Clostridium Difficile Infection: What Nurses Need to Know

The goal of this continuing education activity is to provide nurses and nurse practitioners with knowledge and skills to recognize and manage a Clostridium difficile infection (CDI). After reading this article, you will be able to:
– Identify risk factors, signs, and symptoms of a CDI
– Describe goals of care for a patient with CDI
– Describe evidence-based nursing and medical management of a CDI

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Authors: Joseph Brodine, MSN-MPH, RN
Anela Kellogg, BS, RN, OCN

Clostridium difficile (C. difficile) is a well-recognized causative agent of healthcare-associated infectious diarrhea. The incidence and severity of CDIs are increasing,^1–6 as documented by outbreaks of particularly virulent and drug-resistant strains.^{3, 4, 7} A CDI often leads to prolonged hospitalization and significant financial burden.^{8, 9} In an effort to curb these disturbing trends and the enormous burden of disease, The Joint Commission identified the implementation of evidence-based practices to prevent multidrug-resistant organism infections as a 2011 National Patient Safety Goal (NPSG.07.03.01). Nurses are critical to the successful implementation of this goal, and to the proper management and care of patients diagnosed with CDIs.

What is C. Difficile?
C. difficile is an anaerobic gram-positive bacterium that produces spores resistant to heat, drying, and many antiseptic solutions. They are viable outside the gut for five months or longer.^{6, 10} C. difficile is transmitted from person to person by the fecal-oral route. The virulence of the bacteria and spore resilience makes a CDI one of the most contagious diseases in healthcare facilities.

The Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) define the typical case presentation of a CDI as follows:
1. The presence of diarrhea, defined as passage of three or more unformed stools in 24 or fewer consecutive hours;
2. A stool test result positive for the presence of toxigenic C. difficile or its toxins, or colonoscopic and histopathologic findings demonstrating pseudomembranous colitis.⁴

A CDI usually occurs in the presence of ongoing or recent antibiotic therapy or chemotherapy. CDI symptoms typically present within one to two weeks of antibiotic or chemotherapy exposure, but may present as early as one day post exposure to as late as three months post exposure. A patient with a CDI experiences a proliferation of C. difficile in the large intestine, which produces toxins A and B, leading to gut inflammation, fluid and mucus secretion, and colitis. A patient with a severe CDI may also present with fever, abdominal discomfort, and leukocytosis. A CDI ranges in severity from mild diarrhea to fulminant colitis, toxic megacolon, and death. Management depends on symptom severity. It is important to note that some individuals are asymptomatic carriers of C. difficile, which does not warrant routine screening or treatment.^{4, 6}

“C. diff is more than just another infection that requires gown, gloves, and handwashing. It is an illness that can be life-threatening under certain circumstances. The consequences of untreated C. diff can include sepsis, warranting transfer to the ICU; toxic megacolon; colectomy; and sometimes death.  People often underestimate the potential danger of C. diff.”

Julie B. Trivedi, MD
Clinical Associate, Department of Medicine, Division of Infectious Diseases
Johns Hopkins University School of Medicine

What Are the Signs and Symptoms of a CDI?
Patients who present with a new onset of diarrhea as described by the SHEA-IDSA definition, or with a marked increase in unformed stool output from baseline, and have at least one of the risk factors associated with a CDI (see Table 1) should be tested for C. difficile. On rare occasions, C. difficile presents with an ileus, and the patient has no stool output. Nursing staff must perform focused gastrointestinal (GI) assessments on patients at risk for CDIs. Providing prompt medical team notification of symptoms consistent with a CDI allows for early identification of infection, quick initiation of treatment and supportive care, and precautionary isolation measures to reduce the risk of transmission.

How is a CDI Managed?
When caring for a patient with a confirmed CDI, nurses should employ the same protocols as they would when caring for a patient with any GI disease, contagious illness, and diarrhea. Patient assessments should be focused to identify any complications of the disease: the nurse should check to see that the abdomen is not newly firm or distended; stool output should be carefully monitored for any increase in frequency or sudden cessation; the character of the stool should be evaluated for the presence of blood; and the patient’s nutritional status should be assessed through electrolyte and metabolic panel monitoring. If the patient is incontinent or immobile, the nurse should make extra effort to maintain perianal skin integrity and hygiene by cleansing with soap and water and should avoid using topical agents on the patient that have the potential to seal in spores, such as pre-packaged cleansing wipes.

