Antibody Risk Factors for C. Difficile Associated Diarrhea

Diarrhea is a mutual side effect of antibiotic use. Notwithstanding, when Clostridium difficile (C. difficile) leaner are the culprits in post-antibody apply diarrhea, in that location is an increased risk of morbidity and mortality.

Clostridium difficile

Commonly found in hospitals and care facilities, C. difficile are anaerobic gram-positive bacillusi. Anaerobic means the bacteria do non need oxygen to survive so they live well in the colon. Role of the reason they persist in hospital environments is their power to exist for months and fifty-fifty years in spore grade, which tin can withstand heat and drying out.1 C. difficile produces specific toxins, which pb to these symptoms, commonly associated with infection:ane

  • watery diarrhea for more than than iii days,
  • very strong smelling stools,
  • lower intestinal pain,
  • fever,
  • blood in the stool,
  • loss of ambition/weight loss,
  • nausea,
  • malaise, and
  • an atypical simply significant consequence of C. difficile is that some who get infected exercise non get diarrhea, but rather the symptoms manifest equally bloating and constipation.

Infectious diarrhea

Not all contact with C. difficile results in infectious diarrhea. Among those colonized by the bacteria, only xl-60% will develop symptoms.1 For C. difficile-associated diarrhea (CDAD) to develop, specific circumstances must transpire. Initially, there is some class of disruption – unremarkably from antibiotic use – to the normal balance of bacteria native to the colon. Additionally, an private must have exposure to C. difficile that thrive and multiply in the colon, which is now lacking its protective expert bacteria. Finally, the growing population of C. difficile leaner produces toxins, leading to the dangerous condition.

A stool sample test tin assess for a C. difficile infection. Rather than test directly for the presence of the bacteria through common testing methods such every bit cultures or polymerase chain reaction (PCR), near institutions exam for the presence of toxin B. If a C. difficile infection exists, medical treatment includes metronidazole or vancomycin therapy for 7-10 days.

Increasing frequency and severity

CDAD is becoming more frequent and more than astringent, every bit described in surveillance reports globally, nationally, and provincially.ane,2,three

The Centre Hospitalier Universitaire de Sherbrooke reported an increase in new diagnoses, from ii.i cases of CDAD per ane,000 admissions in 2002, to x cases per 1,000 admissions the following twelvemonth, which was at the onset of a C. difficile outbreak in that facility.2 Infection Control surveillance involving British Columbian institutions constitute rates of C. difficile infection rose steadily betwixt 2000 and 2004.3

The severity of CDAD is increasing. Recent outbreaks of C. difficile in Eastern Canada, the U.s.a., the United Kingdom, and the netherlands accept also brought attending to a genetic subtype, the PCR ribotype 027 strain, associated with an increase in frequency and deaths.4 Levels of the bacterial toxins in this strain are institute to be xvi-23 times higher than other strains.4 Conservative estimates from two hospitals in Montreal betoken deaths of 24 patients attributed to CDAD, accounting for a quarter of all CDAD deaths nationwide during the twelvemonth of the outbreak.2 During this timeframe, isolates of the PCR ribotype 027 strain deemed for 75.2% of all C. difficile isolates from ane of these two Montreal hospitals, compared with 10.7% in Calgary, Alberta, and 5.9% in Surrey, BC.v With growing rates of C. difficile infections, and the presence of a hypervirulent strain, community efforts should be directed toward effectively preventing this infection.

Take a chance factors

Mediating take chances factors may provide a solution to the increasing CDAD threat. Gamble factors tin can include the following:1

  • antibiotic employ, particularly broad-spectrum antibiotics
  • increasing age
  • severe underlying affliction
  • a weakened immune organization
  • gastrointestinal surgery
  • frequent enema apply
  • long-fourth dimension hospital or home care stay

The electric current literature describes antibiotic risk factors that tin contribute to CDAD in the hospital environs. Nonetheless, since normal flora disruption can lead to CDAD up to 8 weeks later,6 elucidating community factors related to C. difficile infections will be of import in slowing or halting increasing disease rates.

