Clostridium difficile infections
Wide Use of Antibiotics Allows C. Diff to Flourish
Jane E. Brody : NY Times : May 25, 2015
You might say Jacob Epstein, a lean, healthy, 88-year-old Floridian, died in early May from a broken arm. Following surgery to reset the bone, he was given an antibiotic to prevent postoperative infection, a common hospital practice.
His daughter, Beth Fidanza, recalled that within a week her father developed diarrhea caused by a particularly nasty intestinal bacterium called Clostridium difficile, or C. diff. Another antibiotic seemed to eradicate the disease, but a month later the gut infection recurred. Mr. Epstein was given another antibiotic, but within days developed a fatal combination of kidney failure, dangerously low blood pressure and gastrointestinal bleeding.
Although this sounds like an example of “the operation was a success but the patient died,” Mr. Epstein’s demise is really the result of inappropriate use of antibiotics, which has given rise to a virulent, antibiotic-resistant strain of C. diff., an organism that now causes close to 500,000 new cases and 30,000 deaths a year in the United States alone.
C. diff. is a spore-forming, toxin-producing bacterium that can colonize the large intestine and wreak havoc there, causing frequent watery stools and severe dehydration. The spores are resistant to heat, acid and antibiotics; they can be washed away with soap and water but are not inhibited by the alcohol-based hand sanitizers now widely used in health facilities. Thus, poor bathroom hygiene can spread this nearly ubiquitous organism to vulnerable individuals.
Dr. Dale N. Gerding, an infectious diseases specialist at Loyola University Chicago, said in an interview: “C. diff. is found in soil and water, even chlorinated water, and is a low-level contaminant in food. Most of us ingest C. diff. every day.”
However, he explained that in most people the myriad micro-organisms that normally reside in the gut protect against C. diff. infection. That is, until antibiotics disrupt the healthy balance of micro-organisms. Freed of competition, C. diff spores can germinate and reproduce unchecked, and not only in people with compromised immune systems.
“The healthy gut microbiota has three features: a large number of micro-organisms, a large number of different species, and an increased representation of certain bacterial phyla and a decreased representation of other phyla,” Maja Rupnik wrote in The New England Journal of Medicine last month. “The disruption of any of these features can result in increased susceptibility to the growth of C. difficile,” Dr. Rupnik added.
Since the early 2000s, hospitals have reported drastic increases in severe C. diff. infections, Dr. Daniel A. Leffler and Dr. J. Thomas Lamont of Beth Israel Deaconess Medical Center in Boston reported in the same journal. The predominant virulent strain, known as NAP1, has a mortality rate three times as high as that associated with the less virulent forms most prevalent in decades past.
“The most important risk factor for C. difficile infection remains antibiotic use,” the doctors wrote. “Ampicillin, amoxicillin, cephalosporins, clindamycin and fluoroquinolones are the antibiotics that are most frequently associated with the disease, but almost all antibiotics have been associated with infection.”
Dr. Gerding said most antibiotics “are being used inappropriately, for things like upper respiratory infections that are caused by viruses.” And eating yogurt or taking commercially available probiotics while on an antibiotic have not proved protective, he said. However, in England, where a program of more judicious use of antibiotics was put into effect, C. diff. infections have declined.
The risk and severity of a C. diff. infection rises with age, as does the risk of a recurrence. In a study of an outbreak in a Quebec hospital, people over 65 were 10 times as likely as younger patients to become infected. Even after infected individuals recover, about 5 percent continue to harbor the toxic strain in their stool for six months, and if they take another antibiotic during that time, the illness can recur, Dr. Gerding said.
Although traditionally associated with hospitals and other inpatient medical facilities, C. diff. infections acquired outside hospitals have “increased dramatically in the past decade and may now account for up to a third of new cases,” Dr. Leffler and Dr. Lamont wrote.
But Dr. Gerding, who has studied C. diff. for three decades, said that among those infected outside hospitals, “about 80 percent had a recent health care exposure,” for example, at a clinic or a doctor’s office, where they may have been prescribed antibiotics and exposed to the spores.
The good news, he said, is that new treatment approaches are proving capable of preventing recurrences in infected individuals, and may be able to prevent an initial infection in the future.
This month in JAMA, Dr. Gerding and his colleagues described treatment using a nontoxin-producing strain of C. diff. in patients who initially recovered from an infection. While not a permanent solution, the strain persists in the intestine long enough to allow the normal healthy microbiota to repopulate the gut and greatly reduce the risk of a recurrence.
