Clostridioides difficile, formerly known as Clostridium difficile, is an anaerobic, spore-forming bacillus that causes a serious bacterial infection in the colon. It is spread through the fecal-oral route and once ingested, the spores travel to the small intestine where they become vegetative, and then on to the colon where they reproduce and release toxins. It’s the toxins that cause severe inflammation and the symptoms associated with a C. diff infection (CDI):

  • Toxin A: attracts neutrophils and monocytes
  • Toxin B: weakens the epithelial cells of the colon and is thought to be the main contributor to the symptoms

Because the spores can survive outside the body for months and are resistant to many disinfection procedures, C. diff is highly transmittable unless very stringent infection control measures are taken. While healthcare-associated CDI has declined in recent years, it remains one of the most common healthcare associated infections in the United States. In addition, rates of community-acquired CDI have almost doubled in the past 10 years.

How does C. diff infection occur?

In addition to being spread from person to person or from contaminated items in the environment, a key way CDI occurs is with antibiotic use. When a patient takes certain antibiotics, the antibiotic kills off the “good bacteria” that live in our intestine, allowing C. diff to proliferate, attach to the mucosa in the colon, produce toxins, and cause the associated symptoms of infection. Note that if diverse intestinal flora are present, this can prevent C. diff from proliferating in the colon.

Who is most at risk for C. diff infection?

Individuals most at risk for CDI are those taking antibiotics, especially clindamycin, cephalosporins such as ceftriaxone, carbapenems such as meropenem, and fluoroquinolones such as levofloxacin. Not only are C. diff strains resistant to these antibiotics, they also disrupt the normal intestinal flora, making room for this invasive pathogen to proliferate, release toxins, and cause inflammation in the colon.

Other risk factors for CDI include:

  • Use of proton pump inhibitors, though the clear link has not yet been established.
  • Staying in a healthcare facility of any kind, including long-term care.
  • Comorbidities such as inflammatory bowel disease, rheumatoid arthritis, chronic renal disease, liver disease and diabetes.
  • Female gender
  • Older age
  • Immunocompromised
  • Previous C. diff infection
Did you know 20 to 35% of patients will have a recurrent C. diff infection within 30 days?

What are the complications of C. diff infection?

C. diff causes a serious bacterial infection of the colon that causes severe diarrhea and abdominal pain. Complications of CDI include increased length of stay, dehydration, acute renal failure, bowel perforation, toxic megacolon, ascites, ileus, inflammatory arthritis, sepsis, and death. In fact, studies show hospitalized patients with CDI are twice as likely to die when compared to those without infection. It affects approximately half a million patients in the U.S. each year, with death occurring in 30,000 patients.

Now that you’ve got some background information on C. diff, let’s learn how to care for these patients using the Straight A Nursing LATTE method.

L: How does the patient LOOK? 

The main indicator of CDI is the presence of three or more loose stools a day (and this can increase to up to 15 times per day when severe). Other signs and symptoms include abdominal pain or cramping, abdominal distention, fever, and loss of appetite. As the condition progresses and becomes more severe, electrolyte imbalances and signs of dehydration set in which include hypotension, tachycardia and fatigue. In some cases, the condition progresses to sepsis or other complications as listed above.

A: How do you ASSESS a patient with C. diff infection?

Key assessments for a patient with CDI include:

  • Bowel movement frequency – note that diagnostic criteria are at least three unformed stools in a 24-hour period, and most patients with CDI will have at least this many (and probably more).
  • Stool characteristics utilizing the Bristol Stool Form Scale. Generally, only stool at a Bristol 5 or higher is sent for C. diff testing, but a 2015 study suggests that stools lower on the Bristol scale may have detectable CDI if the patient is symptomatic with frequent bowel movements.
  • Monitor intake and output, noting that fluid losses can be severe.
  • Perform an abdominal assessment, making note of abdominal distention, abdominal pain, abnormal bowel sounds, and tenderness with palpation.
  • Monitor VS. The patient may be febrile and, if dehydration is present, hypotensive and tachycardic. Also, an elevated respiratory rate is an early warning sign of sepsis!

T: What TESTS will be ordered? 

  • Stool sample per facility protocol. Note that some facilities have pre-determined exclusion criteria and will not test stool for CDI if the patient has been using laxatives or has another explained cause for diarrhea. 
  • CBC to monitor WBC count
  • BMP to monitor electrolytes and BUN/Cr since acute renal failure can occur.
  • Abdominal X-ray or CT scan may be utilized to assess for complications.
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T: What TREATMENTS will be provided? 

