Clostridium Difficile

Introduction

According to Bouza (2005), Clostridium Difficile is a bacillus that is gram positiveandforms spores. Its mainmode of distribution is theenvironmentwherebyitalsocolonizes 3-5% of allhealthyadults without causinganysymptoms that can be noticed. At infancy, clostridium difficilecolonizes between 2% and 70%, buttheratesdecrease with advancement in ageandfalling to about 6% whentheinfantgrows to two years. Above theage of two, therate of clostridium difficile is muchsimilar to that of an adult, around 3% (APIC, 2008). Thestrainsresponsiblefortheproduction of clostridium difficile are characterized by their ability in the production of bothtoxins A and B. The mostcommonandrampantsymptom of CDI is diarrhea that is not alwaysbloody, but can range from thesoftandunformedstools to the watery and mucoid stools.Otheroutstandingsymptomsinclude abdominal painsandfeverand cramping in others.

Clostridium difficile spores are highlyresistant to destruction by most of the environmental agentsandconditions. Their resistance can go as far as resistingsome of thechemicalsused in disinfection (Zanotti-Cavazzoni, 165). Therefore, thisgives clostridium difficiletheability to surviveformonthsor longer in theenvironmentandeven in healthcare facilitiesandthesurroundingcommunity. Mainly, thespread of clostridium difficile is through thetransfer of spores from a contaminated environment to thepatient, orperhaps through thehands of healthcaregiverswhodo not followproperhygieneand gloving practices. Theonlypropercontrolmeasure that can be adopted is thethorough disinfection andcleaning of thepatient’s environmentandalso through thephysicalremoval of the spores.

In recent decades, there has been a recordedincrease in thenumber of reportedrates of clostridium difficile-associated disease (CDAD). There has alsobeen a recording in theincreasein thenumber of outbreaksaccompanied by severediseaseandalso an increase in mortality. Theincrease in CDAD is mainlycharacterized by thefollowing; changes in theuse of antibiotics, a change in infectioncontrolpracticesortheemergence of newstrains of clostridium difficile that haveincreased virulence or antimicrobial. It is alsoimportant to comprehendthelifecycle of clostridium difficile in order to understandhow to controlitandifpossible, preventit. Its lifecyclebegins in the spore formwherebythey are becausethey are resistant to heat, antibioticsorevenacid.

In a hospitalsetting, clostridium difficile can be found in bedding, medicalequipment, and furnitureand on the caregivers. Upon ingestion, the spores pass through to theintestineswherebytheygerminateandlatercolonizethe colon. Studieshaveindicatedthatthis bacterium colonized about 21% of patientswho are in theprocess of receivingantibioticsand at thesametimeadmitted to a generalhospital. Through therelease of bothtoxins A and B, clostridium difficilelaterinduces diarrhea and colitis. However, themajorriskfactorsassociated with clostridium difficile are advancement in age, hospitalization, and antimicrobials.

There are two majorreservoirs of clostridium difficile in the healthcare setting, which are humans (asymptomatic andsymptomatic) andinanimateobjects (medicalequipmentandfurniture). The level of environmental contamination depends primarily on theseverity of thedisease of thepatient. Howeverthe asymptomatic colonized patients should be regarded as thepotentialprimarysource of thecontamination.

Clostridium difficileinfection is morerampant among theelderly in thesociety.Themainreasonsforthis are not fully, butit can be attributed to thefactthattheelderlypatientshave a muchlesseffectivebarrier to infection. Theimportance of havingage as a riskfactor is characterized by theagedistribution in lab reports as wasreceived by CDSC during theresearchperiod of 1990-1992. Resultsshowedthat there was a biasforadults over theage of 65 andtheyweremoresusceptible to havingseverecases of clostridium difficileinfections. There havealsobeensuggestionsthat clostridium difficile is endemic in facilities that are considered long-stay fortheelderly. However, otherstudiesindicatethatthedifference in the endemic nature of clostridium difficile may be as a result of case mix wherebypatients are from otherfacilitieswherebytheinfectionratewashigh. Also, clostridium difficile is endemic in many of the long-stay facilitiesbecausetheelderlytend to stay longer in theacutewards than theotheryoungergenerations. Therefore, their increasedrisk of infection is attributed to theincreasedexposure to antibioticsand nosocomial pathogens.