In another approach, Dr. Israel Lowy of Medarex in Princeton, N.J. (now with Regeneron Pharmaceuticals), Dr. Deborah C. Molrine of MassBiologics at the University of Massachusetts Medical School and their colleagues demonstrated that monoclonal antibodies created to attack the C. diff. toxins reduced the risk of a recurrence to 7 percent from 25 percent. This, too, is a stopgap measure designed to provide time for the restoration of normal gut microbiota.
A more permanent solution now under study involves an injectable antitoxin vaccine. Because it can take weeks to months for vaccine protection to take effect, one of the temporary measures could be used in the interim, Dr. Gerding said.
Well-publicized treatments using fecal transplants from healthy individuals are reserved for patients who have experienced multiple recurrences of C. diff. Researchers are trying to isolate the organisms in feces from healthy people that are most effective, with the hope of incorporating them into a capsule that could be taken orally as a treatment or preventive.
Dr. Gerding foresees the possibility that people taking an antibiotic might simultaneously receive a dose of live therapeutic bacteria that can prevent colonization by hazardous organisms. “If this works, it will be huge in preventing transmission of C. diff.,” he said.
Jane E. Brody : NY Times : May 25, 2015
You might say Jacob Epstein, a lean, healthy, 88-year-old Floridian, died in early May from a broken arm. Following surgery to reset the bone, he was given an antibiotic to prevent postoperative infection, a common hospital practice.
His daughter, Beth Fidanza, recalled that within a week her father developed diarrhea caused by a particularly nasty intestinal bacterium called Clostridium difficile, or C. diff. Another antibiotic seemed to eradicate the disease, but a month later the gut infection recurred. Mr. Epstein was given another antibiotic, but within days developed a fatal combination of kidney failure, dangerously low blood pressure and gastrointestinal bleeding.
Although this sounds like an example of “the operation was a success but the patient died,” Mr. Epstein’s demise is really the result of inappropriate use of antibiotics, which has given rise to a virulent, antibiotic-resistant strain of C. diff., an organism that now causes close to 500,000 new cases and 30,000 deaths a year in the United States alone.
C. diff. is a spore-forming, toxin-producing bacterium that can colonize the large intestine and wreak havoc there, causing frequent watery stools and severe dehydration. The spores are resistant to heat, acid and antibiotics; they can be washed away with soap and water but are not inhibited by the alcohol-based hand sanitizers now widely used in health facilities. Thus, poor bathroom hygiene can spread this nearly ubiquitous organism to vulnerable individuals.
Dr. Dale N. Gerding, an infectious diseases specialist at Loyola University Chicago, said in an interview: “C. diff. is found in soil and water, even chlorinated water, and is a low-level contaminant in food. Most of us ingest C. diff. every day.”
However, he explained that in most people the myriad micro-organisms that normally reside in the gut protect against C. diff. infection. That is, until antibiotics disrupt the healthy balance of micro-organisms. Freed of competition, C. diff spores can germinate and reproduce unchecked, and not only in people with compromised immune systems.
“The healthy gut microbiota has three features: a large number of micro-organisms, a large number of different species, and an increased representation of certain bacterial phyla and a decreased representation of other phyla,” Maja Rupnik wrote in The New England Journal of Medicine last month. “The disruption of any of these features can result in increased susceptibility to the growth of C. difficile,” Dr. Rupnik added.
Since the early 2000s, hospitals have reported drastic increases in severe C. diff. infections, Dr. Daniel A. Leffler and Dr. J. Thomas Lamont of Beth Israel Deaconess Medical Center in Boston reported in the same journal. The predominant virulent strain, known as NAP1, has a mortality rate three times as high as that associated with the less virulent forms most prevalent in decades past.
“The most important risk factor for C. difficile infection remains antibiotic use,” the doctors wrote. “Ampicillin, amoxicillin, cephalosporins, clindamycin and fluoroquinolones are the antibiotics that are most frequently associated with the disease, but almost all antibiotics have been associated with infection.”
Dr. Gerding said most antibiotics “are being used inappropriately, for things like upper respiratory infections that are caused by viruses.” And eating yogurt or taking commercially available probiotics while on an antibiotic have not proved protective, he said. However, in England, where a program of more judicious use of antibiotics was put into effect, C. diff. infections have declined.
