Practice Cleanliness, Prevent Infection

C. Difficile and How Proper Hand Washing Could Save your Life

by Quinn Katherman

Who is at Risk

Healthy people rarely contract C. difficile. At the highest risk are those who require a prolonged use of antibiotics, those who have impaired immune systems and the elderly (65 and older).

According to the Association for Professionals in Infection Control and Epidemiology, the risk of C. difficile increases in patients with:

• Antibiotic exposure
• Gastrointestinal surgery/manipulation
• Long length of stay in health care settings
• Serious underlying illness
• Conditions that weaken the immune system
• Advanced age

Findings

According the the APIC, 13 out of a 1,000 hospitalized patients are suffering from C. difficile, based on a national prevalence study conducted in November 2008.

In the United States, C. difficile is increasing at a rapid rate. Based on the APIC study released in November, it is estimated that C. difficile is afflicting more than 7,000 hospitalized patients on any given day.

The number of C. difficile cases in the U.S. is on the rise as result of the bacterium's ever-increasing resistance, the aging population and inadequate infection control in hospitals.

Effective Handwashing

7 steps to prevent the Spread of Germs

• 1) Turn on water to a comfortable temperature and moisten hands and wrists.
• 2) Apply a generous portion of liquid soap.
• 3) Generate a heavy lather and wash well for approx. 15 seconds. Clean between fingers, nail beds, under fingernails and backs of hands
• 4) Rinse well under running water, keeping hands low in sink to prevent splashing.
• 5) Hold hands so that water flows from the wrist to fingertips.
• 6) Dry hands completely with clean paper towels.
• 7) Use the paper towel to turn off the faucet so your hands remain clean.

Hand washing tips

"I think the answer is hygiene," Smith says. "Make everyone responsible for washing their hands. Don't be shy about asking the medical professionals to wash their hands."

• Do not use antibacterial gels or alcohol-based wipes as these are not effective against spore-producing bacteria like C. difficile.
• Wet your hands with warm, running water and apply liquid or clean bar soap. Lather well.
• Rub your hands vigorously together for at least 15 to 20 seconds (you should be able to sing "Happy Birthday" twice).
• Scrub all surfaces, including the backs of your hands, wrists, between your fingers and under your fingernails.
• Rinse well.
• Dry your hands with a clean or disposable towel.

Prevention

• It's just a matter of cleanliness.
• "In almost all of the studies done in hospitals nationwide there has been cross-contamination, generally by health care workers themselves," Swenson says.
• Here are the APIC's recommendations for preventing C. difficile's transmission:
• - Wash hands with soap and water, especially after using the restroom and before eating.
• - Clean bathroom and kitchen surfaces on a regular bases with one cup bleach to 10 cups of water daily to prevent the spread of bacteria.
• - Do not share a toilet with a person who has C. difficile
• - Reduce unnecessary use of antibiotics. Don't demand antibiotics for every cold or sniffle as these are usually caused by viruses, and antibiotics do not kill viruses. Ask your health care provider if antibiotics are necessary, if they are still prescribed, be sure to follow the instruction and take the full course as directed.

Cdiffsupport.com

Smith says it is difficult to cope with the constant physical, mental and financial traumas of C. difficile. As one of the site administrators on cdiffsupport.com, Smith works to help people deal with the overall stress C. difficile creates.

"C. diff is going to affect your life, but you can't let it ruin your life. It's an ugly disease because it's very unpredictable. And doctors truly don't understand that much about it," Smith says.

The C. difficile support site posts studies, new information, media reports and advice for people suffering from C. difficile. It also serves as a forum where people can ask questions and discuss their condition with others who understand what they are going through.

"It's a disease that you'll never understand unless you have it," Smith says.

Symptoms

• Diarrhea (at least three bowel movements per day for two or more days)
• Fever
• Loss of appetite
• Nausea
• Abdominal pain/tenderness

In the worst cases of C. difficile, patients experience the extremes of these symptoms. However, in some cases the symptoms are so mild that the bacterium go undetected, or be misdiagnosed as irritable bowel syndrome.

