Clostridium Difficile Infection CDI

Original Editors - John Hardy from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - John Hardy, Lucinda hampton, Reem Ramadan, Elaine Lonnemann, WikiSysop, 127.0.0.1, Oyemi Sillo, Kim Jackson, Vidya Acharya and Nupur Smit Shah  

Introduction

Clostridium difficile

Clostridium difficile is a type of bacteria that can cause colitis, a serious inflammation of the colon. Infections from C. diff often start after taking antibiotics. It can sometimes be life-threatening.

• Clostridium difficile is an anerobic, gram-positive bacillus. This rode shaped bacterium exists in vegetative or spore form and can survive harsh environments and common sterilization techniques. Clostridium difficile is resistant to ultra-violent light, high temperatures, and antibiotics.

Epidemiology

Clostridium difficile infection (CDI) has become a serious medical and epidemiological problem, especially in well developed countries. There has been evident increase in incidence and severity of CDI. Prevention, proper diagnosis and effective treatment are necessary to reduce the risk for the patients, deplete the spreading of infection and diminish the probability of recurrent infection. Antibiotics are the fundamental treatment of CDI

C. Difficile is commonly a nosocomial pathogen found in a hospital or similar healthcare facility. Colonization rate of healthy adults is estimated to be 2% while the prevalence of hospitalized adults can be high as 40%. Nearly a third of all C. Difficile infections are community acquired which suggests a recent increase in non-nosocmial infections.

Risk Factors

C. diff can affect anyone, however cases of C. diff occur when taking antibiotics or not long after finishing taking antibiotics.

Other risk factorsinclude :

• Being 65 or older
• Recent stay at a hospital or nursing home
• A weakened immune system, such as people with HIV/AIDS, cancer, or organ transplant patients taking immunosuppressive drugs
• Previous infection with C. diff or known exposure to the germs
    

Characteristics/Clinical Presentation

Symptoms may develop within a few days after taking antibiotics, and include:

• Severe diarrhea
• Fever
• Stomach tenderness or pain
• Loss of appetite
• Nausea
  

Medications

- Vancomycin (Glycopeptide Antibiotics)
-Metroidazole (Nirtoimidazole Antibiotic)
- Rifamimin (Antimicrobial)
-Probiotics
-Immunosuppressants 

Diagnosis

For definitive diagnosis a stool sample must be collected. Tests include:

• Enzyme immunoassay
• Polymerase chain reaction
• GDH/EIA
• Cell cytotoxicity assay

If a serious problems with the colon is suspected, an X-rays or a CT scan of the intestines may be ordered. In rare cases, the doctor may examine the colon with procedures such as a flexible sigmoidoscopy or colonoscopy.

Etiology

C. Difficile bacteria colonize the large colon after exposure. Colonization in areas other than the large colon is quite rare in the human body. The natural anaerobic environment and absence of competing gut flora (due to antibiotic treatment) make the large colon an ideal environment for the bacteria to flourish.For the bacteria to flourish in the gut and damage the host several events must occur so that toxin production is possible. To start, the C. difficile spores must reach an area in the gut where an ample amount of bile salts are present so that they can catalyze the germination of these spores. 
After germination is complete, the bacteria begins produce toxins, initially focusing on a binary toxin that produces microtubule-cell extensions allowing adherence of the bacteria to the intestinal walls. During colonization and immediately following, C. difficile now in a vegetative form releases TcdA and TcdB. The mechanism of A and B toxin secretion is not fully understood, but the it is known that amion acid availability is critical to toxin expression. Primarily acting on the epithelial cells of the intestines, TcdA causes inflammation, fluid secretion, and necrosis of colon tissue. TcdB is a potent cytoxin that may be responsible for systemic damaged present in patients with fulminant CDI due to its cardiotoxic behavior.

Systemic Involvement

-Dehydration
-Ectrolyte disturbances
-Hypoalbuminemia
-Toxic megacolon
-Bowel perforation
-Rrenal failure
-Sepsis
-Clonic ileus
-Toxic dilatation
-Systemic inflammatory response syndrome
-Death

Medical Management

     Medical management of CDI depends on the acuity and severity of the infection as well as whether it is an initial or recurrent infection. It is widely recognized that the most important first step in treatment is to discontinue the inciting antibiotic. Discontinuation of antibiotic treatment historically resulted in resolution of the infection, but due to new hypervirulent strains further intervention is recommended. Fluid and electrolyte replacement is suggested for quicker recovery. The available drugs for treatment of a CDI are Vancomycin and Metronidazole. If Vancomycin is the drug selected for treatment it should be administered either rectally or orally. These are the recommended routes of administration because intravenous Vancomycin has shown to be an ineffective treatment of CDI.
     On the other hand, Metronidazole has been shown to deliver similar colonic and intraluminal levels regardless of administration. Some researchers advocate oral administration when possible to avoid potential complications with an intravenous route. Though Metronidazole has been shown to be equally as effective as Vancomycin it has a higher rate of unresponsiveness. If patients do not respond to Metronidazole, Vancomycin is then considered. Vancomycin is more commonly the first treatment especially in severe cases of CDI due its lower rate of unresponsiveness and superior efficacy.
     Mild to moderate cases of CDI are treated with 25o mg of metronidazole every six hours or 125 mg of vacomycin every 6 hours. Treatment course is typically 10-14 days with resolution of symptoms in more than 90% of cases in less than 10 days. Combined use of these drugs is often used in patients with moderate to severe infection especially if accompanied by ileus and or toxic megacolon. Patients with unresolving ileus can be given increased doses as well as frequency of administration (i.e. 500 mg every 6 hours). In severe cases surgical evaluation for colectomy may be indicated to avoid life-threatening complications. In patients with reoccurrent infection pulse or tapering therapy is combined with vancomycin treatment. A course of Rifamimin is also recommended after previous treatments have failed.

Physical Therapy Management

     C. difficile infections are primarily managed through pharmaceutical therapy and associated medical treatments. Exercise recommendations for patients with CDI have not been clearly established and are currently based on clinical decision making of the therapeutic team and treating physician. The therapist should take an active role in infection control and prevention measures whenever working with these patients. Infection control measures include: donning gloves and gowns prior to entering patients room, washing hands with soap and water upon departure, treating patients in a private room, educating visitors on proper hygiene measures. Routine environmental screening and use of chlorine-containing cleaning agents is also recommended. Below is a table summarizing the evidence supporting various infection control measures.

   Infection Control