CLOSTRIDIUM DIFFICILE ASSOCIATED DIARRHEA

CLOSTRIDIUM DIFFICILE ASSOCIATED DIARRHEA

Dr. SNEHA SANTHOSH, MDCCC-142

Diarrhea caused by Clostridium difficile is a dangerous illness that can cause up to 25% mortality in olderp ersons who are already weak. It affects hospitalized, elderly, weak patients as well as young, Immunosuppressed patients.

DIAGNOSIS

• the presence of diarrhea, which is characterized by an increase in stool fluidity and typically an increase in bowel movements. The passing of more than 300 ml of liquid stool in a 24-hour period is a statutory cut-off.
• detection of C. difficile toxins in the stools.

The patient may also have delirium, fever, dehydration, malaise, and stomach discomfort as systemic symptoms. In severe cases, pseudomembranous colitis is evident. The colonic epithelium, which is extensively irritated as a result of C difficile's cytotoxic effects, is sloughing off in this condition.

Clindamycin is traditionally linked to C difficile-associated diarrhea, however it can also happen after using a variety of antibiotics.Usually, symptoms begin during or soon after receiving antibiotics. Asking patients if they are on or recently took antibiotics is important because symptoms might appear weeks or even months after taking antibiotics.

HOW DOES IT HAPPEN ?

The fecal-oral pathway, albeit indirectly through spores left on surfaces, is how C difficile is transmitted. Anaerobic, Gramme positive, spore-forming C difficile is the most common bacterium to be linked to antibiotic-associated diarrhea.

Less than 5% of the population in the community has asymptomatic colonization. Asymptomatic colonization is more common in hospitals, especially among older patients, where it is over 20%.

Toxins produced by C difficile result in diarrhea. The two main toxins, A and B, target small GTP-binding proteins, which are a wide family of guanine nucleotide binding proteins that are connected to several membrane receptors and are thought to play a role in a variety of illnesses. A and B share 63% amino acid sequence homology.

Around 1000 times more harmful than toxin A is toxin B. In the same way that toxin B can enter epithelial cells by loosening the tight connections between the epithelial cells lining the colon, toxin A likewise functions as an enterotoxin.

Some strains also produce a binary toxin, although it's unclear how that toxin contributes to human disease.

Therefore, the shift from an uncolonized condition to C difficile colonization, followed by toxin generation, defines C difficile-associated diarrhea. This is dependent in part on the particular strain of C difficile, with one strain (toxigenic S-type 5236) accounting for over 70% of infections in the UK. Toxin production and host conditions that favor invasion, however, are equally significant.

RISK FACTORS

• serious underlying illness
• gastrointestinal procedures without surgery
• a nasogastric tube is present
• receiving antibiotics for ulcers
• Continue in the intensive care unit.
• a protracted hospital stay
• prolonged course of antibiotics
• taking several antibiotics
• Clindamycin, cephalosporins, and penicillins are the antibiotic groups most frequently linked to diarrhoea brought on by C. difficile.

PREVENTION

Consists of general infection control measures and those more specific for C difficile.

• Revision and enforcement of the isolation policy to include wearing of gloves and gowns, and hand washing by healthcare staff; patients isolated in single or double bedded rooms or cohort bays; equipment such as thermometers and stethoscopes dedicated to each patient
• Monthly educational programme for all healthcare workers
• Phenolic disinfectant used for environmental cleaning
• Triclosan (0.03%) soap used for hand washing
• Sterilization department centralized
• Cart washer installed for cleaning wheelchairs and stretchers that have not come into
• direct contact with patients
• Aggressive surveillance activity.

TREATMENT

Diarrhea caused by C. difficile is treated with the following:

• Supportive actions (adequate hydration and restoration of electrolytes)
• If feasible, stop taking the antibiotics you're taking now.
• Treatment using antibiotics to get rid of C difficile.

Metronidazole 400 mg is the typical first-line antibiotic treatment and is taken orally three times a day. Oral vancomycin 125 mg four times a day, or at a higher dose for serious bouts, is an alternative. According to one study, this should be the first line of treatment for patients with albumin levels under 25 g/l or for those receiving intensive care. Although metronidazole and vancomycin resistance has not been shown, if symptoms persist after a week, a different antibiotic is frequently used on a trial basis.

Around 20% of patients with diarrhea caused by C. difficile will improve without receiving antibiotic medication, according to placebo arms in clinical trials. Metronidazole and vancomycin generated results that were equivalent, according to a previous systematic study.If a patient is unable to take oral medications, a nasogastric tube will be required to deliver antibiotics because the infection must be treated via an enteral route.

For the treatment of individuals with established C difficile-associated diarrhea, there is insufficient evidence to recommend the use of prebiotics (nutrients that support "normal" intestinal bacterial flora) or probiotics (live microbial supplements, for example including bifidobacteria, lactobacilli, and so on).

If a patient has a positive stool culture but no toxins, you should only treat them if you have strong suspicion that they have C difficile-associated diarrhea and if they are systemically ill. This is owing to the possibility of C difficile being discovered accidentally in individuals' feces who have diarrhea from other causes.

If a patient is in the intensive care unit or has low albumin levels, start treating them with high doses of vancomycin.The most frequent cause of antibiotic-associated diarrhea in hospitals is Clostridium difficile.The recommended therapies are oral metronidazole 400 mg three times per day and vancomycin 125 mg four times per day. Typically, you should continue treatment until symptoms go away