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Dr. Cliff on Tackling C. difficile – Part 1 of 3

Posted on by CDC's Safe Healthcare Blog
C. difficile
C. difficile

Dr. L. Clifford McDonald
Prevention and Response Branch Chief in CDC’s Division of Healthcare Quality Promotion

In this blog series, I would like to talk about a healthcare-associated infection (HAI) that I have spent a good portion of my career tackling – Clostridium difficile (C. difficile, or C. diff for short). C. difficile is a bacterium that causes a range of potentially serious intestinal conditions such as diarrhea and colitis. Unfortunately, people who are most at risk for C. diff infections are also the most vulnerable, such as the elderly and other hospitalized patients.

In short, C. difficile is having a major impact on healthcare. It causes 500,000 infections each year, resulting in nearly 30,000 deaths and costing the system almost $4 billion a year. We at CDC believe that an especially strong, widespread epidemic strain is the cause of many of these infections.

A major risk factor for C. diff infection is recent antibiotic use, as these drugs upset the balance of bacteria in the gut and allow C. diff entering the body to grow aggressively. In fact, 90% of C. diff infections occur in people who recently took antibiotics. People become infected when they touch things that are contaminated with feces and then touch their mouth or face. Healthcare workers can spread the bacteria to patients or contaminate surfaces through hand contact. Although most of our research shows that only people who are hospitalized or who are on antibiotics are likely to become ill, any person who is infected can spread the organism to any other person.

There are several national and local efforts underway to prevent C.difficile infections. These include:

Next week, colleagues from APIC will discuss how infection preventionists are tackling C. difficile, and SHEA will dive more into antibiotics’ role in C. diff. In the meantime, I am interested to hear your thoughts on C. diff and how to best prevent these infections.

Posted on by CDC's Safe Healthcare Blog

27 comments on “Dr. Cliff on Tackling C. difficile – Part 1 of 3”

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    My children and I all have C-Diff without the classic symptoms of watery diarrhea, at most the diarrhea symptoms have been the least disabling part of it, it has lasted is 1-2 days with the other times having intense gastro pain, nausea, extreme fatigue, bloating, and a sluggish bowel. If you tell a doctor that you feel blocked or constipated, the last thing they will test for is C-Diff. Odor is different, yes, but not like horse manure like always described, so there is a distinct discrepency in the diagnostic guidelines. I spent hours researching and educating myself so that I felt justified in going to the ER. My gut was silent, and I had to manually provide a sample, in the public bathroom in the ER. No gloves, germicidal wipes or any sort of measures were taken to protect other patients. When I questioned this, the provided me with a package of warm wipes for bedbaths. I was appalled. I told other nurses about this and nothing was done, my partner was directed to use that same bathroom when he needed to use the restroom. I was admitted with the Dx acute diarrhea, (which was a non-issue by that point) discharged with advice on constipation and a pat on the head basically. When I balked at this, the ER doctor said, ” I am sure it is not C-Diff, but that after diarrhea we sometimes to not have a bowel movement for a few days- but that he would give me a “little poke down there” if that would make me feel better”. He sent me home, and the staff at the ER station were loudly joking over who would have to give an enema. I was leaving the ER doctor chased me down to tell me the C-Diff test was positive and quickly re-printed my discharge papers with the Dx of C-Diff and wrote a script for Vanco. I had to demand testing for myself in the ER, and was told I definitely did not have it, because I did not have watery diarrhea, but had all the other symptoms of ileus, confusion, numbness, swollen extremities and a chest pain, but no diarrhea, just necrotic mucous. Later my ID doctor told me that I was severely ill due to the neuro and systemic symptoms that I was showing when I was admitted. At that point I wanted my children tested, who were also showing signs of C-Diff. Stools were definitely “formed” and two samples were submitted the same day to the same lab. One child tested positive. The second child’s sample was rejected by the lab because the stool was formed when both samples were indeed formed. I still have not managed to convince anyone to re-test the second child, yet she has had pneumatosis from unspecified causes, and has extreme gastro issues, malabsorption, and drinks Ensure for meals, and has had these symptoms for several years. She is 19 and weighs 93lbs, a drop in 20 lbs. She sleeps close to 16 hours per day, and cannot leave the house, due to pain in her gut, numbness in her limbs, extreme fatigue, but no watery diarrhea. The testing guidelines need to change. All of her other tests have come back negative. Due to all the flagyl in our house currently, we started her on treatment and she is doing much better in the past 10 days…. She may in fact, not have C-Diff, but I am so tired of being the doctor, figuring out what is wrong with us, going to the doctor with the diagnosis in hand, asking for a specific test and not getting it, due to diagnositc criteria that contradicts the real symptomology everyday consumers, are facing. I feel like epidemics are highly undertested, until there is a pharmaceutical drug, or better yet, a vaccine available that can be purchased to cure/successfully treat the condition, then all of a sudden everyone can be tested and is prescribed the new drug. Until then, no sense in alarming the public, and people are dying, needlessly.