The risk and severity of a C. diff. infection rises with age, as does the risk of a recurrence. In a study of an outbreak in a Quebec hospital, people over 65 were 10 times as likely as younger patients to become infected. Even after infected individuals recover, about 5 percent continue to harbor the toxic strain in their stool for six months, and if they take another antibiotic during that time, the illness can recur, Dr. Gerding said.
Although traditionally associated with hospitals and other inpatient medical facilities, C. diff. infections acquired outside hospitals have “increased dramatically in the past decade and may now account for up to a third of new cases,” Dr. Leffler and Dr. Lamont wrote.
But Dr. Gerding, who has studied C. diff. for three decades, said that among those infected outside hospitals, “about 80 percent had a recent health care exposure,” for example, at a clinic or a doctor’s office, where they may have been prescribed antibiotics and exposed to the spores.
The good news, he said, is that new treatment approaches are proving capable of preventing recurrences in infected individuals, and may be able to prevent an initial infection in the future.
This month in JAMA, Dr. Gerding and his colleagues described treatment using a nontoxin-producing strain of C. diff. in patients who initially recovered from an infection. While not a permanent solution, the strain persists in the intestine long enough to allow the normal healthy microbiota to repopulate the gut and greatly reduce the risk of a recurrence.
In another approach, Dr. Israel Lowy of Medarex in Princeton, N.J. (now with Regeneron Pharmaceuticals), Dr. Deborah C. Molrine of MassBiologics at the University of Massachusetts Medical School and their colleagues demonstrated that monoclonal antibodies created to attack the C. diff. toxins reduced the risk of a recurrence to 7 percent from 25 percent. This, too, is a stopgap measure designed to provide time for the restoration of normal gut microbiota.
A more permanent solution now under study involves an injectable antitoxin vaccine. Because it can take weeks to months for vaccine protection to take effect, one of the temporary measures could be used in the interim, Dr. Gerding said.
Well-publicized treatments using fecal transplants from healthy individuals are reserved for patients who have experienced multiple recurrences of C. diff. Researchers are trying to isolate the organisms in feces from healthy people that are most effective, with the hope of incorporating them into a capsule that could be taken orally as a treatment or preventive.
Dr. Gerding foresees the possibility that people taking an antibiotic might simultaneously receive a dose of live therapeutic bacteria that can prevent colonization by hazardous organisms. “If this works, it will be huge in preventing transmission of C. diff.,” he said.
Rising Foe Defies Hospitals' War On 'Superbugs'
Laura Landro : WSJ : September 17, 2008
Shortly after being admitted to a Cleveland-area hospital with severe abdominal pain, 52-year-old Maureen O'Hearn was transferred to intensive care. An intestinal infection had distended her abdomen so badly she appeared to be six months pregnant. To save her life, a surgeon had to remove her colon.
The cause of Ms. O'Hearn's illness was an epidemic strain of Clostridium difficile -- C. diff for short -- that is fast emerging as one of the most dangerous and virulent foes in the war against antibiotic "superbugs." C. diff is spawning infections in hospitals in the U.S. and abroad that can lead to severe diarrhea, ruptured colons, perforated bowels, kidney failure, blood poisoning and death.
Even as hospitals begin to get control of other drug-resistant infections such as MRSA, a form of staph, rates of C. diff are rising sharply, and a recent, more virulent strain of the bug is causing more severe complications. The Centers for Disease Control and Prevention estimates there are 500,000 cases of C. diff infection annually in the U.S., contributing to between 15,000 and 30,000 deaths. That's up from roughly 150,000 cases in 2001.
"We've been trying to sound the alarm repeatedly since 2004 that the trend is continuing upward," says Cliff McDonald, a CDC epidemiologist. He adds that C. diff, once mainly a concern for older patients, is now a growing risk for pregnant women, children and healthy adults.
Many patients get C. diff infections as an unintended consequence of taking antibiotics for other illnesses. That's because bacteria normally found in a person's intestines help keep C. diff under control, allowing the bug to live in the gut without necessarily causing illness. But when a person takes antibiotics, both bad and good bacteria are suppressed, allowing drug-resistant C. diff to grow out of control.
As a result, hospitals are more closely monitoring and limiting their use of antibiotics. It's a strategy that also has shown some success in preventing the spread of other drug-resistant bacteria. Once patients do contract a C. diff infection, hospitals sometimes can treat them with certain "last ditch" antibiotics, such as vancomycin, but many patients relapse after treatment.
