Clostridium difficile-associated disease

by the Infection Prevention and Control Committee

The increasing incidence and severity of Clostridium difficile-associated disease (CDAD) is a serious concern. Therefore, focusing attention on the prevention and elimination of this infection is paramount for our healthcare system. The Centers for Disease Control and Prevention has produced an excellent Web site regarding the epidemiology and treatment of C.difficile: http://www.cdc.gov/ncidod/dhqp/id_Cdiff.html.

Highlights from a 2009 presentation from the HCA Clinical Services Group:

  • 3 to 5 percent of healthy adults and 16 percent to 35 percent of inpatients might be colonized with C. difficile.
  • Antimicrobial exposure is major risk factor for disease. In fact, 90 percent of healthcare associated infection occurs during or after a course of antimicrobial therapy.
  • Although the elderly are most greatly affected, more disease has been reported in "low-risk" persons, including healthy persons in community, peripartum women
  • APIC national prevalence study of CDI in U.S. healthcare facilities showed 13 of every 1000 in-patients in the survey were either infected or colonized with Clostridium difficile (94.4 percent infected).  This is much higher than previous estimates. [November 11, 2008  www.apic.org]
  • Work-up for C. difficile is indicated:
    • for those patients whom with nosocomial diarrhea due to non-infectious causes has been excluded (osmotic diarrhea due to oral nutrition, non specific diarrhea):
    • Patients with febrile diarrhea, with or without leukocytosis.
    • Patients with diarrhea that persists after discontinuing the offending drug.
    • Patients with diarrhea and previous hospitalization and / or antibiotic use.
  • The antigen test we use has sensitivity greater than 90 percent.
  • Ordering C. diff times three is unnecessary, but if there is a strong suspicion, it is not unusual to repeat the test
  • After treatment it is not necessary to re-test (many patients are colonized) if the patient doesn't have any symptoms. If the patient develops diarrhea again, repeat testing would be indicated because of the 25 percent relapse rate.
  • Refer to the C. diff order set for treatment guidelines: for mild disease Flagyl (metronidazole) for 10 days is standard; for severe CDAD or failure to improve on Flagyl, oral vancomycin for 10 days is usually recommended.

Hand hygiene and strict isolation precautions are still the best methods to help prevent infection. Since alcohol has been shown not to be effective in inactivating the spores of C. difficile, washing with soap and water is preferred for healthcare providers caring for a patient with known or suspected C.difficile. Bleach wipes should also be available for use on the isolation carts.  The contact isolation signs should have a "blue dot" on them indicating the "special precautions."