When possible, the triggering antibiotic is discontinued and the patient is switched to an antibiotic less likely to contribute to CDI. Other treatments include: 

  • Antibiotics that are effective against CDI such as fidaxomicin, vancomycin or metronidazole.
  • Patients with recurrent CDI may receive the monoclonal antibody bezlotoxumab along with antibiotics.
  • Fecal transplant may be utilized with recurrent CDI and is meant to restore healthy gut microbiota. The transplanted stool is usually administered via a colonoscopy but may also be administered via a nasogastric tube, a capsule or an enema. Stool can be transplanted from an individual who has not had an antibiotic exposure for at least six months, is not immunocompromised or at risk for infectious disease, and is free from chronic GI disease as well as communicable diseases such as hepatitis or HIV. If colonoscopy is being utilized for the transplant, the patient will need to undergo bowel prep prior to the procedure.
  • Replace fluids and electrolytes as needed to prevent hypovolemia and electrolyte imbalances.
  • Support nutrition with a low residue diet of foods that are low in fiber and that don’t stimulate bowel activity. Foods permitted on a low residue diet include white rice, refined pasta, meats, banana, applesauce and eggs.
  • Maintain skin integrity, especially in incontinent patients. This includes keeping skin clean and dry, utilizing absorbent pads, and a barrier cream such as Boudreaux’s Butt Paste.
  • When serious unresolved illness, toxic megacolon or perforation occur, the patient will require surgery that often includes a total colectomy with the creation of an ileostomy.
  • Probiotics may be utilized to help preserve the gut microbiota when taking antibiotics, though there is no overwhelming evidence that it is effective in the prevention of CDI.
  • Antidiarrheal medications are not generally utilized with CDI because it has long been recognized that slowing down peristalsis may allow the pathogen to have increased contact with the mucosal epithelium, leading to increased complications. However, this is being studied further so it’s possible you could see antimotility agents utilized in some patients.
  • Enhanced contact precautions to prevent the spread of infection should be initiated upon suspicion of CDI. Because C. diff spores are resistant to most disinfectants, enhanced precautions must be taken. This includes using soap and water for hand hygiene (though this does not kill the spores, it helps physically remove them from the skin) and special disinfectant wipes that contain bleach to clean the environment. In addition, patients should be placed in a private room with a toilet that is for their use only. If a private room is not available, cohorting with another patient with CDI may be acceptable until a private room becomes available. In addition to using soap and water for hand hygiene, anyone entering the room should don a gown and gloves when entering the room.
    In some facilities, enhanced contact precautions remain in place for 48 hours after the resolution of symptoms. However, studies show that shedding of the C. diff bacteria increases after treatment ends. So, don’t be surprised if you see a continuation of enhanced contact precautions all the way to discharge or one to four weeks after treatment ends (whichever occurs first)..

E: How do you EDUCATE the patient or family about CDI?

One of the most important things to teach your patient/family in the clinical setting is about infection prevention. This includes all visitors donning a gown and gloves when entering the room and everyone using soap and water for hand hygiene to remove the spores from their skin. 

Other key things to teach include:

  • CDI prevention – Teach patients to avoid antibiotic use if there is no indication such as with viral infections. If antibiotics are indicated, patients should be instructed to take the full course of antibiotics to avoid the development of resistant bacteria.
  • Hydration – CDI can cause large volume losses, so patients should increase PO intake to avoid dehydration. In some cases, IV fluids will be necessary.
  • Watch for recurrence – If diarrhea returns after symptoms have resolved, it’s important the patient let their physician know as this could indicate a recurrent infection.
  • Proper handwashing – Teach patients how to properly perform hand hygiene using soap and water. They should lather for 15 to 30 seconds (sing “Happy Birthday”) and rinse under running water with their fingers pointing down. Next, they should pat their hands dry with a paper towel and use the towel to turn off the faucet.
  • Laundry – Wash linens and clothing that has been soiled separately from other items. Use hot water, detergent and bleach if possible.
  • Cleaning – Clean the bathroom at home with a mild bleach solution, especially items that have been in contact with stool such as faucet handles, flush handles and door knobs.

Looking for tips on managing strong odors in the clinical setting? I’ve shared my best tips with you here.

Take this topic on the go by tuning in to episode 344 of the Straight A Nursing podcast. Listen from any podcast platform, or straight from the website here.

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