July 2016-1

Clostridium difficile is a spore-forming, Gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated diarrhea, accounting for 15% to 25% of all episodes.

Symptoms include watery diarrhea, fever, loss of appetite, nausea, and abdominal pain or tenderness. It can cause pseudomembranous colitis, toxic megacolon, perforations of the colon, sepsis, and in some cases death. There are about 500,000 cases of illness caused by C-difficile annually, and the infection recurs at least once in about 1 in 5 individuals who have had it. According to the CDC, one in 11 people 65 or older die within a month of contracting C-difficile, with 80% of all C-difficile-related deaths occurring in C-difficile is shed in feces. Any surface (e.g., toilets, bath tubs, shower chairs, electronic rectal thermometers, bed rails, IV poles, bedside tables, floors) contaminated with feces may spread the spores. C-difficile spores are mainly transferred by the hands of healthcare personnel who have touched a contaminated surface. People taking antibiotics are 7 to 10 times more likely to get C-difficile while taking the antibiotics and during the month immediately thereafter. More than half of all hospitalized patients receive an antibiotic during their stay, with studies showing that 30% to 50% of these antibiotics are unnecessary or incorrectly prescribed. C-difficile infections can be
prevented through judicious use of antibiotics and by following recommended infection control practices. C-difficile spores survive for as long as 5-6 months in the environment, so careful attention to cleaning is critical. The spores are resistant to many forms of antiseptic cleaners. One of the few ways to kill C. difficile spores is by using bleach in the correct concentration. Rigorously use a 1:10 dilution of bleach (9 parts water to 1 part bleach) or another EPA-approved, spore-killing disinfectant. Once mixed, the bleach solution remains effective for 24 hours, at which point fresh solution must be mixed.

The CDC suggests taking the following actions:

  • Prescribers should order and use antibiotics carefully.
  • Order a C-difficile test if the patient or resident has three or more unformed stools within 24 hours.
  • Isolate individuals with confirmed or suspected C-difficile immediately using contact precautions, and provide separate toilet facilities.
  • Wear gloves and gowns when treating individuals with C-difficile, even during short periods in the room. Hand sanitizer does not kill C-difficile. Handwashing is better, but not sufficient alone, so gloves must be used with appropriate handwashing techniques.
  • Room surfaces where an individual has C-difficile must be thoroughly cleaned everyday, when feces contamination occurs, and upon discharge or transfer.
  • Notify anyone transporting a resident with C-difficile, as well as the healthcare facility to which the person is being sent.

Individuals may be colonized, exhibiting no symptoms, or they may be infected. Treatment is not used for colonization. Whenever possible, other antibiotics should be discontinued during treatment. For a small number of individuals, diarrhea will stop when other antibiotics are discontinued.

Treatment of primary C-difficile infection is by use of an antibiotic such as metronidazole, vancomycin, or fidaxomicin. Although metronidazole is not approved for treating C-difficile infections by the FDA, the CDC notes that it has been commonly used for mild C-difficile infections, but should not be used when the infection is severe. Give treatment by mouth when possible, and continue for a
minimum of 10 days. Another important consideration is the provision of probiotics to promote gastrointestinal health. The resident’s physician, in collaboration with your pharmacist, can determine the best product to use.

If you are not already committed to antibiotic stewardship in your facility, start today. Involve your pharmacist with your medical director and infection preventionist in developing and monitoring your program. The pharmacist can provide reports detailing antibiotic use in your setting, make recommendations, and monitor for appropriateness of antibiotic prescribing during the monthly drug regimen review.

For more information about C- difficile or antibiotic stewardship, visit www.cdc.gov.


Saul Greenberger, Founder