Although pharmacologic and medical treatment selection is determined by the provider, nurses should be well-informed of optimal, evidence-based treatment algorithms for C. difficile to effectively partner with providers. Table 2 shows The Johns Hopkins Hospital (JHH) 2010 CDI treatment algorithm,¹¹ which is grounded in IDSA-SHEA guidelines. CDI treatment is based on severity of the disease. Goals of pharmacotherapy are to ameliorate symptoms and prevent transmission by eliminating C. difficile in the gut.¹²

Some experts suggest that initial management of a patient diagnosed with a CDI is simply to discontinue the offending antibiotic combined with supportive measures. They also suggest that antibiotic intervention may not be necessary for a mild CDI.^{6, 10} Pharmacologic management—typically metronidazole, vancomycin, or a combination of both—would be selected according to patient presentation and response. Generally, metronidazole is a first-line medication for a mild-moderate CDI, but if the patient suffers from a severe or complicated disease, the provider may bypass metronidazole and treat with vancomycin or a combination of the two.^{6, 10-13} Oral pharmacological therapy is the preferred route of administration as evidence of efficacy of intravenous (IV) antibiotic treatment for a CDI is limited.^{11, 12} Antimotility agents, including narcotics, should not be used.¹²

As many as 25% to 35% of patients will experience recurrent CDIs. Evi-dence of the best treatment for recurrent CDIs is limited. Many experts believe patients with recurrent CDIs will respond to another round of antibiotic therapy,^12,14 although this practice may ultimately lead to increased antibiotic resistance. Other clinical experts support fecal bacteriotherapy (stool transplant from a healthy donor into the GI tract of a patient) as an alternate to antibiotic therapy.¹⁵ Until more evidence is available on the best treatment approach for recurrent CDIs, providers should select medical interventions based on patient history and presentation.

How Can C. Difficile Transmission Be Prevented?
Nurses play a critical role in preventing C. difficile transmission. Spores are transmitted from patient to patient via improperly sanitized hands and also through the use of contaminated shared equipment. Meticulous hand hygiene—using soap and water—and strict adherence to isolation protocols are therefore the foundation for effective C. difficile transmission prevention. Handwashing and strict isolation should be observed when caring for patients even after resolution of CDI symptoms, as they are still capable of shedding spores long after clinical symptoms subside. It is important for nurses to communicate with their institutional epidemiology staff to determine appropriate duration of isolation for the patient with a current or prior history of CDI on a case-by-case basis. Also, nurses must be careful to clean equipment that is shared between patients, and partner with housekeeping services to effectively clean areas of potential contamination. Typically, regular active cleansing ingredients in hospital disinfectants are quaternary ammonium compounds and do not kill spores. The Centers for Disease Control (CDC) currently recommends using hypochlorite-based germicides, such as bleach-based solutions, for cleaning C. difficile-contaminated environmental surfaces and equipment.

“To prevent C. diff transmission, wash your hands with soap and water after patient care, and ensure that all patient care equipment is meticulously disinfected prior to use on another patient.”

Polly Ristaino
Associate Director, Department of Epidemiology and Infection Control
The Johns Hopkins Hospital

What Should Patients and Families Be Taught About C. difficile?
All patients infected or colonized with C. difficile must be educated about this bacterium, proper disease management, and transmission prevention. The nurse should use patient-centered communication—free of jargon and appropriate to the patient’s health-literacy level. It is best to use multiple delivery methods to share information such as printed hand-outs, face-to-face discussion, and hands-on demonstration. The Joint Commission recommends using the “teach-back” and “show-back” methods to educate patients; that is, ask the patient to “teach back” the information provided or demonstrate understanding by “showing” a skill such as handwashing or proper donning of isolation equipment. The Joint Commission requires that multidrug-resistant-organism patient-education topics, education methods, and the assessment of efficacy of training be documented in the medical record.

Table 1

RISK FACTORS

Treatment Factors
• recent antibiotic exposure—particularly clindamycin, cephalosporins and fluoroquinolones
• recent chemotherapy exposure
• proton pump inhibitor exposure
• prolonged tube feeding

Medical Factors
• neutropenia
• immunosuppression
• history of CDI
• GI comorbidity
• critically ill patients
• recent surgery

Environmental Factors
• recent exposure to healthcare facility (particularly prolonged exposures as in an inpatient or long-term care facility)
• recent co-habitation with a patient diagnosed with a CDI

Other Factors
• advanced age
• non-newborn hospitalized infants <1 year old

Table 2 CLOSTRIDIUM DIFFICILE INFECTION (CDI) Treatment • STOP ALL ANTIMICROBIAL AGENTS WHENEVER POSSIBLE. • Oral therapy must be used whenever possible as the efficacy of IV Metronidazole is poorly established for CDI and there is no efficacy of IV Vancomycin for CDI. Treatment depends on clinical severity
Infection severity Asymptomatic carriage* Mild or moderate Severe	Clinical manifestations C. difficile antigen or PCR positive without diarrhea, ileus, or colitis C. difficile PCR positive with diarrhea but no manifestations of severe disease C. difficile PCR positive with diarrhea and one more of the following attributable to CDI: • WBC > 15,000 • Increase in serum creatine >50% from baseline
Severe Complicated	Criteria as above plus one or more of the following attributable to CDI: • Hypotension • Ileus • Toxic megacolon or pancolitis on CT • Perforation • Need for colectomy • ICU admission for severe disease
Infection severity Asymptomatic carriage Mild or moderate Severe Severe Complicated	Treatment Do NOT treat; treatment can promote relapsing disease • Metronidazole 500 mg PO/NGT Q8H Unable to tolerate oral therapy • Metronidazole 500 mg IV Q8H (suboptimal; see note at start of CDI section) • Vancomycin solution 125 mg PO/NGT Q6H • Consult surgery for evaluation for colectomy and ID • Vancomycin solution 500 mg by NGT Q6H PLUS Metronidazole 500 IV Q8H Unable to tolerate oral therapy or complete ileus • Vancomycin 500 mg in 100 ml NS Q6H as retention enema via Foley catheter in rectum + Metronidazole 500 mg IV Q8H
* >50% of hospital patients colonized by C. difficile are asymptomatic carriers; this may reflect natural immunity. Reproduced with permission from the Johns Hopkins Antibiotic Management Program. Johns Hopkins Medicine. (2010). Antibiotic guidelines: Treatment Recommendations for Adult Inpatients. Retrieved from www.insidehopkinsmedicine.org/amp.