New enquiry

Researchers with the Fraser Wellness Potency conducted a retrospective case-control study to address this lack of knowledge, using patient information from a 370-bed tertiary intendance hospital in the Metro Vancouver surface area. Subjects were acute care inpatients over the age of eighteen who provided stool samples for a C. difficile toxin examination. Control subjects included patients who did non test positive for C. difficile. There were 102 case subjects and 97 command subjects in total, matched by the post-obit criteria:

  • age within 5 years
  • gender
  • comparable access date
  • comparable exposure to the same ward, defined as admission date until index date (date of positive stool sample (case) or discharge date (control))

The written report tracked these subjects and looked at rates of CDAD infection relative to the type of antibiotics prescribed. Furthermore, antibiotic use was analyzed separately in two phases: those used in the community (i.eastward. outside the hospital) and those used in the hospital. Unlike patterns of medication utilize and different risk factors for CDAD exist in these settings.

In the community setting, the researchers gathered information on medications dispensed from PharmaNet, a provincial registry administered by the College of Pharmacists of British Columbia, for the 8 weeks prior to the C. difficile toxin test. In the infirmary, data collection focused on the medications ordered and dispensed for the same period.

In the community, cotrimoxazole and antibiotics of the fluoroquinolone class were used more than often in the group of patients who went on to develop CDAD. In the infirmary setting, beta-lactam and beta-lactamase inhibitors, carbapenems, cephalosporins, clindamycin, macrolides, metronidazole, penicillins, quinolones, and vancomycin were used more than often in the group that adult CDAD. Aminoglycosides and nitrofurantoin were non found to differ in rates of employ betwixt groups.

Information technology is important to note that the study simply compares the rates of antibody use betwixt the case group of patients who developed CDAD and the command group of patients who did non develop this disease. There is no determination of the magnitude of CDAD risk, but rather an extrapolation demonstrating the association between a statistically significant difference in antibody use between case and control subjects.

Moving frontward

While the results from this report simply brand up part of the current trunk of show regarding antibiotics and CDAD risk, it is clear that antibiotics play a significant office in an individual's risk for CDAD. Information technology would be cavalier to label all antibiotics as dangerous, as they have an essential role to play in managing infection. However, as nearly all antibiotics tin increase a patient's take chances for Clostridium difficile diarrhea, an accent on antibody stewardship is of import in the strategy for reducing Clostridium difficile-associated diarrhea rates.

Anthony Tung, B.Sc. (Pharm.) Clinical Pharmacist
Fraser Health Authority Surrey, British Columbia
Get-go published in the Inside Tract® newsletter upshot 168 – July/September 2008
1. Putanen SM, et al. Clostridium difficile-associated diarrhea in adults. Canadian Medical Association Journal. 2004;Jul;171(1):51-8.
2. Valiquette L, et al. Clostridium difficile infection in hospitals: a brewing storm. Canadian Medical Association Journal 2004;Jul;171(1):27–ix.
3. Cheng L, et al., eds. Clostridium difficile associated diarrhea. Fraser Health Pharmacy News. Fall 2004.
four. Pepin J, et al. Bloodshed attributable to nosocomial Clostridium  difficile-associated disease during an epidemic caused past a  hypervirulent strain in Quebec. Canadian Medical Association Periodical. 2005;Oct;173(nine): doi:ten.1503/cmaj.050978.
5. MacCannell DR, et al. Molecular analysis of Clostridium difficile PCR ribotype 027 isolates from Eastern and Western Canada. Journal of Clinical Microbiology. 2006;Jun;44(6):2147-52.
6. Simor AE, et al. Infection due to Clostridium difficile among elderly residents of a long-term-intendance facility. Clinical Infectious Diseases. 1993;October;17(4):672-8.
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