NEW YORK NURSE: January/February 2009
Q.: As an experienced med-surg RN, I’ve seen more cases of C-diff infections in hospital and community settings in the past few years than ever before. Is this due to the increased use of antibiotics or are there other reasons? Is there anything that nurses can do?
A.: Research continues to track an increase in the rate and severity of Clostridium difficile infections (CDI) in hospital settings as well as community outbreaks. Information presented during the 18th annual meeting of the Society for Healthcare Epidemiology of America and subsequent articles has reviewed strategies and research regarding changes in the epidemiology of this pathogen, effectiveness of current and possible treatments, suggestions to increase surveillance, and routine use of evidence-based diagnostic methods.
The pathogenesis of infection from ingestion of the spore, which is resistant to stomach acid, to the production of toxins has been shown to be related to factors that include antimicrobial use, age, and co-morbidities. The new strain BI/NAP1/027 has become more resistant to fluoroquinolones, appears to produce greater amounts of toxins, and is associated with increased rates of morbidity and mortality. As of November 2007, 38 states and 10 European countries have reported cases of this strain.
In hospital settings, studies have found a connection between an increased number of patients on a unit with CDI and a higher risk of transmission by healthcare workers via hand contact or through commonly used multi-patient equipment. Some newer factors that possibly contribute to the increase in community cases include the use of antimicrobials within three months, use of proton pump inhibitors, outpatient visits, and evidence of the new strain in retail ground meat. CDI has also shown an increase in previously low-risk populations of pregnant women.
Research shows that the strains of community acquired C. difficile are variant; however, studies also suggest commonality between animal and human strains. Regardless of the strain, surveillance, diagnosing, and treating CDI continues to be a challenge.
Presently there is no CDI surveillance system in the United States. ICD-9 coding is the best alternative with no consistent case definitions recognized, few institutions culturing for CDI, and few laboratories using molecular typing of C. difficile. Current diagnostic techniques show low sensitivity in most tests and a slow turnaround in the most sensitive testing available, which is cell cytotoxicity and culture. Treatment for moderate CDI remains metronidazole. Treatments for severe complicated CDI, which may occur with or without diarrhea, include oral and rectal instillation of vancomycin via indwelling rectal tube, IV metronidazole, and colectomy. For recurring CDI, optimal treatment includes tapering/pulsed vancomycin regimens, probiotic and immunologic approaches, fecal transplant, and follow-up with a rifaximin “chaser.” These treatment options continue to be researched, and serious questions remain for the clinical arena.
Nurses and other healthcare providers are at the forefront of interventional opportunities, which include, but are not limited to, prevention; continued timely communication of symptoms, treatment successes, and failures to providers; and involvement with ongoing research initiatives. A positive impact on the current pattern of CDI may happen sooner as a result of healthcare providers remaining current and proactive in evolving epidemiological issues.
Robert Michael Educational Institute. (2008). Clostridium difficile: Changing diagnosis, epidemiology, and treatment. Online lecture derived from a satellite symposium presented on April 7, 2008, during the 18th Annual SHEA Scientific Meeting. Retrieved November 15, 2008, from http://www.rmei.com/CDI010/
Dubberke, E. R., Gerding, D. N., Classen, D., Arias, K. M., Podgorny, K., Anderson, D. J., et al. (2008). Strategies to prevent clostridium difficile infections in acute care hospitals. Infection Control Hospital Epidemiology, 29(Suppl. 1), 81-92.
This is a sample of the questions NYSNA’s experts answer each day. The advice given is specific for the situation described and may not be applicable generally. If you have questions about your own work setting, it is recommended that you contact your NYSNA Nursing Representative or the Education, Practice, and Research Program, 11 Cornell Road, Latham, New York 12110-1499 or call 800-724-NYRN, ext. 282.