Often referred to as a “nail fungus,” clostridium difficile can be a very serious infection that can affect your entire body, from your mouth to your lungs. Learn about this disease and how it can be prevented, diagnosed, and treated.
Diagnosis
During the last 20 years, there has been an increased incidence of Clostridium difficile infection (CDI). The reasons for this increase are unclear. The most likely explanation is that there are more virulent strains of the bacterium. Another possible explanation is that antibiotic therapy affects the bacterial flora in the colon.
This infection may result in pseudomembranous colitis, a condition characterized by mucosal edema, and fulminant colitis. The disease is typically diagnosed with an enzyme called glutamate dehydrogenase (GDH), which is present in stools. GDH is a sensitive enzyme that can cross-react with other clostridial species.
However, GDH is not a perfect test for CDI. Toxin A+B enzyme-linked immunosorbent assays (EIAs) is a better method for detecting toxin production by C. difficile strains. EIAs have a sensitivity of 75-95% and a specificity of 83-98%. The use of EIAs should be considered as part of a multistep diagnostic approach, including an antimicrobial stewardship strategy.
Clostridium difficile infection is a serious health problem that affects the United States. It accounts for a large percentage of hospital-associated gastrointestinal illnesses and costs the healthcare system 3.2 billion dollars annually. Infection occurs in patients with inflammatory bowel disease (IBD) and accounts for about half of the symptomatic relapses in IBD patients.
The bacterium is typically transmitted by the fecal-oral route. Infection occurs in the hospital setting, but can also occur in the community. In healthcare facilities, transmission occurs due to surface contamination of the environment by staff members and hand carriage by infected patients. The incidence of CDI is increasing and may be associated with the use of broad-spectrum antibacterial agents.
The diagnosis of CDI may be difficult and may involve repeated laboratory testing. However, repeat testing should only be ordered when new clinical evidence supports the CDI diagnosis.
Clostridium difficile is a Gram-positive spore-forming bacterium that is typically transmitted by the fecal-oral path. Although the majority of patients with CDI do not develop fulminant colitis, there is a risk of recurrent symptoms after initial diarrhea resolves.
Toxin A+B EIAs are the most commonly used diagnostic tests but are not as specific as GDH detection. They are also not appropriate for routine clinical use.
Treatment
Currently, the most common Clostridium difficile treatment is vancomycin. Patients with the severe disease receive a very high dose of vancomycin. Patients with milder diseases may be treated with oral metronidazole. For patients who cannot tolerate metronidazole, the use of rectal vancomycin is recommended.
Several risk factors contribute to the development of CDI. These include age, recent hospitalization, and gastrointestinal tract surgery. The risk of developing CDI increases with each episode. Carriage rates are higher in hospitalized patients. In the US, rates of CDI are higher in older adults, hospitalized infants, and long-term care facility residents.
Although the risk of developing CDI is very high, most patients with CDI have a mild course. A few patients are refractory to treatment and develop recurrent CDI (RCDI). These patients may have a different strain of the bacterium, an altered colonic microbiota, or may have another etiology.
Using a non-toxigenic strain of the bacterium may reduce recurrences. In addition, monoclonal antibodies to the toxins A and B have decreased recurrence rates in patients with a prior CDI. However, these therapies are not always effective.
The risk of developing CDI increases with the length of the hospital stay. The disease is usually transmitted through fecal-oral routes. Symptoms of CDI may occur for several weeks after initial treatment. The risk of RCDI within 8 weeks is between 10 and 20 percent. Using antibiotics to treat RCDI may decrease initial treatment failures, but it is not recommended.
A diagnosis of CDI is usually based on stool testing. Diagnostic tests should be performed on patients who have clinically consistent diarrhea. These tests should not be used to detect asymptomatic colonization. The tests are not as sensitive as toxins for CDI and cross-react with other clostridial species. However, the tests are useful for screening and for identifying toxins and strains of bacteria.
A positive result should be used to guide treatment decisions. The decision to wait for a positive test should be guided by the severity of the presentation. The tests are not specific enough to detect the bacterium in individuals with regular stools. In addition, they are not useful for detecting patients with other causes of diarrhea.
Complications
Despite being a common bacterial infection, Clostridium difficile complications are still rare. Researchers have been conducting studies to better understand the cause of complications, as well as how they may be treated.
Studies have indicated that older patients, especially those who have taken antibiotics, are at an increased risk for complications. Studies also indicate that the risk is higher for patients with a weaker immune system, as well as those who have a history of gastrointestinal procedures, such as a colostomy or colonoscopy.