Other efforts to stop the spread of C. diff include isolating infected patients; suiting workers and visitors from head to toe with scrubs, masks and gloves; and blasting patient rooms with super-strength bleach solutions. Milder "green" cleaners don't kill C. diff, undermining some hospitals' efforts to use these products.
Spreading Spores
One problem: C. diff produces spores that can dry out after cleaning and hang around on hospital cart handles, bed rails and telephones for months. Hand cleaning with alcohol, many hospitals' standard practice for keeping staff from spreading infection, can actually help disperse C. diff spores. Many hospitals now have special rules requiring staff to wash their hands with antibacterial soap when dealing with C. diff patients.
Katie Lancey, lead environmental services aide at SSM St. Joseph Hospital West in Lake Saint Louis, Mo., says she spends up to an hour cleaning a room after a C. diff patient leaves. She wears protective garments and wipes down everything in the room with a bleach solution, including the TV, pillows, mattress and lower structure of the bed. "Anything you can think of, you make sure you wipe it down thoroughly," she says.
If a patient coming in to SSM St. Joseph is suspected of having C. diff infection -- severe diarrhea is one symptom -- they are put in isolation even before lab tests come back, says James Hinrichs, the infectious-disease specialist charged with the hospital's C. diff-prevention program. He says that when C. diff patients are discharged, he advises them to eat yogurt with so-called pro-biotics to help restore a healthy balance of bacteria in their intestines. He also tells families to follow strict cleaning and hand-washing rules at home.
The efforts, along with more careful use of antibiotics, have helped SSM St. Joseph reduce the rate of C. diff infections to 0.5 cases per 1,000 patient days currently from 2.5 cases in 2006, Dr. Hinrichs says.
C. diff was first recognized in the 1970s, when it was readily treatable. The more virulent strain was first identified at the University of Pittsburgh Medical Center in 2000, killing 18 patients. By 2004, the new C. diff strain was reported elsewhere in the U.S. and around the world, and studies showed it was producing 20 times more toxin than older strains.
Carlene Muto, medical director of infection control at the University of Pittsburgh, says the hospital was able to reduce its C. diff infections by 50% after the 2000 outbreak and has sustained that rate since then. It instituted strict cleaning practices, restricted its use of antibiotics and began relying on its electronic medical-record system to quickly flag lab tests of patients most at risk so they can be isolated. "You have to be constantly vigilant," Dr. Muto says.
Only 3% to 5% of healthy, non-hospitalized adults carry C. diff in their gut, but that rate is much higher in hospitals and nursing homes, where carriers can spread the bacteria to others. Studies at several hospitals in recent years have shown that 20% or more of inpatients were colonized with C. diff, and a 2007 study of 73 long-term-care residents showed 55% were positive for C. diff. Even though the majority had no symptoms of disease, spores on the skin of asymptomatic patients were easily transferred to the investigators' hands.
The CDC is launching a national surveillance effort to gather more precise data about the prevalence of C. diff. It is working with states to identify local outbreaks. It also is working with Medicare and the Environmental Protection Agency to develop new guidelines for fighting C. diff.
Nursing Home Infections
Ms. O'Hearn, the Cleveland-area patient, says she took an antibiotic for a sinus infection and then visited a nursing home, where she may have picked up the C. diff bug. During her hospital treatment, Ms. O'Hearn says she suffered an irregular heartbeat and dehydration, and required additional surgery to temporarily attach her small intestine to the abdominal wall to bypass the large intestine. "It was the worst nightmare that anyone could imagine," says Ms. O'Hearn, a nurse by training. Though she has returned to work and a more normal lifestyle, she continues to have digestive troubles, and must take medications to regulate her heart.
Kettering Medical Center near Dayton, Ohio, had 305 cases of C. diff last year and has had 165 cases so far this year. Even newborn babies have gotten the disease from their mother during birth, says Rebekah Wang-Cheng, Kettering's medical director for clinical quality. She says that among other measures, the hospital has cut its post-operative antibiotic doses for all joint-replacement surgeries to two from three to avoid C. diff infections. Patients who come into the hospital with suspected pneumonia now get an antibiotic within six hours, instead of four hours previously, to allow more time to assess the need for drugs.
Fecal Transplants
One controversial strategy: fecal transplants. For one patient with recurrent C. diff, Kettering suggested a stool transplant from a relative, to help restore good bacteria in the gut. But Jeffrey Weinstein, an infectious-disease specialist at the hospital, says the patient "refused to consider it because it was so aesthetically displeasing."
