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05/23/2012

Infection Control in Hospital and Ward Setting: The Case of Clostridium Difficile in Health Care


Infection Control in Hospital and Ward Setting:

The Case of Clostridium Difficile in Health Care

 

Abstract

Infections are one of the leading causes of serious health care problems that became popular and found among the health care settings. The awareness among the patients and the health professionals about the rapid transmission of infections and even other viral diseases should be part of the health promotion. One of the most leading infections is the Clostridium Difficile that can contribute towards the high mortality rate across nations.

In order to understand the issues of Clostridium Difficile, the paper will assess the factors involved such as the transmission, prognosis, diagnosis, safety precaution which is applied most especially among the health care settings, the treatment, and the impact that it may create in Hong Kong (and international) health care settings in the present and in the future.   

Introduction

With regards to the infection and the issues of its prevention and control, the hospitals are the main settings that can facilitate its transmittance. However, many infectious diseases also spread even in other health care settings or care homes, where there are a large number of people. Because of the accommodation of people in one settings and the involvement of various health cases, there is a great possibility that the infections can be easily transmitted. Infections can be the major causes of illness among the patients that can lead to hospitalization or otherwise, prolongs their hospitalization and slows their recovery. The microorganisms that are invisible to the eyes can be acquired by the patients upon the admittance in hospitals. In present times, the experts discovered that these microorganisms became resistant in antibiotics and other intervention which makes the infection worse. The health care professionals therefore become more pressured in the conditions of the services, in which they are anticipated to bring the appropriate solution.  The Health Care Associated Infections (HCAIs) are the term applied in the infections that can be transmitted to patients and even among the health care workers. Because of the on-going strategizing, the health care procedures can be implemented and create changes within the hospitals and other health care settings and care home.

Clostridium Difficile

Based on the assessment of the infections, the result can range from mild food poisoning to life threatening bloodstream infections that are caused by various viruses, bacteria, or toxins. In the association of the infections found in hospital settings, the Clostridium Difficile is alarming cases in the health care issues (CQC, 2009). Therefore, it is important to determine the various factors that might contribute to the development of the virus and the appropriate medical intervention and be part of the standardization of infection prevention and control. However, the idea of providing the clean and safe environment starts in recognizing the pathopysiology of the virus.

Clostridium Difficile or also known as C difficile is a kind of bacillus that includes the diarrhea, pseudomembranous colitis, toxic megacolon, perforation of the colon, and, in some instances, sepsis. The clostridium difficile associated diseases is the result of the toxins that might often lead to serious gastrointestinal problems. In the development of C difficile, there is a high-risk in the use of antibiotics, increase in the nursing works and services, and creates an impact on the hospital environment (Pelleschi, 2008). In the study of changes involved in C difficile, the organisms associated in the infections can be tested through the laboratories provided by a fresh stool specimen. The testing and diagnosis of the infections are based on the presence of the C difficile toxins found (Thompson, 1993).

1.0 Transmission

There is an easy transmission of C difficile just by the hand contact. If the toxin successfully entered the human body, the most common first symptom is described to be diarrhea and if not properly treated might lead to admittance in intensive care unit (POST, 2005). It is identified that C difficile is resistant to many types of disinfectants, heat, and dryness and may persist for months on surfaces such as bed rails, commodes, electronic thermometers, stethoscopes, skin folds, and the hands of caregivers. Moreover, even the healthy people get infected by the toxin because of C difficile’s ability to reproduce or propagate even when used with antibiotics and other known medical interventions, making it hard to destroy once found in the body (Pelleschi, 2008). The associated infections that caused by the antibiotic resistant viruses became the center of the health care settings’ action to describe the nature, spread, and appropriate treatment. The challenges, however, in discovering the appropriate policy, regulations, and standards in terms of the detection, prevention, and management should be addressed.   

2.0 Pathopysiology

Source: Pelleschi, M.E., (2008) Clostridium Difficile–Associated Disease: Diagnosis, Prevention, Treatment, and Nursing Care

Once the toxin is found in the body, the usual area where it stays is in the colon. The illustration of Clostridium Difficile is shown in Diagram. The growth of C difficile can be supported by the stomach acid that produces two types of toxins – toxin A or the enterotoxin and toxin B or the more potent cytotoxin. The toxin A activates macrophages and mast cells that releasing inflammatory mediators. These mediators cause the disruptions of the cell wall junction, resulting in increased permeability of the intestinal wall and subsequent diarrhea. On the other hand, the toxin B causes degradation of epithelial cells in the colon. As the colitis worsens, purulent and necrotic debris accumulates and forms characteristic ulcers, the pseudomembranes (Pelleschi, 2008).

