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Review microbiology and epidemiology of
Clostridium difficile
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Gram positive spore forming bacillus (rods)
Obligate anaerobe
Part of the GI Flora in
◦ 1-3% of healthy adult
◦ 70% of children < 12 months
Some strains produce toxins A & B
Toxins-producing strains cause C. diff Infection
(CDI)
CDI ranges from mild, moderate, to severe and
even fatal illness
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A common cause of nosocomial antibiotic-
associated diarrhea (AAD)
Most common infectious cause of acute diarrheal
illness in LTCFs
The only nosocomial organism that is anaerobic
and forms spores (survive> 5 months and hard to
destroy)
Pathogenesis is mainly due to toxins production
Infective dose is < 10 spores
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Fecal – oral route
◦ Contaminated hands of healthcare workers
◦ Contaminated environmental surfaces.
Person to person in hospitals and LTCFs
Reservoir:
◦ Human: colonized or infected persons
◦ Contaminated environment
C. diff spores can survive for up 5 months on
environmental surfaces.
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Colonized
no symptoms
Antimicrobials
Admitted to
healthcare facility Infected
Symptomatic
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Exposure to antimicrobials (prior 2-3 months)
Exposure to healthcare (prior 2-3 months)
Infection with toxogenic strains of C. difficile
Old age > 64 years
Underlying illness
Immunosuppression & HIV
Chemotherapy (immunosuppression & antibiotic-like
activities)
Tube feeds and GI surgery
Exposure to gastric acid suppression meds ??
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Very commonly related Less commonly related Uncommonly related
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Illness caused by toxin-producing strains of
C. difficile ranges from
◦ Asymptomatic carriers = Colonized
◦ Mild or moderate diarrhea
◦ Pseudo membranous colitis that can be fatal
A median time between exposure to onset of
CDI symptoms is of 2–3 days
Risk of developing CDI after exposure ranges
between 5-10 days to 10 weeks
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Watery diarrhea ( > 3 unformed stools in 24 or
fewer consecutive hours)
Loss of appetite
Fever
Nausea
Abdominal pain and cramping
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Test Advantage Disadvantage
Testing Enzyme • Detects toxin A or both A & B Less sensitive
Toxins immuno-assay • Rapid (same day) 63-94%
(EIA)
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Testing should be performed only on diarrheal
stool
Testing asymptomatic patients is not indicated
Testing for cure is not recommended
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For clinical use: two-step testing uses initially EIA
detection of GDH for screening followed by
cytotoxicity assay or toxigenic culture for
confirmation
Gold standard is stool culture followed by toxigenic
culture assay
Toxin is very unstable, degrades at room
temperature, and undetectable within 2 hours (false
negative results)
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Case definition
Clinical: presence of diarrhea AND
Laboratory: A stool test result positive for toxigenic C.
diff or its toxins OR colonoscopic / histopathologic
findings demonstrating evidence of pseudomembranes
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Surveillance definitions of CDI by time of onset:
Healthcare facility (HCF)-onset, HCF-associated CDI Onset >
48 hrs of admission
Community-onset, HCF-associated CDI Onset in the
community or within 48 hours of admission and within < 4 weeks
of the last discharge
Community-associated CDI Onset in the community but within
more that 12 weeks of last discharge
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Admission Discharge
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At minimum: conduct surveillance for HCF-
onset, HCF-associated to
detect outbreaks
monitor patient safety
Rate of HCF-associated CDI (number of cases
per 10,000 patient-days
Compare your rates with other facilities
In outbreaks stratify rates by patient location
in order to target control measures
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2.5
Male
Female
2.0 White
Black
Entire US population
1.5
Rate
1.0
0.5
0
1999 2000 2001 2002 2003 2004 2005 2006
Year
*Per 100,000 US standard population
Heron et al. Natl Vital Stat Rep 2009;57(14).
Available at http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf
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Contact Precautions for duration of diarrhea
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Extend contact precautions beyond duration of
diarrhea (48 hours)
Presumptive isolation for symptomatic patients
Implement soap and water for hand hygiene before
exiting room of a patient with CDI
Implement universal glove use on units with high CDI
rates
Use sodium hypochlorite (bleach) - containing agents
for environmental cleaning
Implement an antimicrobial stewardship program
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Core Supplemental
Gloves/gowns on room Extend use of contact
entry precautions beyond
Private room (preferred) or duration of diarrhea
cohort with dedicated Presumptive isolation
commodes Universal glove use on
Dedicated equipment units with high CDI rates
Maintain for duration of Intensify assessment of
diarrhea compliance
Measure compliance
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Identify and remove environmental sources of C. diff
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