Key Points
C. difficile is an increasingly common and virulent microorganism. CDI incidence is rising and starting to affect populations previously considered low-risk. Nurses need to integrate CDI knowledge and assessment skills into their practice to combat the international epidemic of multidrug-resistant organisms.

This 1-hour educational activity (which includes 0.5 of pharmacology hours) is provided by the Institute of Johns Hopkins Nursing. Contact hours will be awarded until December 19, 2013.

The Institute for Johns Hopkins Nursing (IJHN) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center?s Commission on Accreditation.

The Institute for Johns Hopkins Nursing is approved as a provider of nurse practitioner continuing education by the American Academy of Nurse Practitioners: AANP Provider Number 061216.

REFERENCES:

1 Dubberke, E., Butler, A., Yokoe, D., Mayer, J., Hota, B., Mangino, J., Khan, Y., Popovich, K., & Fraser, V. (2010). Multicenter Study of Clostridium difficile Infection Rates from 2000 to 2006. Infection Control and Hospital Epidemiology, 31(10), 1030-1037.

2 Jobe, B., Grasley, A., Deveney, K., & Sheppard, B. (1995). Clostridium difficile Colitis: An Increasing Hospital-Acquired Illness. The American Journal of Surgery, 169, 480-483.

3 McDonald, L., Killgore, G., Thompson, A., Owens, R., Kazakova, S., Sambol, S., Johnson, S., & Gerding, D. (2005). An Epidemic, Toxin Gene-Variant Strain of Clostridium difficile. The New England Journal
of Medicine. 353(23), 2433-2441.

4  Cohen, S. Gerding, D., Johnson, S., Kelly, C., Loo, V., McDonald, C., Pepin, J., Wilcox, M. (2010). Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control and Epidemiology, 31(5), 431 – 455.

5 Elixhauser, A. & Jhung, M. (2008). Clostridium Difficile-Associated Disease in U. S. Hospitals, 1993 – 2005.  HCUP Statistical Brief #50. Agency for Healthcare Research and Quality, Rockville, MD.

6 Kelly, C. (2009). A 76-Year-Old Man With Recurrent Clostridium difficile-Associated Diarrhea: Review of C Difficile Infection. The Journal of the American Medical Association, 301(9), 954 – 962.

7 Tillotson, G., & Tillotson, J. (2011). Clostridium difficile – a moving target. F1000 Medicine Reports, 36.

8 Kyne, L., Hamel, M., Polavaram, R., & Kelly, C. (2002). Health Care Costs and Mortality Associated with Nosocomial Diarrhea Due to Clostridium difficile. Clinical Infectious Diseases, 34, 346-353.

9 Dubberke, E., Reske, K., Olsen, M., McDonald, L., & Fraser, V. (2008). Short- and long-term attributable costs of Clostridium difficile-associated disease in nonsurgical inpatients. Clinical Infectious Diseases, 46(4), 497 – 504.

10 Yassin, S., Young-Fadok, T., Zein, N., & Pardi, D. (2001). Review: Clostridium difficile-Associated Diarrhea and Colitis. Mayo Clinical Proceedings, 76, 725-730.

11Johns Hopkins Medicine. (2010). Antibiotic guidelines: Treatment Recommendations for Adult Inpatients. Retrieved from www.insidehopkinsmedicine.org/amp.

12 Gould, C. & McDonnald, C. (2008). Review: Bench – to bedside review: Clostridium difficile  Colitis. Critical Care, 12(1), 203 – 210.

13Nelson, R. (2007).  Antibiotic treatment for Clostridium difficile-associated diarrhea in adults (Review). Cochrane Database of Systematic Reviews, (3), CD004610

14Schroeder, M. (2005). Clostridium difficile-Associated Diarrhea. American Family Physician, 71(5), 921 – 928.

15Bakken, J. (2009). Fecal bacteriotherapy for recurrent clostridium difficile infection. Anaerobe, 15, 285 – 289.

16Sehulster, L., Chinn, R., Arduino, M., Carpenter, J., Donlan, R., Ashford, D., Besser, R., Fields, B., McNeil, M., Whitney, C., Wong, S., Juranek, D., & Cleveland J. (2004). Guidelines for environmental infection control in health-care facilities: Recommendations from CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Retrieved from www.cdc.gov/ncidod/hip/enviro/guide.htm.

17 The Joint Commission. (2007). What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety. Oakbrook Terrace, IL: The Joint Commission.

The authors would like to especially thank Julie Trivedi, MD, and Polly Ristaino for their expert input during the writing of this article.