3.0 Risk Factors and Risk Groups Involved

According to the clinical manifestations, the associated diseases in C difficile commonly targets the patients who are advanced in age or the elderly, the people with severs underlying diseases, patients who have nasogastric tubes in place, the individual who have long hospital stays, or are taking proton pump inhibitors and histamine receptor antagonists (Pelleschi, 2008). The infection has no sexual preferences and the young children and infants have uncommon clinical infections. Although the newborn or neonatal units includes the facilitation of the cross-infection, it is found that the infections do not develop and been associated with diarrhea. Recently, the populations that includes the young healthy persons and not exposed in any hospital environment or antimicrobial therapy and young women in peripartum (the last month of gestation or few months after giving birth) setting appeared to have a low risk in acquiring the C defficile (Abrera, Gronczewski, & Katz, 2009). In addition, there are suspicions that homosexual men, with or without the Acquired Immunodeficiency Syndrome (AIDS), can increase the spread of infections, be the carrier and victim at the same time, since C difficile is a kind of enteric infection (Thompson, 1993). The risk in acquiring the mild, sever, or systemic, which is shown in Table 1, depends on the impact the toxin reached the colon and how the colon reacts on its attacks (Pelleschi, 2008).

Table 1: Clinical Manifestations

Source: Pelleschi, M.E., (2008) Clostridium Difficile–Associated Disease: Diagnosis, Prevention, Treatment, and Nursing Care

In mild disease, the diarrhea is often mucoid and foul smelling. The associated signs and symptoms include the nausea, dehydration, and low-grade fever. Leukocytosis or the sudden raise in white blood cell count against the normal range of blood count may also occur. In the severe diarrhea, the characteristics are described with the raised in white and yellow plaques that can be visualized during sigmoidoscopy or the medical examination of the large intestine. And lastly, there are complications may involve in systemic disease. There is an evidence of Hypoalbuminemia, which is a medical condition wherein the levels of albumin in blood serum are abnormally low; and Ascites that describes as a gastroenterological term for an accumulation of fluid in the peritoneal cavity. A decrease in diarrhea may occur in systemic disease as a result of toxic megacolon or paralytic ileus (an intestinal paralysis). 

4.0 Diagnosis

The diagnosis of associated diseases due to the infection of C difficile is based on the signs and symptoms and the verification of the presence of toxins (both A and B). In many instances, the detection of pseudomembranous colitis is prioritized. The experts suggest that colonoscopy or sigmoidoscope should be used with caution, and only for patients with severe colitis of unclear origin (Pelleschi, 2008). Colitis, as described earlier is the attack of C difficile, is a bloody diarrhea. Through the use of sigmoidoscope, a physician can see an inflamed rectum and evaluate the extent and severity of the disease. The usual manifestation of the colitis is at a minimum normal blood vessel pattern in which the inner surface is diffused with redness. In some cases, the assessment of ulcerative colitis, the colon is identified to have a bright and glistening mucosa or inner surface of the colon which becomes dull due to the abundance of minute ulcers. There are also tiny bleeding points which can be seen in deeper ulcers. In the severe cases of diseases, the colon becomes rigid, tubelike, and foreshortened. The C difficile is not solely responsible in the colitis but it is often found to be the most common infectious cause that triggers to its acute attack. The Table 2 shows some infectious causes of Colitis that impairs the immunity of the body and the ability to show resistance on other associated infections (Thompson, 1993).  

Table 2: Some Infectious Causes of Colitis

Left colon

Campylobacter

 

Salmonella

 

Shigella

 

Clostridium difficile

 

Enterohemorrhagic Escherichia coli

 

Gonococcus

 

Entamoeba histolytica (a protozoan)

Right colon

Yersinia

 

Campylobacter

Source: Thompson, W.G., (1993) The Angry Gut: Coping with Colitis and Crohn's Disease

The use of the stools in detecting any toxins is highly specific and sensitive for detection of toxin B. Testing the stools as part of the culture results on excellent specificity in which sensitivity ranges from 75% to 85% and the results can be available for about 2 hours of examination. The disadvantage in using this type of testing is that the process involved is time consuming that is why the process is not often used. In addition, the collection of specimen can be easy and gives opportunity to study thoroughly but because of the toxins are unstable in a room temperature; there is a high possibility in acquiring the false results if not properly tested within 2 hours. The reason behind the quick pace of testing is the stools can harbor C difficile spores easily and thus; appropriate handling and care should be taken in place to avoid the contamination on the specimens. However, there are many suggestions regarding the appropriate testing procedures to give accurate results like the use of specimens with watery or liquid characteristics, or isolation rather than waiting for the results. The most evidential in diagnosing the cases of C difficile is the fact that the infection is not likely is found in persons who do not have diarrhea (Pelleschi, 2008).

