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what is cdiff?
What is C. diff. (Clostridioides difficile)?
Clostridioides difficile (Formally known as Clostridium difficile) is gram-positive, anaerobic, and a spore, rod/spindle-shape, a common bacterium of the human intestine in 2 – 5%.
C diff. becomes a serious gastrointestinal infection when individuals have been exposed to antibiotic therapy, and/or have experienced a long-term hospitalization, and/or have had an extended stay in a long-term care facility. However; the risk of acquiring a C diff. infection has increased as it is in the community and found in outpatient settings. There are significant risk factors in patients who are immunosuppressant, ones who have been on antibiotic therapy, and the elderly population.
How Antibiotics can cause C diff.: The antibiotics cause a disruption in the gut microbiome which leads to an over growth of C difficile bacteria in the colon. There are leading antibiotics known to disrupt the gut microbiome causing dysbiosis.
A C. diff. infection is an individual infection and no two individuals will present with the same initial symptoms (abdominal pain, fever can be present, elevated white count may occur, cramping, fatigue) except for the common denominator of unformed, liquid diarrhea and with more than three times within 24 hours, which should be discussed with a healthcare provider prior to a stool test to confirm the diagnosis.
Each individual may be prescribed different courses of treatment and the infection may resolve quickly or there may be episodes of recurrent C. difficile which will require additional courses of treatment. Physicians (Primary Care, Gastroenterologist, Infectious Disease) will determine the course of treatment based on the patient's symptoms, infection, and age, if there are additional illnesses to consider, a discussion of treatments with the patient will develop a plan of care.
As far back as November 2012, the CDC created public announcements regarding antibiotic use: Colds and ear and sinus infections can be caused by viruses, not bacteria. Taking antibiotics to treat a “virus” can make those drugs less effective when you and your family really need them. Limiting the usage of antibiotics will also help limit new cases of Clostridioides difficile (C-diff)
*Always discuss the symptoms and medications with the treating Physician/Healthcare Provider.
Previous studies indicate that C. difficile has become the most common microbial cause of healthcare-associated infections in U.S. hospitals and costs up to $4.8 billion each year in excess health care costs for acute care facilities alone. The new study found that 1 out of every 5 patients with a healthcare-associated C. difficile infection experienced a recurrence of the infection and 1 out of every 9 patients aged 65 or older with a healthcare-associated C. difficile infection died within 30 days of diagnosis.** (1)
(1) http://www.cdc.gov/media/releases/2015/p0225-clostridium-difficile.html
Strain Types and Changing Epidemiology
Excerpts from the Clinical Practice Guidelines : IDSA
https://academic.oup.com/cid/advance-article/doi/10.1093/cid/cix1085/4855916#.WoUYufzsWpk.twitter
The emergence of the virulent, epidemic ribotype 027 strain was associated with increased incidence, severity, and mortality during the mid-2000s and resulted in outbreaks across North America [36, 48, 49], England [50, 51], parts of continental Europe [52, 53], and Asia [54]. The recent isolates of the 027 strain are more highly resistant to fluoroquinolones compared to historic strains of the same type [48]. This, coupled with increasing use of the fluoroquinolones worldwide likely promoted dissemination of a once uncommon strain [48].
Consistent with the presence of one or more molecular markers responsible for increased virulence, patients infected with the 027 epidemic strain in Montreal were shown to have more-severe disease than patients infected with other strains [36]. In a later Canadian multicenter study of hospitalized patients, the 027 strain was predominant among patients with a C. difficile infection whereas other strains were more common among asymptomatically colonized patients [46]. Similarly, in a sample of isolates and patient information collected from 10 CDC EIP sites between 2009 and 2011, ribotype 027 was the most prevalent strain (28.4%) and was associated with more severe disease, severe outcomes, and death than other strains, controlling for patient risk factors, healthcare exposure, and antibiotic use [55].
