Prof A Simor addressed the challenge of Clostridium difficile infection (CDI) by posing some leading questions:
- why is C difficile infection so challenging in the 21st century? and
- why is this happening now?
1 Fast facts
The challenge of CDI:
- changing epidemiology in the Northern Hemisphere - increasing incidence & severity
- linked to apperance of ‘hypervirulent’ NAPI strain, aka ribotype 027
- increasing need for CDI-related colectomy, increased attributable hospital stay, readmission & mortality
Recent changes:
- possible changes in environmental cleaning or infection control practice
- changes in mix or total use of antibiotics
- changes in C difficile such as increased virulence, toxin gene regulation, antibiotic susceptibility
2 Overview of CDI
3 Keynotes
CDI risk factors: age > 70 yrs, small bowel obstruction, colorectal inflammation on CTS, raised WCC or creatinine, low albumin
Case outline: hospitalised patient with diarrhoea, who had antibiotics in last two months, often with fever and raised WCC
Laboratory confirmation: anaerobic stool culture takes 3-5d to show toxigenic strain; cytotoxin assay by cell culture may lack sensitivity; early EIAs for toxin A only; PCR-based assays sensitive & specific and can be same day
Treatment: new recommendations divide CDI into moderate, severe & severe-complicated; revised guidelines in preparation emphasise superior effect of Vancomycin over Metronidazole in severe disease; however, no treatment regimen shown to be 100% effective; none completely prevent recurrent in % CDI patients
Prevention: still unclear whether through infection control or restricted antibiotic use; evidence supports both; hand hygiene, environmental cleaning and private hospital rooms combined with antibiotic stewardship probably all have a place in CDI prevention; role of probiotics is less clear
Decontamination: ["the patient's environment has a faecal veneer"]
- increased risk of CDI in room mates of patient with CDI
- increased level of environmental contamination
- increased carriage of C difficile on hands of health care workers
- most effective agents are chlorine-based disinfectants or vaporised H2O2
Notes by μgnome; insight by Prof A Simor, 12th March, 2010.
