COMMENTARY

Dying From C diff: Who Is Most Vulnerable?

Nimalie Stone, MD

Disclosures

June 02, 2015

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Medscape &

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Hello. I'm Dr Nimalie Stone, an infectious disease physician and medical officer at the Centers for Disease Control and Prevention (CDC). I am pleased to speak with you as part of the CDC Expert Commentary Series on Medscape.

Today I would like to talk about a new study published in the New England Journal of Medicine[1] describing the burden of Clostridium difficile infection (C diff) in the United States. CDC's new study describes data from 2011 on infections among patients in hospitals, nursing homes, and in the community, and indicates that the risks for C diff infection and death increase with age in every setting.

The study found that C diff caused nearly half a million infections among US patients in a single year. Approximately 29,000 patients died within 30 days of the initial diagnosis. Based on other estimates of the attributable mortality in hospitalized patients, about half this number (15,000 deaths) were probably directly caused by C diff infection.

Older Americans are especially vulnerable to this deadly diarrheal infection. Two out of every three healthcare-associated C diff infections occur in patients aged 65 years or older. More than 80% of the deaths associated with C diff infection occurred among Americans aged 65 years or older, and one out of every nine older adults with a healthcare-associated C diff infection died within 30 days of diagnosis, according to the new study.

Unnecessary antibiotic use and poor infection control practices may increase the spread of C diff within a healthcare facility and from facility to facility when infected patients transfer, such as from a hospital to a nursing home. More than 100,000 C diff infections develop among residents of US nursing homes each year, making C diff infections among the most serious healthcare complications that affect the nursing home population.

Patients who take antibiotics are most at risk of developing C diff infection. More than half of all hospitalized patients will receive an antibiotic at some point during their hospital stay, but studies have shown that 30%-50% of antibiotics prescribed in hospitals are unnecessary or incorrect. When a person takes broad-spectrum antibiotics, beneficial bacteria that are normally present in the human gut to protect against infection can be suppressed for several weeks to months. During this time, patients can become infected with C diff picked up from contaminated surfaces or spread from person to person.

Healthcare providers can take several steps to prevent C diff infections and reduce the spread of infection.

If the patient has had three or more unformed stools within 24 hours, order a C diff test considering the fact that some tests, such as nucleic acid amplification tests (NAATs), are much more sensitive in detecting the infection than others. Institute isolation precautions immediately for patients with C diff, and wear gloves and gowns when caring for these patients, even during short periods of time. Visitors and healthcare workers should wash their hands with soap and water after visiting or caring for patients with C diff infections.

C diff can live for long periods of time on the surfaces and materials of devices and equipment, such as toilets and bedside tables. Room surfaces should be cleaned thoroughly on a daily basis while treating a patient with C diff and upon patient discharge or transfer. To kill C diff, bleach or another Environmental Protection Agency-approved disinfectant active against spores is necessary.

When a patient transfers, especially between hospitals and nursing home, notify the new facility if the patient has a C diff infection. When a patient transfers, if healthcare providers are not told that the patient has or recently had a C diff infection, then they may not take appropriate actions to prevent spread if the patient develops symptoms.

Clinicians must prescribe antibiotics carefully. For example, obtain appropriate cultures when an infection is suspected, and once culture results are available, check whether the prescribed antibiotics are correct and necessary. Improving antibiotic use and preventing infections will also reduce costs of care and improve the quality of life for every patient.

CDC is working with various professional partners, including Advancing Excellence in America's Nursing Homes, to communicate the threat of C diff and the steps needed to prevent infections and spread. Preventing all healthcare-associated infections is critical, and implementing strategies to prevent C diff will also improve measures to prevent the spread of other infections among your patients.

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Nimalie Stone, MD, is the medical epidemiologist for long-term care in the Division of Healthcare Quality Promotion (DHQP) at the Centers for Disease Control and Prevention (CDC). She is a board-certified infectious disease physician who has a research and clinical background in managing infections and antibiotic-resistant pathogens in older adults and long-term care settings. She completed her internal medicine residency at Johns Hopkins University and an infectious disease fellowship at Emory University.

In her role at the CDC, Dr Stone develops guidelines, educational resources, and quality improvement programs to reduce healthcare-associated infections in long-term care facilities. She was the lead author of the revised McGeer surveillance definitions of infections in long-term care facilities and the chair of the workgroup that developed the resources and tools for the infections goal in the Advancing Excellence Campaign. She works with state and federal programs to increase awareness and resources for infection surveillance and prevention activities by long-term care facilities, and supports long-term care facilities enrolled in and reporting infections to the CDC's National Healthcare Safety Network.

Dr Stone collaborates with many partners who are engaged in preventing healthcare-associated infections and improving antibiotic stewardship in the long-term care setting, including the Society for Healthcare Epidemiology of America (SHEA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Health Care Association (AHCA), the National Association of Directors of Nursing Administration in Long-term Care (NADONA/LTC), and the AMDA Society for Post-acute and Long-term Care Medicine (AMDA).

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