5.0 Infection Control Precaution

According to the health care settings, aside from the C diffcile, there are other leading infectious diseases that can affect the system of human body when transmitted. Escherichia Coli (E Coli) is the most frequent infection that attacks the urinary system and is present in the hospital settings. The Pseudomonas Aeruginosa (P. Aeruginosa) can cause the infections all over the body but mostly attacks the respiratory systems that are evidence among the ill patients. Klebsiella Pneumoniae (K. Pneumoniae) and Glycopeptide-resistant Enterococci (GRE) may cause infections primarily in the lungs, urinary tract and abdomen. And the Extended Spectrum Beta Lactamase (ESBL) are the kind of bacteris that produces another bacteria like the E. Coli and K. Pneumoniae, and apparently becoming far more prevalent (POST, 2005). Because of the increasing number of patients who suffer in the infections coming not only with C difficile but also with other diseases, the action towards control and precaution plays a special strategy among the health care settings and other health care institutions. 

5.1 Monitoring

It is important that the health care professionals are aware in the prevalence of the infections and therefore, appropriate monitoring among the patients is advised which takes part in the action towards prevention is. The patients who are treated with antibiotics are the people who should be closely monitored because they have the high possibility for the infection of C difficile. The risks of the elderly in acquiring the disease should be also placed under the surveillance most especially if there is underlying illness, low immunity in diseases, and had a recent surgery in their gastrointestinal tract.

5.2 Hand Hygiene

It is already part of the core service of the hospitals to perform with cleanliness. The hands must be washed with an antimicrobial soap for at least 15 seconds. This is advised instead of using the alcohol-based hand rubs because, although it gives protection in other viruses still, it may not be effective against C difficile spores. As part of the hand washing technique, a paper towel should be used to turn off the faucet to avoid contamination after cleaning the hands. Part of the hygiene is the routine in washing the hands before and after contact with a patient and after glove removal. These techniques must be also part of the campaign and educating the patient’s family members as well as the patient to avoid the infections. Through the use of effective staff education programs, the health care workers can help the reduction on the incidence of the infection. Other than the simple way of hand washing, there are other suggestions that can be also effective in the health care settings and other care homes such as clustering of nursing care, ongoing audit and surveillance programs.

5.3 Contact Isolation

Part of the health care interventions in preventing the diseases and controlling the spread of infections is through mandatory contact isolation for all patients that are identified with Clostridium Difficile associated diseases. The use of private rooms is recommended if available and if necessary, two patients with Clostridium Difficile associated diseases or CDAD can be placed together. Due to the close monitoring among the patients, all of the people who will enter the patient’s room, including the patient’s family members and nurses, must use protective gowns and gloves. Moreover, the use of dedicated equipment such as thermometers and stethoscopes is also recommended to manage the temperature of the patients as well as determining their condition towards the disease. This kind of guideline is promising in the high C difficile cases which can teach the patients and their families in the appropriate prevention. Therefore, the use of guidelines should be approved and be effective to all the staff of the hospitals avoid the spread of viruses and other bacteria.

5.4 Environmental Measures

The spores of C difficile tend to thrive on hospital surfaces. Because of the incidence of easy transmission, the strict daily cleaning in all hospital surfaces is advised, more specifically the places where there are more likely to be contaminated with feces or stool. A hypochlorite-based disinfectant or bleach is recommended to use as a primary agent in thorough cleaning. The areas that should be needed often cleaning are the frequently touched surfaces such as doorknobs, light switches, call lights, television remote control devices, soap dispensers, faucets, bed rails, and telephones because there are associated direct contact. The thorough daily cleaning is expected to be part of the hospital policies. The same policy should be applied in the hospital equipments, dishes, linens, waste, and patient transport should be in place and enforced. However, the non-disposable equipment such as glucose meters, cardiac monitors and electrocardiography and x-ray machines should be disinfected according to manufacturers’ guidelines. To decrease the transmission of the infectious diseases like C difficile, changing the mattresses and its replacement can be effective. Most of all, the decrease in the length of stay of the patient will not only help them save their money but also contribute in preventing the spread of the infections.

