Quick Guide: Clostridium difficile Infection Control
Clostridium difficile is a spore-forming, Gram-positive anaerobic bacteria that causes an estimated 25% of all cases of antibiotic-associated diarrhea.1 Elderly persons residing in long-term care facilities are at high risk of C difficile infection (CDI) because of advanced age, the presence of comorbidities, and high exposure to antibiotics. The symptoms of infection create a substantial burden on frail, vulnerable elderly persons, including diarrhea, fever, loss of appetite, abdominal pain, and nausea, all of which can contribute to poor outcomes. In recent years, a more virulent strain of C difficile has emerged. Now collectively referred to as NAP1/BI/027, the new strain of C difficile is noted to be more frequent and refractory to therapy, causing more severe cases of CDI worldwide and increasing the rate of hospital readmissions due to recurrent CDI. The World Health Organization (WHO) recently published an important report illustrating the most comprehensive picture of antibiotic resistance to date, with data gleaned from 114 countries.2 In its report, the WHO described C difficile as an “urgent threat,” to public health, noting that although C difficile is not currently significantly resistant to antibiotics used to treat it, it has a unique relationship with resistance issues, antibiotic use, and high rates of morbidity and mortality. Since the WHO has sounded the alarm on this and other drug-resistant “superbugs,” long-term care professionals are urged to prevent and control outbreaks of CDI.
Clostridium difficile Infection Control in Long-Term Care
In its report, the WHO stresses the importance of antibiotic stewardship programs for preventing CDI.2 Inappropriate, overprescription of antibiotics is a widespread problem in nursing homes; however, efforts to reel in this practice have been stunted by institutional attitudes toward delayed or withheld prescribing, a lack of standardization among the components of an effective antibiotic stewardship program, and a lack of guidance on program implementation and evaluation methods.3 Overcoming these barriers for CDI prevention will likely take years of research, education, and facility-wide culture change. In the interim, long-term care professionals can take an active role in preventing the spread of CDI among residents.
Treatment of the infection is challenging and not always successful in elderly long-term care residents. The burden of initial CDI is compounded by the high rate of recurrent CDI, which is defined as the presence of diarrhea and a stool test result positive for the presence of toxigenic C difficile or its toxins within more than 2 weeks and 8 weeks or fewer of the initial positive test result. Recurrent CDI can be caused by reinfection from a different strain of C difficile or relapse from the same strain as initial infection. According to a recent study, approximately 13% of patients with a principle or secondary diagnosis of CDI during hospitalization are readmitted for any type of CDI,1 and 50% of CDI cases are due to reinfection from a different strain of C difficile.4
Most guidelines advise that the first step to treating CDI is to stop the inciting antibiotic as soon as possible. Ongoing treatment with antibiotics is associated with increased duration or diarrhea and increased risk of hospital readmission for recurrent infection. However, if ongoing antibiotic therapy is necessary to treat the primary infection, prescribers must consider an antibiotic that is less frequently associated with CDI and is also safe to take with the patient’s other medications. This can be difficult as elderly persons residing in long-term care settings are taking, on average, 7 or more medications for managing multiple acute and chronic conditions.5
Environmental strategies are also crucial to resolving CDI and preventing its outbreak among other residents. As C difficile is shed through feces, CDI most often occurs via fecal–oral transmission; for example, when a healthcare worker who has touched a contaminated surface has direct contact with a patient. The frequency of person-to-person contact in long-term care settings is higher, increasing the risk of C difficile transmission. As such, the burden of primary CDI and recurrent CDI can be substantially reduced with conscientious application of infection control guidelines. However, as a recent study revealed, very few long-term care facilities have developed CDI-specific policies.5 In 2002, the Society for Healthcare Epidemiology of America (SHEA) published a position paper based on available evidence outlining recommended CDI prevention strategies in the long-term care setting.7 Additionally, in 2012, SHEA and the Infectious Diseases Society of America (IDSA) released clinical practice guidelines for controlling the spread of CDI in adults.8
In the absence of national regulatory guidelines for managing CDI specifically in the long-term care setting, facilities are encouraged to follow the IDSA and SHEA’s guidelines, which are outlined in a table that you can access by logging in above and downloading the PDF version.
References
1. Elizhauser A, Steiner C, Gould C. Readmissions following hospitalizations with Clostridium difficile infections, 2009. Statistical brief #145. Healthcare Cost and Utilization Project Statistical Briefs. 1.usa.gov/1uB3VmB. Published December 2012. Accessed September 15, 2014.
2. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. 1.usa.gov/1qixxyR. Accessed September 15, 2014.
3. Nicolle LE. Antimicrobial stewardship in long term care facilities: what is effective? Antimicrob Resist Infect Control. 2014;3:6.
4. Chopra T, Krishna A. Managing Clostridium difficile infection on the verge of the postantibiotic era. Annals of Long-Term Care: Clinical Care and Aging. 2014;22(7-8):29-31. bit.ly/1y7Z3Jx.
Accessed October 15, 2014.
5. Gnjidic D, Le Couteur DG, Kouladjian L, Hilmer SN. Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing and clinical outcomes. Clin Geriatr Med. 2012;28:237-253.
6. Archbald-Pannone L. Survey of C difficile-specific infection control policies in local long-term care facilities. Int J Clin Med. 2014;5(7):414-419.
7. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile in adults: 2010 update by the Society for Healthcare Epidemiology of America and the Infectious Disease Society of America. Infect Control Hosp Epidemiol. 2010;31(5):431-455.
8. Simor AE, Bradley SF, Strausbaugh LJ, et al. Clostridium difficile in long-term-care facilities for the elderly. Infect Control Hosp Epidemiol. 2002;23:696-703.
9. Scott DR. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. 1.usa.gov/1DbKWTD. Published March 2009. Accessed September 15, 2014.
10. Centers for Disease Control and Prevention. Healthcare-associated infections. 1.usa.gov/1sbv3E7. Updated November 2012. Accessed September 15, 2014.
