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C. difficile Infections Hit All-Time High

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Why is It So Difficult to Control CDI?

The recent alarm by the Centers for Disease Control and Prevention which reports on the increasing incidence and burden of Clostridium difficile infections (CDI) in the United States is drawing attention to a phenomenon which is already well- known to gastroenterologists and infectious Ddisease physicians worldwide. In fact, the sweeping changes in the epidemiology of CDI – with reports of increasing rates, outbreaks, and elevated morbidity and mortality since 2002 originally in parts of Canada and the United States – has now been described in almost every developed country which keeps statistics on this infection.

The only fact which is even more alarming in the CDC’s report is that there has not been any “leveling off” or abatement in this health care–associated complication in the U.S. Although GI and ID physicians, hospitalists, and many other health care providers around the globe have been aware of the disquieting rise in CDI since 2002, the hoped-for stabilization or reduction in its incidence due to aggressive infection prevention and control (IPC) techniques, as has been seen in the U.K., has not materialized in the U.S. and central Canada.

Why is it so difficult to control CDI? Because it requires the accomplishment of multiple simultaneous aggressive IPC maneuvers – all of which must be done correctly -– in order to overcome this infection on an institutional level:

- Appropriate antimicrobial use and stewardship

- Rapid testing, isolation, and treatment of any patient with diarrhea who has recently received antibiotics, while awaiting test results
- Rigorous hand-washing and appropriate use of personal protective equipment when in contact with suspected or confirmed cases
- Meticulous and frequent environmental cleaning with sporicidal agents which are tolerable to patients and personnel
- Attention to cleaning and disinfection of the innumerable shared pieces of medical equipment, like blood pressure cuffs, thermometers, bladder scanners, and the like
- High level of scrutiny for quickly detecting and treating recurrences, which occur in 15%-40% of CDI patients
- Real-time surveillance to detect outbreaks and effect heightened measures, when necessary.

The “new CDI” has demonstrated itself to be an unforgiving infection in health care facilities. Any lapse in one or more of the above IPC interventions is enough to cause a rise in the incidence or complication rate.

It is unclear exactly why the “new CDI” is behaving as it does. Certainly, the appearance of a new hyper-virulent strain with additional fluoroquinolone resistance (on top of C. difficile’s “usual” multi-drug resistance), a mutation in the toxin regulator gene, and a seemingly greater propensity to sporulate (and thus resist disinfection) appears to be the event which has coincided with the re-emergence of this disease during the past 10 years.

However, not all of the clinical aspects of this “new CDI” can be explained by these findings alone. For instance, the rapid progression from diarrhea to fulminant colitis in the elderly and the immunocompromised, the high recurrence rate (compared with historical controls) and the elevated morbidity (i.e., colectomy and need for intensive care) and mortality remain unnerving manifestations without a real explanation.

The number of scientific publications describing the new epidemiology, pathogenesis, and prophylactic or treatment options has risen impressively over the past several years in order to gain an understanding of this relentless bacterium.

Medical journals are not the only place for CDI-related news, however. The internet and social media sites are rife with stories of personal tragedies from this affliction. Typical stories like a healthy grandfather undergoing uncomplicated elective surgery but then dying from antibiotic-induced CDI during or soon after his hospitalization are too commonly detailed in surveillance data and in personal blogs.

Sites dedicated to and run by patients who have suffered from CDI compete with other sites established by the all-too-commonly depressed individuals who have had to undergo a therapeutic colectomy or who are suffering multiple recurrences of this disease and are searching for centers offering a fecal transplant.

There is no doubt that the true tragedy of CDI, a health care complication with an attributable mortality of almost 15% in the frail elderly over 85 years of age, is the fact that it is more likely to kill than the primary cause of hospitalization (such as a pneumonia, cellulitis, or hip fracture) in this population.

At a time when CDI is clearly overcoming our ability to control it in many parts of the world, it remains puzzling why the U.S. and many European countries do not yet have a true, real-time local and national CDI surveillance network for tracking the number of cases.

Using hospital discharge data or disease coding has been shown to be inaccurate and too late to be of immediate use. Real-time local, state, and national CDI surveillance is essential in telling us where we are, where we are going, and what we have to do to control this affliction. There is clearly a battle going on between health care providers and CDI in many countries, including the U.S. and Canada. We need to use as many tools and tricks as possible to gain control. This is one war we cannot afford to lose.

MARK MILLER, M.D., FRCPC, is Chief, Infectious Diseases, and Head, Infection Prevention and Control Unit, Jewish General Hospital, Montreal.


 

Clostridium difficile infections have reached an all-time high in the United States, and 94% of these infections initiate with medical care, based on data from the Centers for Disease Control and Prevention. C. difficile–related deaths increased from 3,000 in 1999-2000 to 14,000 in 2006-2007, according to the CDC.

The data were published as a CDC Vital Signs report and were presented in a telebriefing on March 6.

C. difficile is "a formidable opponent," and a patient safety issue everywhere that medical care is provided, said Dr. Clifford McDonald, a CDC epidemiologist and the lead author of the report. CDC’s data show that 25% of C. difficile infections first appear in hospitalized patients, while 75% occur either in nursing home residents or in people recently treated in doctors’ offices or clinics. People most at risk are those who take antibiotics and receive care in an outpatient setting.

Courtesy CDC/Dr. Gilda Jones

Clostridium difficile infections, "a formidable opponent," continue to plague patients of all sorts.

In general, the risk of developing C. difficile increases with age; although half of C. difficile infections occur in those younger than 65 years, 90% of C. difficile-related deaths occur in those aged 65 years and older, said Dr. McDonald.

He said that clinicians can help reduce C. difficile infections by following six steps:

• Prescribe antibiotics judiciously.

• Be proactive about testing patients for C. difficile if they develop diarrhea while taking antibiotics.

• Isolate patients with C. difficile.

• Wear gloves and gowns when treating C. difficile patients, even for short visits.

• Clean surfaces in exam and treatment rooms with bleach or other spore-killing products.

• When a patient transfers to another facility, notify the medical team about a C. difficile infection.

Also, be sure to order the appropriate cultures to determine whether antibiotics are really needed, Dr. McDonald suggested, and watch for signs that signal C. difficile. "Antibiotic-associated diarrhea is very common," but C. difficile accounts for only about one-third of that, he said.

However, certain clues suggest C. difficile, including more than three unformed stools in 24 hours, fever, abdominal pain, diarrhea that continues once an antibiotic has been discontinued, or diarrhea that began only once an antibiotic was discontinued, he said.

If someone has been on antibiotics, think about C. difficile early and get them tested, whether they are patients in inpatient or outpatient facilities, Dr. McDonald emphasized.

To determine the current prevalence of C. difficile, CDC researchers reviewed data from their Emerging Infections Program, which conducted population-based surveillance from eight geographic areas, and the National Healthcare Safety Network (NHSN). In 2010, a total of 10,342 cases of C. difficile infection were identified via the Emerging Infections Program in 2010, and a total of 42,157 incident laboratory-identified CDI events were reported via the NHSN.

On a positive note, early results from state-led programs in Illinois, Massachusetts, and New York showed that hospital collaboration can reduce C. difficile infections, Dr. McDonald said. The 71 hospitals in these states that participated in C. difficile–prevention programs reduced infection rates by 20% over 21 months. "These promising results follow similar efforts in England, a nation that dropped C. difficile infections by more than 50% during a recent 3-year period," the CDC researchers said in the full report (MMWR 2012;61:1-6).

For additional information about tracking HAIs infections, contact the Emerging Infections Program or the NHSN.

Dr. McDonald had no financial conflicts to disclose.

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