The Greater New York Hospital Association in March began a 40-hospital effort to halt the spread of C. diff from patient to patient. This included placing signs on patient rooms with pictures of a bottle of bleach and soap and water to remind staff the room needs special cleaning. The association also asks visitors not to use patient bathrooms.
Hospitals face growing legal concerns if they don't take such measures; relatives of 16 patients who were infected or died from a C. diff outbreak are suing a Quebec hospital, claiming that infection-control practices weren't followed.
C. diff infections can emerge days or weeks after antibiotic therapy. Earlier this year, Marcus Glover, a 40-year-old mailroom worker for the Greater New York Hospital Association, was discharged from hospital after a successful rotator-cuff surgery, which included antibiotic treatment. Ten days later, he landed in an emergency room with a C. diff infection that required another week in the hospital. Mr. Glover avoided the worst complications and was successfully treated with strong antibiotics.
But C. diff can be fatal. Philadelphia radio personality Hy Lit, 73, contracted a C. diff infection at a rehabilitation center after being treated at a hospital owned by Main Line Health System last fall. He died in another Main Line hospital two weeks later. "It was a multiple train wreck, when the bug permeated his bloodstream and his kidneys failed," says his son, Sam Lit. "It was a tragedy to lose him like that."
Main Line says it can't comment on individual patients but adds that it follows stringent prevention guidelines and is conducting ongoing initiatives to control infections in its hospitals.
The CDC recommends careful prescribing of antibiotics to avoid killing off the healthy bacteria that can keep C. diff in check. It says patients should be tested for the bacterium when they have diarrhea while taking antibiotics, or within a few months of finishing a course, since that can be a sign of infection.
Patients found to be infected should be isolated, and clinicians should wear gloves and gowns when treating those folks. Room surfaces should be cleaned with bleach or another product that can kill the spores. And when an infected patient is transferred, the new facility should be notified.
Patients should take antibiotics only as prescribed, should tell their physician if they’ve been on antibiotics and get diarrhea within a few months, should wash their hands after using the bathroom and should try to use a separate bathroom if they have diarrhea to avoid spreading a possible infection.
Laura Landro : WSJ : September 17, 2008
Shortly after being admitted to a Cleveland-area hospital with severe abdominal pain, 52-year-old Maureen O'Hearn was transferred to intensive care. An intestinal infection had distended her abdomen so badly she appeared to be six months pregnant. To save her life, a surgeon had to remove her colon.
The cause of Ms. O'Hearn's illness was an epidemic strain of Clostridium difficile -- C. diff for short -- that is fast emerging as one of the most dangerous and virulent foes in the war against antibiotic "superbugs." C. diff is spawning infections in hospitals in the U.S. and abroad that can lead to severe diarrhea, ruptured colons, perforated bowels, kidney failure, blood poisoning and death.
Even as hospitals begin to get control of other drug-resistant infections such as MRSA, a form of staph, rates of C. diff are rising sharply, and a recent, more virulent strain of the bug is causing more severe complications. The Centers for Disease Control and Prevention estimates there are 500,000 cases of C. diff infection annually in the U.S., contributing to between 15,000 and 30,000 deaths. That's up from roughly 150,000 cases in 2001.
"We've been trying to sound the alarm repeatedly since 2004 that the trend is continuing upward," says Cliff McDonald, a CDC epidemiologist. He adds that C. diff, once mainly a concern for older patients, is now a growing risk for pregnant women, children and healthy adults.
Many patients get C. diff infections as an unintended consequence of taking antibiotics for other illnesses. That's because bacteria normally found in a person's intestines help keep C. diff under control, allowing the bug to live in the gut without necessarily causing illness. But when a person takes antibiotics, both bad and good bacteria are suppressed, allowing drug-resistant C. diff to grow out of control.
As a result, hospitals are more closely monitoring and limiting their use of antibiotics. It's a strategy that also has shown some success in preventing the spread of other drug-resistant bacteria. Once patients do contract a C. diff infection, hospitals sometimes can treat them with certain "last ditch" antibiotics, such as vancomycin, but many patients relapse after treatment.
Other efforts to stop the spread of C. diff include isolating infected patients; suiting workers and visitors from head to toe with scrubs, masks and gloves; and blasting patient rooms with super-strength bleach solutions. Milder "green" cleaners don't kill C. diff, undermining some hospitals' efforts to use these products.