Clostridium difficile colitis is caused by an overgrowth of clostridium difficile, which results from a disturbance in the normal bacterial flora of the colon. The organisms clostridium difficile produce toxins, which cause mucosal inflammation. When bacteria are allowed to survive on a surface for a period of time, they can spread from one object to another.
Clostridium difficile colitis can result in complications including colonic perforation, peritonitis, and colonic hemicolectomy. These complications are life-threatening and can result in death. In addition, sepsis, a complication of clostridium difficile, occurs when the body’s immune system responds to infection, resulting in damage to the body’s tissues.
Studies have found that people with a weakened immune system are at an increased risk for complications of clostridium difficile. Other risk factors include gastrointestinal procedures, such as a nasogastric tube or a colostomy, and health care settings.
Researchers studied patients who had clostridium difficile infection at 10 Canadian acute care hospitals. They analyzed data including demographics, the patient’s clinical status, and laboratory results. They identified 1,380 patients with a diagnosis of clostridium difficile and completed follow-ups. The study included data on patient age, gender, functional status, comorbidities, and hospital admission. They also analyzed data on preoperative lab results, relevant surgical procedures, and the recent use of anti-peristaltic agents.
Researchers found that a hypervirulent ribotype of clostridium difficile, ribotype 027, was associated with an increased risk for complications of clostridium diarrhea. Moreover, patients with a ribotype 027 infection had an increased risk for recurrent infection, compared with those with other ribotypes.
The results of the study have shown that recurrent Clostridium difficile infections are common, increasing healthcare resource utilization. A multivariate conditional logistic regression model was used to evaluate the relationship between recurrent infection and clinical outcome.
Prevention
Historically, Clostridium difficile infection (CDI) has been the leading cause of hospital-associated gastrointestinal illnesses. Clostridium difficile is a Gram-positive spore-forming bacterium that produces two toxins (A and B). It causes mild diarrhea and colitis. It is most often transmitted through the fecal-oral route. It is now the most common healthcare-associated infection in the United States. Infection rates have been increasing over the past decade.
Several risk factors can increase the incidence of CDI, including recent hospitalization, antibiotic use, and concurrent diseases. Increasing age is a major risk factor. It is estimated that 5 to 15% of healthy adults are carriers of CDI. The carriage rate of CDI is higher in infants than in adults. Hospitalized patients have a higher carriage rate, especially if they are older.
A number of interventions have been introduced to reduce the incidence of CDI. These include using alcohol-based hand antiseptics, disinfectants with a C. difficile-sporicidal label claim, and ammonium compound cleaning agents. In one study, an ammonium compound cleaning agent decreased the incidence of infection in a bone marrow transplant unit.
Other emerging therapies for CDI involve limiting the perturbation of the intestinal microbiota. The use of oral-fecal microbiota transplantation is one approach. Another approach involves using a nontoxigenic strain of C. difficile. This strain outcompetes the toxigenic strain and prevents further colonization of the intestinal tract.
A new macrocyclic antibiotic, fidaxomicin, has bactericidal activity against C. difficile and is currently being evaluated in phase II clinical trial. The drug has minimal systemic absorption. However, it has shown reduced recurrence rates and may be a useful therapy in the treatment of CDI.
Several emerging immunological therapies also have the potential to prevent CDI recurrence. These include monoclonal antibodies to toxins A and B. These antibodies may protect patients from CDI toxins. They may also decrease recurrence rates in patients with a previous episode of CDI.
Clostridium difficile is a non-invasive disease that causes mild diarrhea. It can also lead to pseudomembranous colitis and colitis. Symptoms may be exacerbated in patients with ileostomy, ileoanal pouch, or fulminant colitis. Patients with these diseases should be screened for CDI. In addition, patients with severe disease may benefit from early co-management with surgeons.
Health Sources:
Health A to Z. (n.d.). HSE.ie. https://www2.hse.ie/az/
U.S. National Library of Medicine. (n.d.). https://www.ncbi.nlm.nih.gov/
Directory Health Topics. (n.d.). https://www.healthline.com/directory/topics
Health A-Z. (2022, April 26). Verywell Health. https://www.verywellhealth.com/health-a-z-4014770
Harvard Health. (2015, November 17). Health A to Z. https://www.health.harvard.edu/health-a-to-z
Health Conditions A-Z Sitemap. (n.d.). EverydayHealth.com. https://www.everydayhealth.com/conditions/