    I do agree with all the ideas you have presented in your post. They’re really convincing and will certainly work. Still, the posts are very short for beginners. Could you please extend them a little from next time? Thanks for the post.

    How long do we wait after finishing antibiotics to get retested for c.diff ? My mohter thought she still had it, but the symptoms quickly went away before another round of drugs. However, a test taken shortly after the antibiotics ended still showed some cells. we heard it takes some time to move out of the systemand should have waited before re-testing. now she also has a Urinary tract infection and need sto take a second antibiotic. First, should she get retested for c.diff to show it is gone and second, is thre a combined antibiotic that works on both if she has to be terated for both? Thank you.

    Magnificent goods from you, man. I’ve understand your stuff previous to and you are just extremely excellent. I really like what you have acquired here, certainly like what you are stating and the way in which you say it. You make it enjoyable and you still take care of to keep it smart. I can’t wait to read far more from you. This is really a terrific site.

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    You made a few fine points there. I did a search on the subject matter and found the majority of people will go along with with your blog. I have been

    my sister recently had 2 stool checks that came back negative for cdiff after
    a 6 month battle. i take care of my two grandchildren, ages 7 mos and 4 years.
    i was to visit my sister and my daughter wants me to find out if i would be
    bringing this back to her children and infecting them. is it that contagious from
    someone who has tested negative and would i be subject to picking it up in her
    home? my sister is almost 80 and i would like to visit her asap.

    thank you for your help

    I don’t understand it when the some of the doctors and nurses have commented that a formed stool should not be tested for c.diff. I was put on three broad spectrum antibiotics in January (30 days of antibiotics) for bronchitis. By February I had nausea, lack of appetite, weight loss, felt exhausted etc… Finally after three months of suffering and switching to a different doctor, I was tested for c.diff. I never had diarrhea. Always formed stools. Now after several treatments of flagyl (I’m allergic to vancomycin) I’m still struggling with c.diff. I have been tested for everything else and the only test that ever comes back positive, is c.diff ( 5 tests ). This past year has been the worst of my life. I pray for a miracle that I can be cured.

    I went into the hospital in Feb. with divirticulitis and came out with MRSA. I was back in for several days. Then in Aug. I had MRSA again and the antibiotic they used to treat it gave me c.diff. A few weeks later I developed a UTI and was given Cipro for three days which gave me c.diff. again. About three weeks later I devepoped c.diff. a third time and this time no one is really sure why. Now I’m on a tapering dose of vacomycin for 50 days but I live in fear of getting MRSA or some other infection and then what? Any suggestions? My quality of life has hit the skids!!

    I’m just starting my 3rd round of Metronidazole/Flagyl for C-Diff. I had colon resection surgery(colon cancer) back on June 23rd which wasn’t as bad as having to deal with this NASTY C-Diff stuff. I was in the hospital for 5 days and believe I had C Diff for weeks before anyone would listen when I told them something was wrong. I never got a fever but I have the watery diarrhea and stomach craps. I’m wondering if I will ever feel better? :((
    I feel for each and every person that has had to deal with this stuff!!

