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Clostridium Difficile

Clostridium Difficile  (klo–strid–ee–um  dif–uh–seel)

What is Clostridium Difficile?
Clostridium difficile (C. difficile), which is also known as C. diff, is a spore-forming bacteria found in feces.  The bacteria cause a toxin-mediated response, which means they release a poisonous substance that causes the symptoms of the infection.

How does C. difficile cause infections?
C. difficile spores enter the body through the mouth and develop into the bacteria, which colonize in the small and large intestines.  Then, the bacteria release toxins, which destroy the mucosal lining of the gut.  Usually, the “good” bacteria in the stomach keep the C. difficile from forming colonies.  However, when patients are on broad-spectrum antibiotics, the antibiotics can kill the “good” bacteria and then there is no longer anything to keep the C. difficile from colonizing and causing an infection.

Are C. difficile infections common?
In the United States each year, about 500,000 people, mostly in hospitals and nursing homes, get C. difficile infections. However, the number of infections occurring in the community is increasing and now account for anywhere from 15,000 to 180,000 cases yearly.  Of those 500,000 people, approximately 14,000 will suffer a C. difficile related death.

Who is at risk for getting a C. difficile infection?
The main risk factor is taking broad-spectrum antibiotics, such as clindamycin, levofloxacin, ciprofloxacin, penicillins, etc., that kill many different types of bacteria, viruses, and fungi that cause disease.  The reason for this occurrence is that these antibiotics can kill the “good” bacteria in the gut that keep C. difficile from growing there.  When C. difficile infections are related to antibiotic use, the infections usually occur during or shortly after completion of the antibiotic therapy; however, the infection onset can be delayed for up to two or three months.

Other risk factors for getting a C. difficile infection include advanced age, taking a proton pump inhibitor such as Prilosec® and Prevacid®, an underlying illness, immunosuppression, tube feeds, a long stay in a healthcare setting, and the use of laxatives.

How is C. difficile spread?
1.Direct contact with infected person
2.Indirect contact with a contaminated surface
3.Indirect contact with an individual with transient hand colonization

People can become infected if they touch items or surfaces that are contaminated with feces and then touch their mouth or mucous membranes, such as eyes, nose, etc.  C. difficile is shed in feces. Therefore, any surface, device, or material such as toilets, bathing tubs, light switches, electronic rectal thermometers etc. that becomes contaminated with feces may serve as a reservoir for the bacterial spores.  C. difficile has been found in some meat products; however, the transmission from animals to humans has not been proven.  The overwhelming majority of C. difficile infections are spread from human to human.

What are the symptoms of a C. difficile infection?
The symptoms of C. difficile infections can range from symptomless carriage, to mild or moderate diarrhea, to severe, life-threatening intestinal inflammation.  The diarrhea, which is usually at least three bowel movements per day for two or more days, may be watery and contain mucus or blood.

Other symptoms that may be present include stomach cramps, abdominal pain or tenderness, fever, nausea, loss of appetite, and altered blood chemicals.

How is C. difficile treated?
The first step is to stop taking the antibiotic if it is thought to be the cause.  Doing so will resolve the infection in about 20% to 25% of patients within two to three days.  However, C. difficile infections usually are treated with antibiotics for 10 days.  Doctors may prescribe metronidazole, oral vancomycin, fidaxomicin, or a combination of these depending on the severity of the infection.

In addition to antibiotics, probiotics are often suggested for patients with C. difficile infections to help replace the “good” bacteria that are missing from the gut.  Our recommendation is to take Floraster® for one month and then Florajen 3® for an additional three months.

Lastly, due to the diarrhea it is also important to maintain hydration by drinking a lot of fluids.

How do you stop C. difficile from infecting other people?
The most important step is practicing good hand hygiene.  Hands should be washed with soap and running water after caring for or being in contact with the infected person. Alcohol-based products, such as Purel®, do NOT kill the C. difficile spores.  They only move the spores around the skin’s surface.  Therefore, hands must be cleaned with soap and running water to physically remove the spores by mechanical washing.

C. difficile spores can survive in the environment for months to years.  As alluded to above, C. difficile spores are highly resistant to killing by alcohol.  Therefore, most typical household cleaners and standard disinfectants do NOT kill the bacterial spores.  Chlorine-based cleaning agents, such as bleach, or other sporicidal agents are the ONLY products that can kill the C. difficile spores.  The available chlorine concentration in products used to kill the C. difficile spores should be at least 1,000ppm and ideally may be 5,000ppm.  The lower concentration is equal to a dilution containing one part bleach for every 10 parts of water.  This product needs to be made fresh every day.

In addition to maintaining good hand hygiene and disinfecting the environment, it is advised to use contact precautions for the duration of the diarrhea.  Using a separate bathroom is recommended.  If doing so is not possible, be sure the bathroom is cleaned well, with the appropriate bleach solution, after the infected individual has used it.  It may also be a good idea to limit unnecessary human-to-human contact as much as possible to further prevent the infection from spreading to others.

How do you lower your chances of getting C. difficile?
Maintaining good hand hygiene is very important for preventing infections in general.  Although Purel® is effective for killing most types of bacteria, it does NOT kill C. difficile spores.   Therefore, it is important to wash your hands thoroughly with soap and running water on a regular basis, and frequently if you have been around someone with a C. difficile infection. Soap and running water is the only way to remove C. difficile spores from your hands if they become contaminated.

Do not demand antibiotics if your doctor says you do not need them.  Antibiotics can be life-saving medicines.  However, in addition to killing the bad bacteria they also kill the “good” bacteria in the gut.  Therefore, when a person takes antibiotics, it may be months before the “good” bacteria grows back to protect against a C. difficile infection.

References:
1. Clostridium difficile Infection.  Centers for Disease Control and Prevention. Accessed 14 December 2012 from http://www.cdc.gov/hai/organisms/cdiff/cdiff_infect.html.
2. Cohen SH, Gerding DN, 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):431-55.
3. Gould C, McDonald C. Clostridium difficile (CDI) Infections Toolkit.  Centers for Disease Control and Prevention 2009. Accessed 14 December 2012 from http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf.
4. Guidelines for Environmental Infection Control in Health-Care Facilities.  U.S. Department of Health and Human Services Centers for Disease Control and Prevention 2003. Accessed 14 December 2012 from http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf.
5. Laino C.  C. diff on the Rise Outside the Hospital.  WebMD Health News 2011. Accessed 14 December 2012 from http://www.webmd.com/digestive-disorders/news/20110920/c-diff-on-the-rise-outside-the-hospital.

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