Spreading Spores
One problem: C. diff produces spores that can dry out after cleaning and hang around on hospital cart handles, bed rails and telephones for months. Hand cleaning with alcohol, many hospitals' standard practice for keeping staff from spreading infection, can actually help disperse C. diff spores. Many hospitals now have special rules requiring staff to wash their hands with antibacterial soap when dealing with C. diff patients.
Katie Lancey, lead environmental services aide at SSM St. Joseph Hospital West in Lake Saint Louis, Mo., says she spends up to an hour cleaning a room after a C. diff patient leaves. She wears protective garments and wipes down everything in the room with a bleach solution, including the TV, pillows, mattress and lower structure of the bed. "Anything you can think of, you make sure you wipe it down thoroughly," she says.
If a patient coming in to SSM St. Joseph is suspected of having C. diff infection -- severe diarrhea is one symptom -- they are put in isolation even before lab tests come back, says James Hinrichs, the infectious-disease specialist charged with the hospital's C. diff-prevention program. He says that when C. diff patients are discharged, he advises them to eat yogurt with so-called pro-biotics to help restore a healthy balance of bacteria in their intestines. He also tells families to follow strict cleaning and hand-washing rules at home.
The efforts, along with more careful use of antibiotics, have helped SSM St. Joseph reduce the rate of C. diff infections to 0.5 cases per 1,000 patient days currently from 2.5 cases in 2006, Dr. Hinrichs says.
C. diff was first recognized in the 1970s, when it was readily treatable. The more virulent strain was first identified at the University of Pittsburgh Medical Center in 2000, killing 18 patients. By 2004, the new C. diff strain was reported elsewhere in the U.S. and around the world, and studies showed it was producing 20 times more toxin than older strains.
Carlene Muto, medical director of infection control at the University of Pittsburgh, says the hospital was able to reduce its C. diff infections by 50% after the 2000 outbreak and has sustained that rate since then. It instituted strict cleaning practices, restricted its use of antibiotics and began relying on its electronic medical-record system to quickly flag lab tests of patients most at risk so they can be isolated. "You have to be constantly vigilant," Dr. Muto says.
Only 3% to 5% of healthy, non-hospitalized adults carry C. diff in their gut, but that rate is much higher in hospitals and nursing homes, where carriers can spread the bacteria to others. Studies at several hospitals in recent years have shown that 20% or more of inpatients were colonized with C. diff, and a 2007 study of 73 long-term-care residents showed 55% were positive for C. diff. Even though the majority had no symptoms of disease, spores on the skin of asymptomatic patients were easily transferred to the investigators' hands.
The CDC is launching a national surveillance effort to gather more precise data about the prevalence of C. diff. It is working with states to identify local outbreaks. It also is working with Medicare and the Environmental Protection Agency to develop new guidelines for fighting C. diff.
Nursing Home Infections
Ms. O'Hearn, the Cleveland-area patient, says she took an antibiotic for a sinus infection and then visited a nursing home, where she may have picked up the C. diff bug. During her hospital treatment, Ms. O'Hearn says she suffered an irregular heartbeat and dehydration, and required additional surgery to temporarily attach her small intestine to the abdominal wall to bypass the large intestine. "It was the worst nightmare that anyone could imagine," says Ms. O'Hearn, a nurse by training. Though she has returned to work and a more normal lifestyle, she continues to have digestive troubles, and must take medications to regulate her heart.
Kettering Medical Center near Dayton, Ohio, had 305 cases of C. diff last year and has had 165 cases so far this year. Even newborn babies have gotten the disease from their mother during birth, says Rebekah Wang-Cheng, Kettering's medical director for clinical quality. She says that among other measures, the hospital has cut its post-operative antibiotic doses for all joint-replacement surgeries to two from three to avoid C. diff infections. Patients who come into the hospital with suspected pneumonia now get an antibiotic within six hours, instead of four hours previously, to allow more time to assess the need for drugs.
Fecal Transplants
One controversial strategy: fecal transplants. For one patient with recurrent C. diff, Kettering suggested a stool transplant from a relative, to help restore good bacteria in the gut. But Jeffrey Weinstein, an infectious-disease specialist at the hospital, says the patient "refused to consider it because it was so aesthetically displeasing."