    Dear Mr. Briere,

    I am so sorry that you had to go through such a devastating experience. Thank you for telling others about it. Your personal story better explains the significance of this issue to patients, families, and healthcare personnel than statistics ever could. We will continue to work toward elimination of healthcare-associated infections including C. diff and try to find better ways to inform patients, families, and healthcare workers on what they can each do to advance patient safety. Your story will help others.

    My sincere regards,
    Dr. Clifford McDonald

    Although Clostridium difficile infections are a challenge there are some basic measures that should be followed. There are new guidelines out…(Cohen SH, Gerding D, Johnson S, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America. Infect Control Hosp Epidemiol 2010; 31(5) ) Review these guidelines and it will give you the information you need. No formed stools should be accepted by the lab unless an ileus related to CDI is suspect. The guidelines are great!

    I am a victim of C-diff, brought on by an antibiotic taken during some dental surgery. It was flu season and the initial thought was “I have the flu”. I had never heard of C-diff. I became ill on a Tuesday afternoon and by Thursday 5am, I had 104.6 fever. I was taken to the emergency room and properly diagnosed with C-diff then admitted to the hospital for aggressive treatment as the disease was in full swing. I was extremely ill and lost 20 pounds in 2 weeks. While laying in the hospital bed, I developed a blood clot(s), and had a pulmonary embolism. A total of 3 clots were found in the lungs. My experience with C-diff equated to 12 days in the hospital and 9 months on Coumadin, with recurrences of C-diff for over a year. I have learned to deal with the fact it will never go away. I can’t eat yogurt on a daily basis as I have many allergies and yogurt just doesn’t agree with me if taken on a continuum. I keep Lactinex granules in my refrigerator at all times and I have learned when I need to take it. If you suspect anyone in your family may be a C-diff victim, get help immediately. Every minute counts.

    I am from the north-eastern part of India. Infection control in these parts is unfortunately a theoretical possibility to most physicians & surgeons. Trying to change mind-sets is extremely difficult. To cut a long story short, we do not have the facilities for toxin testing in C. diff, having said that, the literature from eastern India SUGGESTS that the incidence is low. Since i do not have the tools for confirming it, i just pray that the suggestion is reasonably accurate.

    C.diff. is a critically important problem to be dealt with because it can kill. It is important that patients given antibiotics to eliminate another harmful infection also wind up having a number of bacteria they need in their system killed to and that makes it easier for a c.diff invasion. It also looks like one of the weak links here is the nursing homes/convolescent hospitals who say they watch for c.diff but need to watch more carefully for sudden changes that could mean infection. Since it looks like this infection moves fast, the nursing homes need to have a policy in place to get samples and get them to a lab quickly for testing to confirm c.diff and begin treatment as soon as possible. It maybe too expensive for the nursing home to have its own lab, and private labs maynot be open after hours or on weekends and holidays, but agreements might be made with hospital labs that are open 24 hours 7 days a week to do the testing. Best wishes, Michael E. Bailey.

    I think the “airborne spread of C. diff” reference that is mentioned above is from Clinical Infectious Diseases 1 June 2010 Volume 50 Number 11. The title is “The Potential for Airborne Dispersal of Clostridium difficile from Symptomatic Patients” by Emma L Best, Warren N Fawley, Peter Parnell and Mark H Wilcox. There is also an editorial commentary by Dr. Curtis Donskey.

