Recognizing and Managing Clostridium Difficile-Associated Diarrhea

MedSurg Nursing, Dec, 1998 by Joanne M. Miller, Jane C. Walton, Lydia L. Tordecilla

Clostridium difficile-associated diarrhea poses a significant physical risk and cost to the recovery of hospitalized older adults. C. difficile is responsible for 75% or more of the diarrhea-associated enteric infections acquired during a hospital stay (Gerding, Johnson, Peterson, Mulligan, & Silva, 1995). C. difficile is easily spread by direct or indirect contact, therefore placing other patients at great risk for contamination by this organism. Nursing plays a significant role in early identification, management, and control of the spread of this potentially lethal infection.

Mr. Jones, 86, is a nursing home resident who was admitted to the emergency department with a rectal temperature of 101.9 F. Transfer notes indicate that he was febrile for the last 2 days. He has scattered coarse crackles in both lung fields. His gastrostomy tube site is unremarkable. Clear amber urine is draining from his Foley catheter. He has one stage IV sacral pressure ulcer with a black necrotic wound base and foul smelling greenish discharge. Mr. Jones is admitted with a diagnosis of rule out sepsis and pneumonia. He is started on clindamycin 300 mgm IVPB every 6 hours and ceftazidime 1 gram IVPB every 12 hours.

Mr. Jones' urine culture has multiple organisms, but with less than 100,00 colonies. He continues to spike a fever with ceftazidime. A bone scan reveals osteomyelitis and he is started on vancomycin 1 gram IVPB every 24 hours and Zosyn[R] 3.375 grams IVPB every 8 hours.

Four days after the vancomycin and Zosyn are initiated, Mr. Jones starts to have 8 to 10 loose mucoid, malodorous stools a day. His temperature is 101 F rectally. A stool specimen for Clostridium difficile (C. difficile) toxin is obtained and is positive.

Diarrhea can pose a significant health threat to a hospitalized older adult, who like Mr. Jones, may already be compromised with serious chronic illnesses or have been treated recently with antibiotics or chemotherapy agents. Because of the possibility of severe manifestations of C. difficile enteric disease in the older population (Vogel, 1995) or the frail hospitalized patient, it is important to assess and understand the etiology and pathophysiology of diarrhea and C. difficile-associated diarrhea.

Various factors affect the immune system of older adults and increase their susceptibility to infections. Mr. Jones and other older adults are more prone to develop urinary tract infections, pneumonia, and influenza (Lueckenotte, 1996). Also, they are more vulnerable to issues related to immobility, especially pressure ulcers which can subsequently lead to osteomyelitis. These medical diagnoses often require antibiotic therapy and can therefore increase the risk of developing C. difficile-related diarrhea.

Incidence

C. difficile was first identified in 1935 as part of the normal intestinal flora of healthy infants (Bartlett, 1986; Gerding et al., 1995). The name, C. difficile, was given because of the difficulty in culturing this organism (Bartlett, 1997). Bartlett (1986) indicated that colonized C. difficile has been identified in 25% to 60% of healthy children under 1 year of age. In 1977, C. difficile first became associated with pathologic enteric disease. Currently, C. difficile enteric disease represents the first or second most common source of infectious diarrhea in industrialized countries (Bartlett, 1986). Moreover, C. difficile is the most common nosocomial infection; with 75% or more of the diarrhea-associated enteric infections acquired during a hospital stay (Gerding et al., 1995; LaMont, 1995). C. difficile-associated illness is considered epidemic and its "transmission in the hospital setting is a significant concern" (Bartlett, 1992).

The clinical course of the infection ranges from asymptomatic colonization or carrier state to a mild-to-severe disease ranging from diarrhea to the more serious pseudomembranous colitis (PMC) which can lead to toxic megacolon and even colon rupture. Failure to recognize and treat C. difficile PMC can lead to fatalities with incidences as high as 10% to 20% in older debilitated patients (Holmes & Notarangelo, 1987).

Risk factors

According to Bartlett (1986), clostridium difficile should be suspected as an enteric pathogen in any patient who develops a diarrhea or colitis either during or up to 4 to 6 weeks after antibiotic therapy. Twenty-percent of all antibiotic-associated diarrhea and most cases of pseudomembranous colitis are attributable to this organism (Walker et al., 1993). Antimicrobial exposure places the patient at the greatest risk for developing C. difficile diarrhea. Although any antibiotic can cause the problem, recently treatment with clindamycin, cephalosporins, and penicillins are most commonly the culprits. There are a few cases where C. difficile occurred without a previous history of treatment with antimicrobials or chemotherapeutic agents (Gerding et al., 1995), especially fluorouracil and methotrexate (Bartlett, 1992).

Antibiotics are only one of the risk factors in acquiring C. difficile. Increased age and cross contamination (Bennett, 1993; Holmes & Notarangelo, 1987) are major risk factors. See Table 1 for other less common risk factors (Hurtin et al., 1997; Jackson, 1993).