The New Era of C. difficile-Associated Diarrhea

  • Fri, 9/5/08 - 4:54pm
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Author(s): 

Maxwell M. Chait, MD, FACP, FACG, AGAF, FASGE

Introduction
Clostridium difficile-associated diarrhea (CDAD) is the most common form of nosocomial diarrhea. C. difficile is a gram-positive spore-forming anaerobic bacillus that was first described in 1935, but it was not associated with antibiotic-related diarrhea and pseudomembranous colitis until 1978.1

A new era of CDAD has been entered with a significant change in nearly every aspect of the disease. With the emergence of a new more pathogenic strain, there is an increase in the number of cases and disease severity and recurrences, coupled with a decrease in response to therapy.2 Factors that have adversely affected CDAD include a change in the hospital environment to a population of more immunocompromised, elderly patients with comorbidities, associated with a reduction in nursing and housekeeping staffs and response to therapy. Additional factors include the increased use of broad-spectrum antibiotics; the increased use of acid-reducing agents such as proton pump inhibitors (PPIs); and the increased use of invasive measures, such as feeding tubes, that allow for more contamination. This has forced investigators to seek other potential treatments and to develop a multifaceted approach to managing CDAD, which includes education of hospital personnel regarding spread and prevention of CDAD, surveillance programs for detection of CDAD, institution of preventive techniques to combat CDAD, and a reduction in the use of high-risk antibiotics.

Epidemiological Features of CDAD
C. difficile is the cause of approximately 25% of all cases of antibiotic-associated diarrhea, with more than 300,000 cases per year in the United States alone. Most cases of CDAD occur in hospitals or long-term care (LTC) facilities. The incidence in the outpatient setting is rising and is at approximately 20,000 cases per year. 3

Many antibiotics have been implicated in CDAD. The most commonly associated antibiotics are clindamycin, third-generation cephalosporins, and fluoroquinolones.4 Even the antibiotics used in treating CDAD, vancomycin and metronidazole, have been associated with CDAD. Therefore, clinicians should be aware that nonessential antibiotic prescriptions should be avoided since they could potentially lead to significant morbidity and mortality.5

The rate and severity of CDAD is rapidly increasing, especially among patients over age 65 years.2,3 CDAD is twice as common as all the other causes of infectious diarrhea combined.6 The rate of CDAD increased 109% and the total mortality increased to 147% from 1993 to 2003, even after adjusting for comorbidities.

In one study, CDAD community-acquired infection occurred in 22% to 28% of cases, with 43% of all patients developing symptoms at home.6 In another study, 41% of CDAD cases were diagnosed among outpatients.7 However, 14% resided in the community, and 83% were nursing home residents. An important risk factor for CDAD among the nursing home residents was recent antibiotic treatment of urinary tract infections.

Although less than 3% of all healthy adults are asymptomatic carriers, colonization of C. difficile occurs in up to 21% of hospitalized patients. Clinical symptoms of CDAD develop in only about one-third of previously asymptomatic colonized patients.8

Pathogenesis and Immunological Features of CDAD
There is a complex interaction between host factors, the environment, and an antibiotic’s effect on the gastrointestinal flora, the activity of the antibiotic against the C. difficile strain involved, local patterns of antibiotic use, and effects on toxin formation that promote CDAD. C. difficile forms spores that can persist in the environment for years. Contamination is common in hospitals and LTC facilities, especially in rooms occupied by an infected individual. Patient-to-patient transmission of the organism occurs.

References: 

References
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  Anonymoussays:
  August 16.2010 at 18:16 pm
  
This was an excellent overview of the c-diff problem and potential solutions.  I would like to see follow-ups with more details on the new treatments and their effectiveness and availability

  

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