COMMENTARY

Clostridium difficile Infection: 5 Things to Know

David A. Johnson, MD

Disclosures

September 10, 2018

The Burden of CDI

Clostridium difficile infection (CDI) causes inflammation of the colon and is a potentially life-threatening diarrheal illness.

CDI has become the most common microbial cause of healthcare-associated infections in US hospitals, resulting in $4.8 billion yearly in excess healthcare costs for acute care facilities alone.[1] The most recent data suggest an incidence of approximately 500,000 cases annually, with as many as 29,000 patients dying within 30 days of their initial diagnosis.[1] Additionally, patients with CDI are twice as likely to be readmitted to the hospital as those without CDI. The length of stay upon readmission was also significantly higher, adding 4 to 7 days over other admission diagnoses.[2,3]

Given the importance of CDI, five key focus areas are highlighted here; while they might not all be well recognized, they need to be known.

1. Spores Are Hardy and Hard to Kill

C difficile spores are extremely hardy and can survive for long periods on exposed surfaces. An important mechanism of transmission is via the hands of healthcare providers or other individuals who have touched a contaminated surface. But transmission from an infected patient is not the only mode, or even the primary mode of transmission, within the hospital setting. Another mechanism of C difficile dissemination is asymptomatic colonization.[4,5] Despite having no symptoms of disease, colonized patients can serve as an infectious reservoir, posing an under-recognized risk to vulnerable patients. Colonization may be the result of antibiotic therapy, which disrupts the intestinal microbial composition, enabling colonization with C difficile.[6]

Isolation reduces patient-to-patient transmission within the institutional setting. Private rooms and dedicated toilets are recommended for infected patients to prevent transmission to noninfected patients. Gloves and gowns are standard practice for healthcare providers and any visitors of patients with suspected disease. The recommendation is to continue this practice for at least 48 hours after resolution of the diarrhea. Handwashing before and after wearing gloves is also recommended.[7]

2. Metronidazole May Be on the Way Out

Although previous guidelines recommended metronidazole for mild CDI, in the most recent guidelines, oral vancomycin (125 mg four times daily) or fidaxomicin (200 mg twice daily) for 10 days are the preferred treatments. Further support for the avoidance of metronidazole as initial therapy comes from a recent study demonstrating that the risk for 30-day mortality for all combined severities is reduced with vancomycin versus metronidazole.[8] Of note, branded oral vancomycin is an expensive drug.[9] Clinicians may wish to investigate the cost savings of using a compounding pharmacy to encapsulate parenteral vancomycin powder, which might be less expensive.

The recommended vancomycin dose for fulminant disease with hypotension, shock, ileus, or toxic megacolon is 500 mg four times daily. In patients with ileus or megacolon, using vancomycin 500 mg in 100 cc normal saline per rectum every 6 hours as a retention enema may be considered.[7] It is important to roll the patient onto his or her right side to facilitate transfer of the solution to the right colon. Use a large Foley catheter and inflate the 30-cc balloon, leaving it inflated for an hour while repositioning the patient.[10] Metronidazole given intravenously (500 mg every 8 hours) is recommended in addition to rectal vancomycin if ileus is present.

Oral metronidazole is an alternative for CDI only when access to vancomycin or fidaxomicin is limited.

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