Part of its name comes from the Latin for "difficult," which accurately describes how life can be when you're suffering from an infection of Clostridium difficile.

According to the Centers for Disease Control and Prevention, Clostridium difficile (also referred to as C. difficile or C.diff) is a bacterium that causes diarrhea and more serious conditions such as colitis, the inflammation of the colon.

Once in your intestines, this bacterium is capable of causing anything from mild diarrhea to life-threatening colitis.

C. difficile has plagued the life of Bobbie Smith, a Kansas City resident and site administrator for cdiffsupport.com, an online support group.

In 1979, one year after the bacterium was discovered, Smith's 4-year-old son contracted C. difficile as a result of taking amoxicillin for a prolonged period of time to treat several illnesses. Fourteen years later, at the age of 52, Smith had an upper respiratory infection and received antibiotics as a treatment, she then contracted pneumonia and received more antibiotics until she was finally hospitalized with sinusitis, pneumonia and C. difficile.

Smith suffered from C. difficile for four years after she first contracted the disease in 1993, and it wasn't until 1997 that she finally felt cured. The relief was short-lived, and she relapsed in 1999.

Smith's story, once considered rare, is now something 500,000 people in the United States can relate to every year.

The Causes of C. Difficile

Several factors play a role in the development of C. difficile. The large intestine houses a lot of good bacteria, which help protect your body from infection. When you are taking antibiotics to treat an infection, the good forms of bacteria are destroyed in addition to the harmful bacteria.

"Antibiotics tend to decrease the normal flora of the gut," says Gayle Whitmore, RN and infection control coordinator at Heartland Spine & Specialty Hospital. As a result, an environment is created in which C. difficile can flourish.

C. difficile is virtually everywhere, but it is most commonly found in hospitals and nursing homes. The C. difficile bacteria can be passed through fecal contamination.

"If I have it and I don't wash my hands after using the bathroom, then I can spread it to someone else, or they can pick it up from anything I've touched," Whitmore says.

C. difficile produces seemingly resilient spores that can persist in a room or on an object, such as a bedrail or door handle, for weeks and even months.

Many cases of C. difficile are the result of a lack of cleanliness within the health care facility as well as among the staff. Smith says that she won't let a doctor or nurse come near her unless they've properly washed their hands.

Treatment

"It's ironic because C. diff is caused by antibiotic therapy but it's also cured with antibiotic therapy, too," says Joyce Swenson, Surgicenter Administrator at South Kansas City Surgery Center.

There are two main antibiotics used to treat C. difficile: Flagyl and Vancomycin. However, some of the more severe cases of C. difficile are proving to be resistant to this antibiotic treatment.

"There are some severe strands of C. diff that are harder to treat because they don't react to the antibiotics," says Colleen Brown, gastroenterology nurse at Saint Luke's Hospital of Kansas City.

In Smith's case, C. difficile caused inflammation of the colon (colitis), which led to a more severe form of C. difficile known as pseudomembranous colitis. In these more severe cases of C. difficile there are several alternative treatments available.

"We do simple procedures, such as broth infusions, which introduce good bacteria back into the intestines to hopefully get rid of the infection," Brown says.

"It's called 'the broth,'" Smith says of the endoscopic procedure that reintroduces good bacteria into the gut.

Brown works with Dr. Mark Allen, M.D., a gastroenterologist with Mid-America Gastro-Intestinal Consultants on staff at Saint Luke's Hospital of Kansas City, who specializes in broth infusions. Dr. Allen has performed three broth procedures on Smith since 1993.

The other option for severe cases is fecal bacteriotherapy, also known as a fecal transplant, developed by Dr. Thomas J. Borody as a treatment for pseudomembranous colitis caused by C. difficile. Fecal bacteriotherapy involves reintroducing normal bacterial flora into the patient's body from a stool from a healthy donor.

C. difficile can survive in the intestines even after treatment, making the possibility of another infection very high.

"Once you have C. difficile, you're always at risk again," Smith says. "I like to call it the gift that keeps on giving."