The Greater New York Hospital Association in March began a 40-hospital effort to halt the spread of C. diff from patient to patient. This included placing signs on patient rooms with pictures of a bottle of bleach and soap and water to remind staff the room needs special cleaning. The association also asks visitors not to use patient bathrooms.
Hospitals face growing legal concerns if they don't take such measures; relatives of 16 patients who were infected or died from a C. diff outbreak are suing a Quebec hospital, claiming that infection-control practices weren't followed.
C. diff infections can emerge days or weeks after antibiotic therapy. Earlier this year, Marcus Glover, a 40-year-old mailroom worker for the Greater New York Hospital Association, was discharged from hospital after a successful rotator-cuff surgery, which included antibiotic treatment. Ten days later, he landed in an emergency room with a C. diff infection that required another week in the hospital. Mr. Glover avoided the worst complications and was successfully treated with strong antibiotics.
But C. diff can be fatal. Philadelphia radio personality Hy Lit, 73, contracted a C. diff infection at a rehabilitation center after being treated at a hospital owned by Main Line Health System last fall. He died in another Main Line hospital two weeks later. "It was a multiple train wreck, when the bug permeated his bloodstream and his kidneys failed," says his son, Sam Lit. "It was a tragedy to lose him like that."
Main Line says it can't comment on individual patients but adds that it follows stringent prevention guidelines and is conducting ongoing initiatives to control infections in its hospitals.
The CDC recommends careful prescribing of antibiotics to avoid killing off the healthy bacteria that can keep C. diff in check. It says patients should be tested for the bacterium when they have diarrhea while taking antibiotics, or within a few months of finishing a course, since that can be a sign of infection.
Patients found to be infected should be isolated, and clinicians should wear gloves and gowns when treating those folks. Room surfaces should be cleaned with bleach or another product that can kill the spores. And when an infected patient is transferred, the new facility should be notified.
Patients should take antibiotics only as prescribed, should tell their physician if they’ve been on antibiotics and get diarrhea within a few months, should wash their hands after using the bathroom and should try to use a separate bathroom if they have diarrhea to avoid spreading a possible infection.
RISK FACTORS FOR THE DEVELOPMENT OF C. DIFF INFECTIONS:
Although people — including children — with no known risk factors have gotten sick from C. difficile, your risk is greatest if you:
- Are now taking or have recently taken antibiotics. The risk goes up if you take broad-spectrum drugs that target a wide range of bacteria, use multiple antibiotics or take antibiotics for a prolonged period.
- Are 65 years of age or older. The risk of becoming infected with C. difficile is 10 times greater for people age 65 and older compared with younger people.
- Are now or have recently been hospitalized, especially for an extended period.
- Live in a nursing home or long term care facility.
- Have a serious underlying illness or a weakened immune system as a result of a medical condition or treatment (such as chemotherapy).
- Have had abdominal surgery or a gastrointestinal procedure.
- Have a colon disease such as inflammatory bowel disease or colorectal cancer.
- Have had a previous C. difficile infection.
Gut Infections Are Growing More Lethal
Clostridium difficile and the Norovirus
By Denise Grady : NY Times : March 19, 2012
Gastrointestinal infections are killing more and more people in the United States and have become a particular threat to the elderly, according to new data released last week.
Deaths from the infections more than doubled from 1999 to 2007, to more than 17,000 a year from 7,000 a year, the Centers for Disease Control and Prevention reported. Of those who died, 83 percent were over age 65.
Two thirds of the deaths were caused by a bacterium, Clostridium difficile, which people often contract in hospitals and nursing homes, particularly when they have been taking antibiotics. The bacteria have grown increasingly virulent and resistant to treatment in recent years.
But researchers were surprised to discover that the second leading cause of death from this type of illness was the norovirus. It causes a highly contagious infection, sometimes called winter vomiting illness, that can spread rapidly on cruise ships and in prisons, dormitories and hospitals.
“I think there is perhaps a misperception that norovirus causes a mild illness,” said Aron Hall, an epidemiologist at the disease centers. “But this suggests a major problem that requires some attention.”
Both diseases are spread by the fecal-oral route, meaning that people swallow germs found in feces, often spread by people who did not wash their hands after using the toilet.
Problems with C. difficile are not new: Health officials first began warning in 2004 that a more virulent and drug-resistant strain had emerged. It produces high amounts of two potent toxins that can wreak havoc in cells lining the intestine.