Since the emergence and spread of 027, recent data from Europe suggest that the prevalence of this strain is decreasing. England has seen a dramatic decrease in 027 prevalence since the establishment of a nationwide ribotyping network in 2007 [56]. Ribotype 027 decreased significantly between 2007 and 2010, dropping from 55% prevalence to 21%, coincident with significant decreases in reported C. difficile incidence and related mortality. The decrease in 027 prevalence was likely driven by significant reductions in fluoroquinolone use during this time period [56], although increase in awareness and improved infection control may also have impacted C. difficile incidence.
Continued molecular typing will enable detection of emerging C. difficile strains with novel virulence factors, risk factors, and antibiotic resistance patterns. For example, evidence of emergence of a virulent strain, ribotype 078, has been reported from the Netherlands [57]. The prevalence of ribotype 078 increased between 2005 and 2008 and was associated with similar severity compared to C. difficile cases due to ribotype 027, but was associated with a younger population and more Community acquired C. difficile infections.. There was also a high degree of genetic relatedness between 078 isolates found in humans and pigs, an association also noted in the United States [58].
What is the role of antibiotic stewardship in controlling C.diff. infection rates?
- Minimize the frequency and duration of high-risk antibiotic therapy and the number of antibiotic agents prescribed, to reduce .C. difficile infection risk (strong recommendation, moderate quality of evidence).
- Implement an antibiotic stewardship program (good practice recommendation).
- Antibiotics to be targeted should be based on the local epidemiology and the
C. difficile strains present.
Which Antibiotics Are Most Associated with a Clostridioides difficile infection
What is the role of proton pump inhibitor restriction in controlling C. diff. infection rates?
- Although there is an epidemiologic association between proton pump inhibitor (PPI) use and CDI, and unnecessary PPIs should always be discontinued, there is insufficient evidence for discontinuation of PPIs as a measure for preventing C. diff. infections (no recommendation).
What is the role of probiotics in primary prevention of C. diff. infections?
- There are insufficient data at this time to recommend administration of probiotics for primary prevention of C. diff. infections outside of clinical trials (no recommendation).
Since November 2012 the CDC shared a public announcement regarding antibiotic use: Colds and many ear and sinus infections are caused by viruses, not bacteria. Taking antibiotics to treat a “virus” can make those drugs less effective when you and your family really need them. Limiting the usage of antibiotics will also help limit new cases of CDI.
*Always discuss the symptoms and medications with the treating Physician.
FOR HEALTHCARE PROFESSIONALS:
What is the minimal surveillance recommendation for institutions with limited resources?
- At a minimum, conduct surveillance for HO-C. diff. infection in all inpatient healthcare facilities to detect elevated rates or outbreaks of C. diff. infection within the facility (weak recommendation, low quality of evidence).
What is the best way to express C. diff. infection incidence and rates?
- Express the rate of HO-C. diff. as the number of cases per 10000 patient-days. Express the CO-HCFA prevalence rate as the number of cases per 1000 patient admissions (good practice recommendation).
How should C. diff. infection surveillance be approached in settings of high endemic rates or outbreaks?
- Stratify data by patient location to target control measures when C. diff. incidence is above national and/or facility reduction goals or if an outbreak is noted (weak recommendation, low quality of evidence).
EPIDEMIOLOGY (PEDIATRIC CONSIDERATIONS)
What is the recommended C. diff. infection surveillance strategy for pediatric institutions?
Recommendations
Use the same standardized case definitions (HO, CO-HCFA, CA) and rate expression (cases per 10000 patient-days for HO, cases per 1000 patient admissions for CO-HCFA) in pediatric patients as for adults (good practice recommendation).
- Conduct surveillance for HO-C. diff. infection for inpatient pediatric facilities but do not include cases <2 years of age (weak recommendation, low quality of evidence).
- Consider surveillance for CA-C. diff. infection to detect trends in the community (weak recommendation, low quality of evidence).
To review the Clostridioides difficile (C. difficile, C. diff) Guidelines for Adults and Children 2017 Update by Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) — Published February 2018 & Adult Updates 2021
