It starts innocently enough. A long-term care resident has an infection that requires an antibiotic. After a time, the antibiotic triggers a Clostridium difficile infection, causing bloating, pain and severe diarrhea. Even though the patient is isolated as soon as C. diff is discovered, other patients come down with the infection. Pretty soon, this LTC facility has set aside one end of a corridor for rooms for residents with C. diff.
"In a hospital, you can somewhat control the environment, but for people in long-term care facilities, this is their home," said Hudson Garrett, PhD, MSN, MPH, FNP-BC, CSRN, VA-BC, industry infection prevention expert and senior director of clinical affairs at PDI, an infection prevention solutions company headquartered in Orangeburg, NY. "That and the fact most LTC residents have the decreased immunity that comes with age bring unique challenges."
"You want to limit the use of antibiotics - that's the best way to reduce C. diff - but with residents with a chronicity of conditions that isn't always possible," explained Rich Bach, RN, infection preventionist at Moravian Village, Bethlehem, PA.
Since 2000, the incidence of C. diff has increased 400 percent, said Garrett, who is also an active member of the American Association for Long Term Care Nursing. And 90 percent of the people who die as a result of C. diff are over age 65, so the problem is a serious geriatric threat. In 2006, the spore-forming bacteria killed more patients in England than MRSA.1 Compounding the problem is the fact C. diff has mutated and developed a hypervirulent pulsed-field type 1 strain, which requires additional vigilance to treat.
"The cost to treat one case in LTC ranges from a few hundred dollars to thousands of dollars," Bach said. Nationally, the annual cost of treating C. diff is about $3.2 billion.1
With money and lives at stake, it is important to understand what C. diff is and why it occurs. It starts with an infection or illness that requires an antibiotic. That antibiotic not only kills the infection, but also the good bacteria in the gut, which can result in diarrhea.
"I know this sounds disgusting, but C. diff spores are transmitted by fecal/oral contact," explained Bridget McEnrue, RN, manager of infection control at St. Luke's University Hospital, Bethlehem, PA. McEnrue works with infection prevention staff at Miners Campus, which includes an LTC facility that is part of the St. Luke's network. "So an infected person touches a door knob and then the next person to touch it picks up the spores," she said. The spores can survive for up to 4 months on surfaces like blood pressure cuffs, meal trays, telephones, bed rails, call buttons and stethoscopes.
One of the best ways of preventing C. diff, or stopping its spread, is the easiest, according to McEnrue. "Fastidious handwashing with soap and water to remove those spores and wash them down the drain is the most effective," he said. Common antimicrobial waterless hand sanitizers are ineffective against C. diff spores, and the friction of scrubbing and drying hands is important to get rid of the bacteria.
Many facilities treat patients infected with C. diff with oral metronidazole or vancomycin, or, if they both don't work, IV metronidazole. After a first treatment with metronidazole or vancomycin, C. diff recurs in about 20 percent of cases; this increases to 40 percent and 60 percent with subsequent recurrences, according to the CDC.
St. Luke's has gone one step further and fostered an infectious disease pharmacist. "That's a pharmacist who takes an additional internship to specialize in infectious diseases," McEnrue explained. "When a patient is placed on antibiotics, they do antimicrobial stewardship and review to be sure it's the right antibiotic, used properly."
Six Things to Remember
"There isn't one single weapon that works best against C. diff, but, according to the CDC, there are six things you can do to prevent the infection," Garrett told ADVANCE:
• Prescribe and use antibiotics appropriately.
• Immediately test patients admitted to LTC with active diarrhea or who develop diarrhea.
• Isolate infected residents, usually in a private room.
• Wear gloves and gown and practice contact precautions when treating affected residents.
• Keep surfaces clean with bleach or another EPA-approved, spore-killing disinfectant after a patient with C. diff has been treated there.
• If transferring a patient with C. diff, ensure whoever is assuming care knows the patient has the infection.
Education is another weapon against the bacteria, explained Bach, who said at any given time 9 percent of residents at Moravian Village have C. diff that is mostly community-acquired. "An ongoing part of the process of fighting C. diff is family teaching," he said. "We demonstrate the proper PPE to use; explain contact precautions; why they should wear a gown and gloves at certain times in the course of the illness."
That education includes instructing families on how to care for family members who have C. diff, McEnrue said. "By the time a patient with C. diff is released from the hospital, the chance of passing on the spores has decreased," she said. "However, we still caution families to designate a bathroom to be used only by the affected person."
Then there is what Bach describes as the nursing strategies. "Maximizing hydration, nutritional and general care levels are needed to help improve recovery," said Bach, who pointed out that since Moravian Village is a skilled nursing facility, many of its residents are admitted for short-term care and rehabilitation, with an average length of stay of 25 days or less.
Incidence and mortality from C. diff are such grave problems, several new therapies have emerged. One is the use of probiotics - lactobacillus acidophilus milk products such as yogurt - that are live microorganisms thought to be beneficial to the host digestive system. Probiotics promote the growth of good bacteria in the gut, thus mitigating the problems caused by antibiotics. "We use probiotics where physicians permit it and nurses recommend it," Bach said.
Another new therapy is fecal transplantation, "taking feces from a healthy relative and transplanting it into a resident who has C. diff to replace the contaminated flora," Garrett explained. This medical therapy has tremendous promise.
According to Jonathan Eisen, an evolutionary biologist at the University of California at Davis, "rather than deliver a couple of probiotic microbes through the mouth, they are delivering a community of probiotics, a community of microbes from healthy donors, through the other end. This has turned out to be very effective in fighting certain intransigent infectious diseases like C. diff infections that can stay with people for years, and has actually been shown to cure systemic C. diff infections in people."2
With the havoc C. diff spores can cause, to say nothing of its rapidly mutating strains, fecal transplants don't sound like such a drastic therapy.
References for this article can be accessed at www.advanceweb.com/Nurses. Click on Resources, then References.
Gail O. Guterl is a frequent contributor to ADVANCE.