But few people anticipated what gains the bacteria would make. Among hospitalized patients, cases rose to 336,000 in 2009 from 139,000 in 2000. Deaths from the infection seem to have leveled off in the past few years, but researchers say they are still far too high and should be dropping, as other hospital-related infections are.
Estimates of cases occurring outside hospitals run as high as three million annually. Overall, C. difficile infections cost $1 billion a year, according to the disease centers.
Two factors typically lead to the infection: taking antibiotics, which make the intestine vulnerable, followed by exposure to the bacteria or their spores in a hospital, clinic or nursing home that has not been properly disinfected. Spores can survive for weeks or maybe even months outside the body, and it takes bleach or other strong disinfectants to kill them.
Many people recover once they stop taking antibiotics, but some become severely ill and require treatment with different antibiotics to get rid of C. difficile. Even then, 20 percent relapse, and some suffer intestinal damage that can be fatal or can require surgery to remove part of the intestine.
In recent years, some people have received fecal transplants, in which stool from a healthy person is placed into the patient’s intestine. The idea is to restore the normal balance of bacteria in the gut, which may include 25,000 to 30,000 different species. There is simply no better way to replace them. Awful as they may sound, the transplants can cure cases that were otherwise intractable.
“The microbes have been at this a lot longer than us,” said Dr. L. Clifford McDonald, a medical epidemiologist at the disease centers. He added, “Our bodies have learned over eons how to keep harmful bacteria out.”
Health officials expressed frustration at a news conference this month, stating that many cases are preventable or at least treatable, and yet death and infection rates have continued at “historically high and unacceptable levels.”
Because nearly all C. difficile infections — 94 percent — come from hospitals or other health care settings, experts say doctors, nurses, other health workers and hospitals should take much of the responsibility for trying to fight them.
A quarter of the infections start in the hospital, and the rest occur in nursing home patients or people recently treated in doctors’ offices or clinics. Patients often carry the germs from one institution to another.
Simple hygiene measures are highly effective, like cleaning surfaces with bleach and wearing gowns and gloves when treating infected people to avoid spreading germs to other patients. One of the disturbing and more disgusting facts about C. difficile is that it is very hard to remove from bare hands: neither soap and water nor alcohol-based hand sanitizers work very well. For health workers, it is much better to wear gloves, to avoid contaminating their hands in the first place, Dr. McDonald said.
He also said that a recent study of hospitals in the United States that set up programs to fight C. difficile found that they were able to lower infection rates by 20 percent in two years. Similar efforts in Britain have cut infection rates by half.
It is also important to use antibiotics only when they are really needed, because people taking them have 7 to 10 times the usual risk of contracting C. difficile while using the drugs and for a month after, and triple the risk for the next two months, according to the disease centers.
For those with serious illnesses that require antibiotics, the risk is unavoidable. But half the antibiotics prescribed in the United States are unnecessary, experts say, so people are being put at risk for no reason.
But why have the bacteria become more virulent? A likely reason, Dr. McDonald said, is that virulence can sometimes be an asset when it comes to evolution. Nice germs finish last, but nasty ones that cause a lot of diarrhea will spread around more, infect more people and beat out the competition — a trait that evolution will tend to favor.
“The strain that is more successful is selected for,” he said.
The finding on norovirus came as a surprise, said Dr. Hall, the C.D.C. epidemiologist, whose report is the first to find that the virus has become the second leading cause of death from gastroenteritis.
The virus causes about 800 deaths a year in the United States, he said, but about 50 percent more in years when new strains emerge.
About 20 million people a year in the United States get sick from norovirus, most often in the winter. It can quickly sweep through a nursing home or dormitory. Just a small dose of the virus, a few particles, is enough to cause illness.
“Someone sick is shedding billions of viruses in every gram of stool,” Dr. Hall said. “One person can expose a lot of people rapidly.”
The incubation period is short, and the virus can persist on surfaces for days or even weeks. Cold and moisture help it last.
Older people are most likely to become severely ill and die from the virus, either from dehydration or aspiration pneumonia, caused by inhaling vomit.
“The second highest death rate is in kids under 5,” Dr. Hall said.
When children die from the infection, the culprit is often dehydration, which can lead to shock and heart problems.
Dr. Hall said that he and his colleagues estimated that 27 children a year die from norovirus, similar to the number killed by another gastrointestinal infection, rotavirus, for which there is now a vaccine.
Researchers are trying to develop a norovirus vaccine, he said. But scientists say vaccines for intestinal infections are among the most difficult to create.