All of the suggested precautionary measures are not effective if applied once of singularly. For example, the hospital is very evident in hand washing but fails to respond in environmental measures like changing the gloves used, will not diminish the prevalence of the infections. Otherwise, it might increase the level of infections present in hospitals. Therefore, to realize the changes, the application of the control and precautions should be in a matter of compliance. Although the effect cannot be noticed in a sudden, at least, in some instances the infections can be reduced, making the hospitals and other health care settings a home to cure the patients and not to make them more ill.    

6.0 Treatment of Clostridium Difficile

Table 3: Treatment Options

Source: Pelleschi, M.E., (2008) Clostridium Difficile–Associated Disease: Diagnosis, Prevention, Treatment, and Nursing Care

The treatment suggested in Clostridium Difficile associated diseases (CDAD) are still on the professional debates and assessment. As listed in Table 3, there are basic and innovative treatments that can be work and safe. However, the efficacy is still in question and should be part of the nursing practices (Pelleschi, 2008). In a more recent study of treatment regarding the C difficile, it suggested that the decisions in medication of C difficile infection should be firstly assessed depending on the severity of the infection. The consultations on medical professionals or physicians are also advised because an intervention might affect the growth of the infection. In an incidence wherein the patient is hospitalized, the use of antibiotic therapy for an unrelated infection may permit overgrowth of C difficile,and cause the pseudomembranous colitis. The common offenders are clindamycin, ampicillin, and amoxicillin (Thompson, 1993).

The medical treatment starts in the examination of the mucosa and the confirmation of toxin from the stool sample. Based on the Clinical Manifestations (Table 1) the medical care is being judged. The cessations of the causative antibiotic is essential and be applicable for the patients with mild diseases (Abrera, Gronczewski, & Katz, 2009). The cessation of the antibiotic by more than a month, and is also acquired from other patients in hospital (Thompson, 1993). Patients with mild to moderate diarrhea or colitis should receive antibiotic therapy, metronidazole (oral or intravenous) or vancomycin (oral) for 10 days. For severe disease vancomycin is considered 1st line due to faster symptom resolution and fewer treatment failures than metronidazole. Symptomatic improvement can be expected within 2-3 days. In fulminant cases combined therapy with intravenous metronidazole and oral vancomycin may be considered. In the systemic diseases where the situation involves the fulminant colitis and toxic megacolon may require operative intervention or surgery (Abrera, Gronczewski, & Katz, 2009).

7.0 Evaluation of Safety and Clinical Practice

With the help of the ongoing clinical practice in the hospitals and health care settings, the complications of the patients with the infections will be reduced. The early recognition and treatment of the diseases will promote the changes. The first evidence of change is the shift in priorities of care. The patients with C difficile and the associated diseases should be treated and apply the aggressive medical intervention to reduce the dehydration. Second, with the association of the first change is the prevention of dehydration. The nutrients and electrolytes should be monitored to lessen the evolution of other complications. Third change is to promote the comfort among the patients because the CDAD is characterized with pain and cramping that might increase the misery. To minimize the problems, the nursing skills should be satisfied the patient like the interaction and providing ongoing communication. Fourth is to maintain the skin integrity which can be challenging because of the frequent bowel movement. The fecal incontinence might result to perineal dermatitis and the nurses or medical staff should comply on the applied measurements to prevent the complication (Pelleschi, 2008).

8.0 No Vaccination for Clostridium difficile and its Public Health Implications

There is a need for effective preventive treatment methods and based on the researches regarding the ways to prevent its occurrence, the “needle free” method is necessary in order to satisfy the elders’ conditions. In the development of the studies, the test done suggested that transcutaneous immunization or vaccination may be feasible to be the immunizations strategy against the C difficile, but there are preventive strategies that keep on falling while; on the other hand, there is a continuous increase or morbidity and mortality rate (Ghose, et al., 2007). Meaning, in order to lessen the prevalence of the infections, it is important the hospitals will deliver the necessary, methods in precautionary, control, and prevention strategies. Aside from the use of vaccination that can cause another pain for the patient, there is no such evidence that the level of clinical manifestations (as shown in Table 1) will be effective. Due to the lack of preventive approach, the serious conditions of mortality rate is recorded to be as high as 25% among the elderly patients and who are frail (Abrera, Gronczewski, & Katz, 2009).