There are severalpatientcareactivities that provide a rifeopportunityforthe fecal-oral transmission of clostridium difficile (CDC). Suchactivitiesinclude; sharing of electronicthermometers that havebeenusedformeasuring rectal temperatures, oralcareor suctioning wherebythehandsorequipmenthavebeencontaminated, administration of contaminated food, medicationor with contaminated handsandemergencyprocedures like intubation. Otherfactors like poorhandhygiene, improper environmental andequipmentcleaningand disinfection havealsobeenreported as a causeforinfectionandspreading of clostridium difficile. It has been rubber stampedthattheenvironment is themajormedium of spreadingfor clostridium difficilewherebyit has beenspreadsowidelythatthatit is impossible to point out a singlelocation that has not beencontaminated. However, theenvironment of the infected patients is rifest with clostridium difficile, forinstance, thetoilets, floors, sinksandlinen. Despite disinfection, clostridium difficile spores are found to existlonger than five months.

Preventionandcontrol of clostridium difficile is theresponsibility of everyindividualwho is aware of its existence. Therefore, preventionmeasures must be endorsed by everyone, andespecially in caregivingfacilitieswherebyindividuals are morelikely to spreadtheinfection. Standardprecautionsrefer to thosepractices at work that are applied to everypersonregardless of their confirmedorperceivedinfectiousstatus. Standardprecautions are thefrontline in thewar against clostridium difficile. Theyhelpcontroltherate of infection from person to person, even in themostprolificriskscenarios. Theyinclude; handhygiene before and after contact with thepatient, thesafeuse as well as disposal of sharps, theuse of protectiveequipmentandthe processing of reusable medicalequipment. Theproperhandling of linen, safety in themanagement of waste as well as aseptic non-touch techniqueshould also be in thestandardprecautions to be implemented in hospitalfacilities.

However, whenthefirstline of defensedoes not seem to work efficiently, there should be a backup plan in place. Thus, whenstandardprecautionsdo not seem to dothejob, transmission based precautions should be implemented. These are additionalworkpracticesforindividually identifiable situations that are putin place to interruptthetransmission of clostridium difficile. Theseprecautions are tailored to specificinfectionsand their mode of transmission. Theyinclude; continued implementation of standardprecautions, havingpatientdedicatedequipment, properhandling of equipment, enhanced cleaningand disinfection of thepatient’s environmentandtherestriction of patients within thefacilities.

Since healthcare settingsdiffergreatly in terms of their day-to-day functioning, it is hard to come up with a managementproposal that would fitallfacilities. Therefore, all healthcare facilities should conductinfectionpreventionriskassessment on a regularbasis alongside adoption of detailedprotocolsandprocessesforinfectioncontrol. In acutecaresetting, personalprotectiveequipment should be providedfornursesandvisitors outside theroom of a patientwho has confirmed clostridium difficileinfection. Healthcare givers should useglovesandgowns in order to preventfurtherspread of infection. Conductingeffectivehandhygiene is necessaryforlimitingthespread of clostridium difficile. They should be performedfrequentlyand with thefollowingconsiderations; should be performedusingthe Four Moments of Hand Hygiene, should be performed at the point-of-care using a dedicated staffsinkortheuse of hand wipes that havebeenimpregnated with antimicrobials oralcoholandsoap.

In acutecaresetting, especiallywheretheelderly are residingpropercare has to be consideredprimarilybecausethey are moresusceptible to infection (Rupnik, 2007). One suchmeasure of preventing clostridium difficileinfection is placingthesuspectedorconfirmedpatients with CDI in a confinedroom that has dedicatedtoilets, sinksandpersonalequipment. Moreover, there is littleneedforspecialtreatmentforlinen in an acutesettingforbothconfirmedandsuspectedpatients. Linenforsymptomaticand asymptomatic patients should be in thesameway. Thesoiledlinen should be carefully. Forexample, it should be placed in a no-touch receptacle in order to avoidcontamination of boththeenvironmentandthepersonsaround.

