhoea and improvement in other problems and clinical abnormalities.

Repeat stool testing “is not indicated within 30 days of a primary episode, and re-treatment should be based on clinical evidence of recurrent disease, which may be the result of reinfection with another strain or relapse with the original infecting strain”

Management overview:

Handwashing and gloves: C. Difficile in its spore form is highly resistant to alcohol based hand rubs (ABHR). In fact one of the techniques they use to isolate CDI from other organisms in the laboratory, is to add alcohol.

However, the vegetative form of CDI is highly sensitive to ABHR.

“The 2011 ASID / AICA position statement on Infection Control Guidelines for Patients with Clostridium difficile Infection (CDI) in Healthcare Settings recommends the primary use of ABHR in accordance with the WHO 5 Moments for Hand Hygiene when caring for patients with CDI. Gloves should be used during the care of patients with CDI, to minimise spore contamination, and if hands become soiled, or gloves have not been used, then hands must be washed with soap and water.”
-Hand Hygiene Australia.

So, always wear gloves when in close contact with these patients. Use alcohol based hand rub as per your usual routine. Additionally, if gloves are not worn or if your hands (or other parts of your anatomy) become soiled, use soap and water to thoroughly clean.

Contact precautions:

Where possible contact precautions should be implemented.
This includes gown, gloves and placing the patient in a single room.

Environmental cleaning:

Clean and disinfect the patients surroundings daily with an agent such as Sodium Hypochlorite (bleach containing) and include the following:
All surfaces such as door handles, bed rails
Room furnishings including over-bed tables, bedside tables, chairs, furniture, telephone, sinks, floors, commodes and toilets
Dedicated equipment including commodes, thermometers, stethoscopes, blood pressure cuffs, walking aids and wheel chairs.

In Summary:

You can use the mnemonic SIGHT:

Suspect each case may be infective where there is no clear alternative to explain diarrhoea

Isolate the patient and contact your Infection Control Unit or officer.

Gloves and gowns for all contacts with patient and their environment.

Handwashing or Handrub before donning gloves and after each contact with patient or their immediate environment. Handwashing is the preferred option. CDI exists in both vegititative and spore forms, these spores can persist for prolonged periods on hospital surfaces necessitating particular attention to cleaning. Alcohol based rubs are not much effective against the spores but hand washing (whilst not killing them) does wash the spores away.

Test the stool.


References:

  1. Australasian Society for Infectious Diseases guidelines for the diagnosis and treatment of Clostridium difficile infection | Medical Journal of Australia [Internet].  Available from:  https://www.mja.com.au/journal/2011/194/7/australasian-society-infectious-diseases- guidelines-diagnosis-and-treatment
  2. Hand Hygiene Australia – ABHR Limitations [Internet]. Available from:  http:// http://www.hha.org.au/About/ABHRS/abhr-limitations.aspx
  3. Pseudomembranous Colitis [Internet]. Available from:  http:// lifeinthefastlane.com/education/ccc/pseudomembranous-colitis/

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