Clostridium difficile Rozila Horton School of Healthcare – University of Leeds

1. Clostridium difficileRozila HortonSchool of Healthcare – University of Leeds

2. Learning Outcomes • Have an insight into the pathogen • Consider the risk factors for patients • Examine the management of infected patients • Understand the Chain of Infection for Clostridium difficile

3. The Infectious Agent A gram positive, anaerobic, spore forming bacillus Usual habitat - large intestine where there is very little oxygen Found in <5% of health adults Described in 1935 as a component of normal body flora in the newborns Background Named difficile because it grows slowly in culture Kept in check in adult carriers by the normal ‘good’ bacteria Does not affect newborns & infants as the toxin does not damage their immature intestinal cells Clostridium difficile – (C. diff) The role of C.diff in antibiotic-associated diarrhoea and colitis was recognised in the 1970s (DoH 2005)

4. Risk Factors • Normal healthy bacterial bowel flora killed off by antibiotics, mainly broad-spectrum antibiotics. The mains ones quoted include: - cephalosporins, ampicillin/amoxicillin and clindamycin BUT - erythromycin, clarythromycin & azithromycin also implicated as are others • C.difficile, normally held in check by the normal flora, can now multiply Gronczewski (2003) http://www.emedicine.com/med/topic3412.htm

5. Risk Factors – Contd. • Produces 2 types of toxins (A & B) that damage the cells lining the intestine – results in diarrhoea • C.difficile forms heat-resistant spores that are excreted in large numbers in liquid faeces – spores canpersist in the environment for several months to years • Diarrhoea often develops during or shortly after starting antibiotics • 25-40% may not become symptomatic for as many as 10 weeks after completing antibiotic therapy Gronczewski (2003) http://www.emedicine.com/med/topic3412.htm

6. Spread • Contamination of the environment occurs: - around the patient’s bed (surfaces, equipment, keypads) - floors - the toilet areas - sluice - commodes - bedpan washers etc. • Source of hand-to-mouth infection for others • Transported on hands of staff who have direct contact with infected patients and with environment

7. Symptoms – range from: • diarrhoea—mild, moderate to severe—explosive, foul smelling • abdominal pain / cramp • pseudomembraneous colitis (adherent yellowish-white plaques on the intestinal mucosa) • ulceration & bleeding from the colon (colitis) • electrolyte imbalance • perforation of bowel leading to peritonitis —rare Type 027 – very capable of spreading between patients - responsible for severe disease - high mortality

9. Management • isolate—follow Isolation Protocol • keep door shut • discontinue antibiotics • metronidazole if diarrhoea persists • vancomycin often recommended if metronidazole not effective • thorough environmental cleaning Handwashing – with soap & water as alcohol gel does not kill spores

10. Organisational Requirement Standards for Better Health – Core Standard C4(a) “Healthcare organisations keep patients, staff & visitors safe by having systems to ensure that risk of HCAI to patients is reduced with particular emphasis on high standards of hygiene and cleanliness, achieving a year on year reductions in MRSA” Universal ‘Standard’ Precautions are designed to help achieve this Standard

11. Universal Standard Precautions – Steps for C.diff thorough hand hygiene protective clothing management of spillage of blood and body fluids, excretions and secretions decontamination of used equipment handling and disposal of clinical waste & used linen patient placement

12. Universal Standard Precautions - Steps thorough hand hygiene protective clothing skin protection of cuts, wound, lesions safe handling and disposal of sharps and prompt and appropriate actions in cases of sharps injury management of spillage of blood and body fluids, excretions and secretions decontamination of used equipment handling and disposal of clinical waste & used linen patient placement

13. Clostridium difficile (toxin producing) result of antibiotics disrupting normal gastrointestinal flora Susceptible Host mainly people receiving or who have received antibiotics Reservoir/source humans C.diff - The Chain Entry Route gastro-intestinal system • Exit Route • faeces Transmission hands of healthcare workers

14. Informed Infection Control Care Finally, the delivery of care should be based on understanding the factors, which predispose patients, and sometimes staff, to risks of infection and actions, which can be taken to prevent or minimise these hazards.

15. References http://www.cdc.gov/ncidod/hip/gastro/ClostridiumDifficile.htm http://www.hpa.org.uk/infections/topics_az/clostridium_difficile/menu.htm http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4115883&chk=yr9/gq http://www.emedicine.com/med/topic3412.htm http://www.leedsteachinghospitals.com/sites/infection_control/