In cases of outbreaks, routineinfectioncontrolmeasures are of graveimportance in order to preventthespread of the clostridium difficileinfection to patientswhohave not yetbeenaffected. The antibiotic policieshave to be monitored as well as their compliance in order to successfullycontrolthespread of infection. Handwashingprocedures should be followed to thelatter by anypersonwho is in contact with infected patientssuch as doctors, nurses, paramedical staffandstudents. Nurses presentchallenges in combating clostridium difficileoutbreaksespeciallybecause of thenecessity to create a homelyenvironmentforthepatients. Thismeansthattheyhave to constantlycheck in with thepatientsandthereforetheybecomeconstantly at risk of infection themselves in properprecaution is not taken.

Forpatients in theelderlyacutecarewards, the surroundings are also tailored to ensure a comfortablestay in thehospital. Therefore, their soft furnishings andcarpetedfloorsprovide a challenge in cases of outbreaks. Forinstances like this, preventivemethods of combating thespread of clostridium difficilehave to be implemented. One suchmeasurethat should be used during cleaning is steam. Althoughtheheatdoes not killthe pathogen, ithelps in the containment of its spread. Patients are alsosusceptible to contracting infection from thecaredevicesused in thehospital. Suchdevicesincludeelectronicthermometersor glucose measuringdevices. Thesedevices are in constantuseand may be used by a variety of patients. Thesedevices are with pathogens derived from bodyfluids. Thusit is important to havemeasures in place to sterilizethesedevicesespeciallymorethoroughly in times of outbreaks.

Anotherpiece of communalapparatususedin wards is the linen, clothing, uniforms, lab coatsandisolationgowns. Because clostridium difficile is commonly in theenvironmentand can lastformore than five months, thesepieces of clothing are always in contactandpossiblecontaminations are likely (Dubberke, 17). Howeverindirectcontact of suchclothingcomes from bedpans, toiletsandsinks of patientswho are eithersuspectedorconfirmed to be infected. Thepresence of soiledlinen is also an area of importance that should be looked into carefully. Becausebedlinen is in hospitalsandwards, they should be cleanedand sanitized before they can be issued to a differentpatient. In order to helpcombatthespread of clostridium difficile, the CDC has come up with the Spaulding classificationsystem, which identifies three risk levels that are associated with surgicalandmedicalinstruments (Michel, 1095). These levels are; critical, semi-critical and noncritical.

Criticalitemsincludeneedles, indwelling urinary catheters and intravenous catheters. These are theitems that normallyenterthesteriletissue, the vascular tissueor through which bloodflows. Based on one of theaccepted sterilization procedures, theequipment has to be sterile before penetratinganytissue. Semi-critical itemsincludethermometers, electricrazorsand podiatry equipmentandthey are as thosethattouch mucous orskin which is not intact. Theyrequiremeticulouscleaningandthereafterfollowed by high-level disinfection. Disinfection is doneusing a chemo sterilizer agent that is approved by the FDA.

In conclusion, clostridium difficile has been on therise in recent decades andit is only through properpreventionandcontrolmeasuresthatit can be. Since it can live in an environment in spore formfor up to five months, it poses a challenge in terms of containment. On theotherhand, theelderly are moresusceptible to clostridium difficileprimarilybecause of their lowimmunityand their prolongedstay in hospitals. However, with propercare, chances of outbreaks can be kept at a minimum andmorelives can be through preventioninstead of cures.

References

Dubberke, Erik. "Strategies for prevention of Clostridium difficile infection."Journal of Hospital Medicine7.S3 (2012): S14-S17. Print.

"Patient Cloth Chairs and Clostridium difficile Outbreak."American Journal of Infection Control37.5 (2009): E102-E103. Print.

Rupnik, Maja.Abstract book: Clostridium difficile : organism, disease, control & prevention. s.l.: [Organizing committee ICDS], 2007. Print.

Zanotti-Cavazzoni, S.l.. "Analysis of an outbreak of Clostridium difficile infection controlled with enhanced infection control measures."Yearbook of Critical Care Medicine2010 (2010): 164-166. Print.

"clostridium difficle."Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 1 Mar. 2013. Web.30 Apr. 2014.