Treating and Preventing Clostridium difficile Infection in Long-Term Care Facilities

A Letter to the Editor was published about this article on March 11, 2019 noting an update to the treatment guidelines. 

Abstract: The spore-forming bacteria Clostridium difficile (C diff) can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. C diff infection (CDI) is most common in older adults who have been hospitalized or who reside in long-term care facilities (LTCFs) and typically occurs after use of antibiotic medications. In recent years, CDIs have become more frequent, severe, and difficult to treat. An overview of CDI in older adults and in LTCFs particularly is provided below, including background, prevention, and treatment. An accompanying quick-reference Tip Sheet is also provided for ease of dissemination and education in facilities. 

Key words: Clostridium difficile, diarrhea, long-term care facilities, colitis

Clostridium difficile infection (CDI) is caused by the gram-positive, spore-forming bacteria Clostridium difficile (C diff), which produce the noninvasive toxins A and B that lead to diarrheal illness.¹ Presentation of CDI can range from asymptomatic carriage to severe ileus and toxic megacolon. Most people with CDI experience watery diarrhea, often with an elevated white blood cell count.^2,3 C diff spreads by way of the fecal-oral route, which is why hand hygiene and appropriate environmental cleaning are the primary means of halting the spread of disease in any setting. Active surveillance is important to initiating early effective treatment and stopping disease transmission.

CDI has several risk factors, including increasing age, comorbidities, and medication use (particularly antibiotics), in addition to other factors. Several studies have shown that living in a long-term care facility (LTCF) is an independent risk factor for CDI and that C diff is endemic in LTCFs, with colonization rates ranging from 4% to 20%.^3-5 CDI in the LTCF setting occurs at rates similar to those of hospital settings and range from 0.8 to 14.1 cases per 10,000 resident days or 1.5% to 3.8% of LTCF admissions.^4,6-9 It is believed that the majority of CDI cases are acquired in the acute hospital setting,¹⁰ but this is difficult to assess in epidemiologic studies and is controversial. One study of a Veterans Affairs facility in Pittsburgh, PA, found that 40% of CDI cases occurred after 30 days of admission to the LTCF, so it can be difficult to ascertain at which point the colonization occurred.¹¹ A more recent study also suggested that colonization occurred more frequently after admission to a LTCF than in the hospital.¹² CDI in this setting tends to be more severe but is significantly understudied.^13,14 Clinical features of CDI in older adults do not differ from those in younger adults, and surveillance recommendations are the same for community-dwelling older adults and LTCF residents.¹⁵

This article provides an overview of CDI in older adults, including CDI screening and treatment in LTCFs with an accompanying quick-reference Tip Sheet (above reference list) for health care professionals.

Prevention

The most important way to reduce the incidence of CDI is to limit the use of antibiotic agents.¹⁶ Infection control procedures that help providers distinguish among asymptomatic bacterial carriage, viral illness, and true bacterial disease are critical for antibiotic stewardship. Mixed evidence exists for the use of probiotics,^4,17 with the best evidence shown for the prevention of recurrent illness¹⁸; however, the overall risk of probiotic use is low, and it should be considered in conjunction with systemic antibiotics during acute infections to prevent CDI.¹⁹

Studies have shown that good hand hygiene (glove use and hand washing)²⁰ and use of disposable equipment such as disposable gowns^16,21 are effective in reducing the carriage and transmission of C diff. Alcohol-based hand sanitizers are not recommended. When sanitizing rooms and medical equipment, providers should understand that C diff is not easily killed with routine cleaning agents because of the formation of spores, which can only be eradicated through mechanical scrubbing with soap and water, 10% bleach solution, or 1:10 hypochlorite solution.⁴

It should be noted that restricted-use antibiotics policy, disposable gowns, environmental cleaning and isolation techniques, and multi-intervention infection control procedures² have all been shown to effectively reduce the incidence of CDI in hospital settings, but their efficacy still needs to be confirmed in the LTCF setting. The routine use of probiotics for the primary and secondary prevention of CDI and the safety/efficacy of fecal microbiota transplant (FMT) also need further study in LTCFs.²²

Diagnostic Testing

Testing for C diff should take place when a person with risk factors for CDI (Table 1) experiences more than 3 unformed stools in a 24-hour period with no other explanation for the diarrhea.¹⁶ A liquid stool sample should be obtained to test for the presence of C diff toxin and bacteria. The newer polymerase chain reaction (PCR) tests are recommended,¹ but recent evidence suggests that toxin immunoassay tests are important to confirm clinical disease and to adequately stratify the patient’s risk.^23,24 The use of PCR molecular testing alone may lead to the misclassification of carrier status as active disease and to unnecessary overtreatment. LTCF clinicians and medical directors should be aware of local laboratory testing procedures and create diagnostic protocols based on available tests. If the diagnosis is still unclear, colonoscopy or sigmoidoscopy showing pseudomembranes is pathognomonic for CDI but is rarely performed. It is not recommended to test asymptomatic patients or to check for cure following a treatment course.¹ Attempts to eradicate asymptomatic carriers have not led to reduced clinical disease in carriers or close contacts.^3,16,25

Once CDI has been identified, isolation techniques can help to reduce the spread of disease³; however, strict isolation is difficult in a LTCF, since it serves as a person’s residence. Experts recommend that a person with CDI remain in his or her room until the diarrhea has resolved.¹⁶ If it is not possible to offer a private room for people with CDI, it is recommended to cohort people with CDI.

Treatment

Treatment should be initiated as soon as CDI has been confirmed or when there is a strong clinical suspicion of disease. If possible, antibiotics used for other infections should be stopped.^1,3 Appropriate regimens for CDI depend on disease severity and presentation. Table 2 describes the various treatment recommendations. The current recommendation for second disease recurrence is a vancomycin taper regimen, but recent evidence suggests that this does not provide long-term benefit over a nontaper regimen,²⁶ and growing evidence of the benefit of FMT is leading to its becoming an emerging treatment of choice.²⁷ FMT has not been studied in the LTCF population. Antiperistaltic agents such as loperamide worsen the outcomes in CDI and are not recommended for control of symptoms.^3,16,28

Conclusion

CDI is not well-studied in LTCFs, but providers can reduce the rates of transmission by educating residents and staff on proper hand hygiene techniques. Appropriate room-cleaning protocols for thorough disinfection of C diff organisms and spores also play a key role in prevention and reducing transmission. Box 1 provides an overview of what not to do in the management of CDI. 

The following Tip Sheet can be disseminated to LTCF staff for educational purposes and quick reference. 

References

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