Volume 194 - Issue 7
Clostridium difficile infection: a new threat on our doorstep
Authors: Rhonda L Stuart and Caroline Marshall
Med J Aust 2011; 194 (7): 331-332. || doi: 10.5694/j.1326-5377.2011.tb02998.x
Published online: 4 April 2011
Published online: 4 April 2011
What can we do to prevent this from becoming the most common health care-associated infection in Australia?
Clostridium difficile, a gram-positive, anaerobic, spore-forming, toxigenic bacterium, is the most common infectious cause of nosocomial diarrhoea. The severity of infection varies from mild diarrhoea to pseudomembranous colitis, toxic megacolon and death.1 In the United States, C. difficile now rivals methicillin-resistant Staphylococcus aureus (MRSA) as the most common health care-associated infection, accounting for US$3.2 billion in excess costs annually.1,2
Since 2000, there has been an increase in the rates of C. difficile infection (CDI) in some health care facilities in the US, Canada and Europe, associated with an epidemic strain of C. difficile. This strain (B1/NAP1/027, toxinotype III or PCR ribotype 027) is characterised by its increased resistance to fluoroquinolones, increased toxin production (toxins A, B and binary toxin), increased sporulation, and increased morbidity and mortality.1,3
Risk factors for CDI include exposure to antimicrobial drugs, gastric acid-suppressive therapy, advanced age, prolonged hospitalisation, cancer chemotherapy, comorbidity and immunosuppression.3 Although most cases have been in hospital inpatients, increasing numbers of community-associated cases are now being reported in the US and Europe.4,5
Australia is now also in the grip of this new strain of C. difficile. The first infected patient was reported in 2009 in Western Australia, but the infection was thought to have been acquired in North America.6 In this issue of the Journal, Richards and colleagues report the first case of C. difficile ribotype 027 thought to have been acquired in Australia (→ Severe infection with Clostridium difficile PCR ribotype 027 acquired in Melbourne, Australia).7 The strain was identified after clinicians alerted the laboratory to the severity of the infection and the possibility of a hypervirulent strain. Since this case was first reported, there have been further clusters of C. difficile ribotype 027 infection centred around residential aged care facilities.
Currently, surveillance for C. difficile is not consistent across Australia, so rates of CDI across the continent are unknown. However, some states have commenced surveillance and show overall rates varying between 1.27 and 2.3 CDIs per 10 000 bed-days.8 This contrasts with a reported overall rate in Canada of around 3.8–9.5 CDIs per 10 000 bed-days based on surveys conducted in 1997 and 2005.9
Clinicians need to be aware of the clinical picture, diagnostic methods and new therapeutic approaches to this disease. The Australasian Society for Infectious Diseases has published guidelines in this issue of the Journal that clearly outline clinical assessment, diagnostic issues and treatment guidelines (→ Australasian Society for Infectious Diseases guidelines for the diagnosis and treatment of Clostridium difficile infection).10
Identification of hospitalised patients with CDI is the key to preventing transmission. Hospitals need to have an optimal surveillance program in place to expedite patient testing and identification. As a minimum standard, all patients with hospital onset of diarrhoea (> 48 hours after admission) should be screened for CDI. The case definition for CDI should include: (i) symptoms (usually diarrhoea); and (ii) a stool test positive for toxigenic C. difficile or its toxins, or colonoscopic or histological findings of pseudomembranous colitis.9 Similarly, clinicians working in residential aged care facilities need to be alert to the possibility of CDI in residents, to undertake testing in the presence of symptoms and to focus on decreasing transmission of the infection within the facility.
In the hospital setting, infection control precautions around cases of CDI need to be enforced. Infection control guidelines for CDI from the Australasian Society for Infectious Diseases and the Australian Infection Control Association have recently been released.11
The main management principles for control of CDI include:
all health care organisations, including residential aged care facilities, giving CDI prevention and control the highest priority, even if the prevailing incidence of CDI is low;
surveillance being integrated into quality improvement programs to optimise prevention and control of CDI and clinical care of infected patients;
antimicrobial stewardship programs being in place that are aimed at minimising the frequency and duration of antibiotic use and promoting a narrow-spectrum antibiotic policy;
emphasis on compliance with hand disinfection and glove use for care of patients with CDI to minimise spore contamination;
contact precautions being employed for symptomatic patients with CDI, including the donning of gowns or aprons and gloves on entry to patient rooms;
use of sporocidal environmental cleaning and disinfection in high-risk areas such as toilets, bathrooms and rooms of patients with CDI, and elimination of other potential fomites by either using disposable equipment or ensuring that equipment is adequately cleaned and disinfected before reuse; and
education of all health care staff, patients and visitors about CDI, its prevention and management.
It is sobering to contemplate that what has occurred in the US, Canada and Europe is potentially and imminently on our doorstep. We must learn from the experience of experts in these countries so that Australia can avoid a similar experience — we already have the benefit of their hindsight to guide us. Our challenge is implementing the necessary interventions — enhanced surveillance and diagnosis, antimicrobial stewardship, environmental cleaning and stringent infection control. Although this solution re-echoes the usual infection control mantra, it is essential that we act pre-emptively to prevent CDI from occurring, especially to the most vulnerable of our patients.
References
- McDonald LC, Owings M, Jernigan DB. Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996–2003. Emerg Infect Dis 2006; 12: 409-415. 0_i1095890
- Dubberke ER, Gerding DN, Classen D, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals. Infect Control Hosp Epidemiol 2008; 29 Suppl 1: S81-S92. 0_i1095892
- Bartlett JG. Narrative review: the new epidemic of Clostridium difficile-associated enteric disease. Ann Intern Med 2006; 145: 758-764. 0_i1095894
- Bauer M, Goorhuis A, Koster T, et al. Community-onset Clostridium difficile-associated diarrhoea not associated with antibiotic usage — two case reports with review of the changing epidemiology of Clostridium difficile-associated diarrhoea. Neth J Med 2008; 66: 207-211. 0_i1095896
- Severe Clostridium difficile-associated disease in populations previously at low risk — four states, 2005. MMWR Morb Mortal Wkly Rep 2005; 54: 1201-1205. 0_i1095898
- Riley TV, Thean S, Hool G, Golledge CL. First Australian isolation of epidemic Clostridium difficile PCR ribotype 027. Med J Aust 2009; 190: 706-708. 0_i1095901
- Richards M, Knox J, Elliot B, et al. Severe infection with Clostridium difficile PCR ribotype 027 acquired in Melbourne, Australia. Med J Aust 2011; 194: 369-371. 0_i1095903
- McGregor A, Riley TV, Van Gessel H. Clostridium difficile associated disease. In: Cruikshank M, Ferguson J, editors. Reducing harm to patients from healthcare associated infection: the role of surveillance. Sydney: Australian Commission on Safety and Quality in Healthcare, 2008: 171-187. 0_i1095905
- Cohen SH, Gerding DN, Johnson S, et al. 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). Infect Control Hosp Epidemiol 2010; 31: 431-455. 0_i1095907
- Cheng AC, Ferguson JK, Richards MJ, et al. Australasian Society for Infectious Diseases guidelines for the diagnosis and treatment of Clostridium difficile infection. Med J Aust 2011; 194: 353-358. 0_i1095909
- Stuart RL, Marshall C, McLaws ML, et al. ASID/AICA position statement: infection control guidelines for patients with Clostridium difficile infection in health care settings. Healthcare Infect 2011. In press. 0_i1095911
Provenance: Commissioned; not externally peer reviewed.