    Reading Mr. Briere’s comments brought me to tears and my heart truly goes out to him and his family. C. diff can be a KILLER and I live in fear of what it can do. My mother was admitted in early January 2006 to the hospital for a pacemaker surgery and was soon ill with a dysentery like diarrhea that her doctors diagnosed as C. diff. They treated her for it with flagyl. It was soon discovered that she could not tolerate it and they changed her medication to vancocin for ten days and it failed as the course of treatment was not long enough. She went back and forth to the hospital with an active infection of C. diff a number of times until they finally sent her home to me with a course of treatment with vancocin that finally ended in mid-March of that year. 16 months later she was given antibiotics for an infection and the C.diff returned. Again admitted to the hospital, she underwent another six weeks of treatment with vancocin, this time supplemented by chewable (probiotic) tablets containing active cultures of acidophilus and bifidus together with Mountain High yogurt and Activia daily. Since the fall of 2007 she has not had a recurrence nor has she failed to have her probiotic tablet, the Mile High yogurt and Activia every single day since her last hospitalization for C. diff. One of her doctors informed us that once introduced into the intestines, C. diff lives there forever and the good bacteria introduced into the system keeps it in check. Mother just recently celebrated her 94th birthday in March and is free of the infection. C. diff is deadly but it can be managed with the right course of treatment supplemented by the introduction of probiotics on a daily basis.

    Our hospital tests for C. diff Antigen and toxin A&B EIA. Any sample that is Antigen Positive, Toxin negative gets reflex PCR testing. Our lab also rejects formed stools and repeat positive tests within seven days. This should help eliminate “testing for cure”. The PCR test is very new here and this is a very confusing subject for staff and physicians, not to mention patients. We are struggling with how to educate patients when the antigen is positive but PCR is negative.We also base discontinuation of isolation on clinical symptoms, not a negative test.

    I am not a physician. My wife had a hip replacement on a Monday and was given an antibiotic. She was transferred to a rehabiltation faciluty on the following Thursday.
    Starting the next Monday she was unable to keep food down, was always nauseous and had extrteme diarrhea. She was given something for the diarrhea on Friday. Her complaint was “I am so sick”. I asked for a culture to be talen on saturday morning and was told the healthcare facility that does this told the nurse on duty it could wait until Monday. Saturday night she was admitted to a local hospural and our family physician was there and diagnosed her as having c diff which I had never heard of. The next day she was transferred to a city hospital where her entire colon was removed and a colostomy done. She was sedated and never opened her eyes again for three weeks to the day and was on life support the entire time. On the third Sunday all her internal organs by then had failed and we as a family agreed to end life support and in seven minutes, my wife of 52 years was dead. I am devastated and angry. My question will alwys be “Why didn’t the rehab facility doctor try to find out why she was so sick. The administrator and doctor both told me personally afterwards they watch for c diff. Yet they completely missed the symptoms here. Nothing will bring her back but maybe our experience, if told, will prevent it from happening to someone else.

    We educated our doctors about when to (not) submit a stool sample and our lab is rejecting formed stools. We also do not allow a “test of cure” formed stool to be sent–cessation of diarrhea should indicate clinical improvement.

    C-diff is one of the most difficult organisms to eradicate. We developed an approach that incorporates antibiotic stewardship, the use of probiotics when possible and intense cleaning with 10% bleach solution daily. I recently read that British researchers were reporting evidence that C-diff could become airborne and that such activities such as opening the door to the room of a C-diff patient could spread the spores into the atmosphere.(Forgive me but I cannot cite the reference).
    An additional complication for us has been the Geriatric Psych unit we have within the hospital. We have experienced two outbreaks in the past two years in this area alone. We have had some success with setting up an automatic notification to our EVS folks so that they know to clean that room daily with 10% bleach; but what can you do when they wander our of their rooms? It remains a constant worry.

    For the past 4 months I have been reviewing the charts of patients’ who have positive C. diff toxin tests. We use a Toxin A & B EIA test. I am finding that many patients’ signs & symptoms do not meet the CDC definitions of “Gastroenteritis”. Very few have had “acute onset of liquid stools” with “no likely noninfectious cause”. Also, our laboratory will test any stool specimen requested for C. diff testing. I am afraid that we might be treating a lab test instead of a real disease. Do you have any suggestions for our clinicians regarding appropriate signs/symptoms or suggestions for laboratory criteria for testing only certain stool samples?

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