The difficult bacillus Clostridium difficile

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The difficult bacillusClostridium difficile

• JANE ODONNELL
• ASSISTANT DIRECTOR
• INFECTION CONTROL

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Worth remembering

• If only causes 10 20 of antibiotics associated
  diarrhoea

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Potted history

• First described in 1935
• Linked to Pseudomomembranous colitis in 1978 by
  Bartlett et al
• Shown to cause disease in Hamsters
• Toxins A B recognised (1982)
• Nosocomial outbreaks observed (1999)

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C. Difficile why it is a problem?

• Found in environment and companion animals
• Selected in bowel by antibiotic use
• Causes mild to severe diarrhoea
• Can be difficult to treat
• Can spread to other patients
• Can cause deaths or make other diseases worse.

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Problems with understanding how C. difficile acts

• 10 of elderly may carry asymptomatically
• 70 of babies carry asymptomatically
• In hospital carriage may rise to 15-20, with no
  diarrhoea
• Colonised patients are less likely to develop
  diarrhoea when exposed to antibiotics, due to IgG
• ?vary immune response to toxin A
• Kyne L et al NEJM 342 390-97

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Costs of HAI some examples

• C. difficile diarrhoea - 4,000 (Wilcox et al.)
• 20-40 of patients die within 4 weeks of C.
  difficile positive stool (W. Yorks. Data)

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What makes patients vulnerable?

• Age
• Antibiotics
• Proton pump inhibitors
• Length of stay (gt21 days)
• Viral gastroenteritis
• Immunocompromised

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What measures help?

• Dont treat unnecessarily
• Avoid high risk agents
• Use low risk agents
• Use short courses review regularly
• Dont use 2 when 1 will do
• Avoid multiple courses
• Actimel? (St Thomas study)

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Other measures

• Patients with diarrhoea in side-room
• Hand washing important
• Cleaning of room probably important as organism
  found in environment round patient
• Improve personal hygiene of patients

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C. difficile and public health

• Increasing number of detections Why?
• Increasing awareness
• Increasing age and vulnerability of patients
• Increased bed occupancy and ward closures
• Increased use of Proton Pump Inhibitors
• Effect of D V due to other causes (Wilcox et al
  2007)
• Resistant strains e.g. 027

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Case Numbers
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Case Numbers
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What the Trusts are doing

• Recording all cases
• Reducing patient movement
• Visiting and carrying out RCAs
• Enhancing training
• Improving Antibiotic policies and control
  measures
• Improving environment and cleaning
• Enhancing information to staff and patients
• Spotting outbreaks more readily
• Discharge planning
• Environmental surveillance and typing

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The Target

• Is it useful
• Missed targets cause bad publicity
• Meeting target becomes main aim not improving
  patient care

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• Any questions?