9.0 Target Group to Raise Public Awareness

It is important that the public awareness should be raised and starts on the young people promoted by the health sectors and medical settings. Through the use of information regarding the infections and how it can be transmitted, the people can understand the importance of simple hand washing. Moreover, the necessary facts on how to care the patients and avoid the contamination of viral diseases, especially in crowded places like schools play a significant role. With that, the impact is expected to lessen the incidence of C difficile not only in hospitals but also in care homes in which most elders can be found.

10.0 The Impact of Clostridium Difficile on Public and Health Services, Now and in the Future

The infections like the SARS or Severe Acute Respiratory Syndrome leaves a mark in the health care settings in the countries like Hong Kong, China, Singapore, and in United States. Because of the weak preventive actions of the health care settings, the infection spread and causes the toll death of about 800 people. With that, the health care settings and public are encourages to take action and promote the health care preparedness and appropriate responses in the activities (CDC, 2004). The incidence of acquiring the Clostridium Difficile in healthcare settings is an endemic issue among the health care settings. Through the diseases caused by an infection, the health care professionals are called to perform, take initiative and action in terms of training, preparing guidance materials, sponsoring satellite broadcasts and holding grand rounds to prevent the bacterial diseases.  

Conclusion

The Clostridium Difficile causes the associated disease which involves the confounding complication. Based on the prevalence of the infections, there is an increase in extended care facilities, acute care areas, and intensive care units. Based on the studies, it was found that the rate of CDAD is 7 times higher in persons more than 65 years old than in persons from 45 to 64 years old. The involvement of elderly in the infections can be explained through the exposure of the elder people in the hospitals and extended care facilities, unlike the young and healthy people. The infections can be easily acquired by the elderly due to their weak immunity or body defenses as matched with the use of antimicrobial drugs promoted by the hospitals. The C difficile became more popular than the other infectious diseases because of the easy transmission and the resistance to the antibiotics. In learning the appropriate methods in precaution and control, it is expected that the hospital and other health care settings like the care home for the elderly will decrease the number of victims. The hospitals and their medical staff must care the patients and not to give them illness, therefore, the position to increase the preventive approach is in their hands.   

References:

Abrera, F.N., Gronczewski, C.A., & Katz, J.P., (2009) “Clostridium Difficile Colitis: Treatment & Medication”, Accessed 22 September 2010, from http://emedicine.medscape.com/article/186458-treatment

CDC, (2004) “Health Care Infection Control Practices”, U.S. Public Health Service Department of Health and Human Services and Centers for Disease Control and Prevention National Center for Infectious Diseases, Accessed 22 September 2010, from http://www.cdc.gov/maso/FACM/pdfs/HICPAC/20040304%20HICPAC%20minutes.pdf

CQC, (2009) “Working Together to Prevent and Control Infections: A study of the Arrangements for Infection Prevention and Control between Hospitals and Care Homes”, Care Quality Commission, Accessed 22 September 2010, from http://www.cqc.org.uk/_db/_documents/Working_together_to_prevent_and_control_infections.pdf

Ghose, C., Kalsy, A., Sheikh, A., Rollenhagen, J., John, M., Young, J., Rollins, S.M., Qadri, F., Calderwood, S.B., Kelly, C.P., & Ryan, E.T., (2007) “Transcutaneous Immunization with Clostridium Difficile Toxoid A Induces Systemic and Mucosal Immune Responses and Toxin A-Neutralizing Antibodies in Mice”, Infection and Immunity, 75(6): 2826-2832, Accessed 22 September 2010, from http://www.sciencedaily.com/releases/2007/06/070620125257.htm

Pelleschi, M.E., (2008) “Clostridium Difficile–Associated Disease: Diagnosis, Prevention, Treatment, and Nursing Care”, Critical Care Nurse, 28: 27-35, Accessed 22 September 2010, from http://ccn.aacnjournals.org/cgi/content/full/28/1/27#T

POST, (2005) “Postnote: Infection Control in Healthcare Settings”, Parliamentary Office of Science and Technology, Number 247, Accessed 22 September 2010, from http://www.parliament.uk/documents/post/postpn247.pdf

Thompson, W.G., (1993) “The Angry Gut: Coping with Colitis and Crohn's Disease”, Perseus Books: Cambridge, MA.

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