The Clostridium difficile Epidemic: A Potential Disaster for Long-Term Care

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Author(s): 

Mary C. Vrtis, PhD, RN

The Scope of the Problem
Clostridium difficile (C. difficile), an anaerobic, spore-forming, gram-positive bacteria, has emerged in recent years as a serious health threat in the United States. Although the organism has been known to cause disease for at least 30 years,1 recent mutations have resulted in healthcare–acquired epidemic outbreaks in the United States,2-5 Canada,6,7 Europe8,9 and Japan.10 Genetic fingerprinting has identified a number of strains in clonal outbreaks, and several of these strains are cause for great concern. The rapidly spreading, hypervirulent, BI/NAP1 toxinotype III strain (also called PCR ribotype 027) has been responsible for many of the epidemic outbreaks. NAP1 toxinotype III strains produce 16 times more toxin than non-mutated strains of C. difficile. These strains are also resistant to some widely used antimicrobials and cause severe illness, including pseudomembranous colitis.1,2,11,12 Relapse rates as high as 19% have been reported.9 Other recent strains with similar mutations have also caused widespread, healthcare–acquired clonal outbreaks.13,14 Because genetic fingerprinting is rarely done, it is impossible to know the particular strains responsible for all of the outbreaks that are now occurring.

The number of cases of C. difficile–associated disease (CDAD) in the United States more than doubled between 1996 (82,000 cases) and 2003 (178,000 cases).3 A non–antimicrobial-resistant form of NAP1 toxinotype III was initially isolated in France in 1988, but cases were rare and sporadic.12 Further mutations of the organism to the hypervirulent state resulted in epidemic outbreaks of CDAD in eight U.S. states2 and Canada6,7 between 2000 and 2003. Since 2003, similar outbreaks have been occurring throughout Europe, and the organism was identified and/or implicated in epidemic outbreaks in 16 European countries by 2007.12,15,16

Attributable Mortality in the Older Patient
These epidemic strains are far more deadly than the organisms of 30 years ago.
Redelings et al17 estimated that U.S. death rates for CDAD increased by 35% per year between 1999 and 2004. Mortality directly attributable to CDAD has been estimated to range between 6.0% to 6.9%.18-20 C. difficile–attributable mortality for older persons is even higher. Pepin et al6 found that 14.3% of those between the ages of 65 and 74 years died within 30 days of diagnosis. For those over age 75 years, nearly 20% died as a direct result of the CDAD. Individuals who develop pseudomembranous colitis have a mortality rate up to 30% that is attributable to the infection.12

Risk Factors
Risk factors for CDAD include antimicrobial use, advanced age, comorbidities, and feeding tubes.

Antimicrobial Use
The relationship between broad-spectrum antibiotic use and CDAD has been known for over 30 years1 and is well documented. Fluoroquinolones (eg, ciprofloxacin, levofloxacin, moxifloxacin, gatifloxacin) and cephalosporins may place an individual at high risk.5,20 However, antimicrobial drugs may no longer be a prerequisite to development of the disease. Recent studies suggest that 20%20 to 30%21 of CDAD occurs in persons with no recent exposure to antibiotics within the previous one to two years. Dial et al22 found that 45% of patients taking a proton pump inhibitor–type medication had not received antimicrobials for at least 90 days.

Advanced Age
Older residents are at high risk for developing CDAD. Using the data from the National Hospital Discharge Survey, McDonald et al23 found that the CDAD rate for persons over age 65 years was 228 per 100,000 population.

References: 

References
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