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Treatment Of Clostridium Difficile Infection Health And Social Care Essay

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The aim of this theoretical assignment is to discuss and analyse the impact of clostridium difficile-associated diarrhoea; how it is spread and the prevention measures. Before introducing the organism C. difficile in clarity, the term healthcare associated infections will be looked at to demonstrate that C. difficile associated diarrhoea is one of those infections that can be acquired in the hospital environment. There will be a focus on hand hygiene, the type of patients that are likely to develop C. difficile and the importance of compliance with infection control.

As a nurse working in acute medical ward for elderly, I work closely with patients with C. difficile infection. I have noticed the effect of C. difficile infection in elderly can be fatal.

C. difficile is a gram positive anaerobic bacillus. They colonise in the oxygen deficient areas of the body.

Organisms responsible for HCAIs includes MRSA, Pseudomonas aeruginosa, S. aureus, Enterococcus species, S. epidermis and Clostridium difficile but according to Department of Health (2007) Clostridium difficile is a particular problem because, unlike other infections, patients become vulnerable to it through the antibiotics used to treat their underlying illness. The rates of Clostridium difficile have gone up dramatically from 1000 in the early 1990s to 44,448 in 2004 (Health protection agency 2007). In the UK, there is a growing concern at the increased incidence of Clostridium difficile-associated diarrhea (Health commission 2005). In January 2004 the Department of Heath (DOH) introduced mandatory surveillance of C. difficile in patients over the age of 65. The total number of reports of C. difficile-associated diarrhea over the period of January to December 2004 in England and Wales was 44,488, rising to 51,690 in 2005, an increase of 16.2 % (Health Protection Agency 2007). The risk that C. difficile poses to the public health is now considered as fundamental as meticillin resistant staphylococcus aureus (MSRA), and it is thought to have contributed to more deaths than MRSA in England, Wales and Northern Ireland in 2003 (Healthcare Commission 2006). Coupled with the fact that the number of cases reported is increasing, this suggests that further controls are required to limit the spread of infection.

That can cause life threatening conditions, including diarrhoea, colitis and septicaemia and resulting death. C. difficile infection can cause serious illness and a significant cause of patient morbidity and mortality. It is a major cause of hospital acquired diarrhoea.
The Health Protection Agency (2005) reports that C. difficile typically infects patients who receive broad-spectrum antibiotics and can be common in older people owing to factors such as underlying chronic illness and weakened immune systems. In addition there, is mounting evidence that the immune system plays a fundamental part in defending against colonisation by C. difficile (Kyne et al 2001). Equally Wilson (2006) points out that, C. difficile is now the predominant enteric pathogen amongst the over 65s this maybe due to the fact that the normal microbial population of the colon diminished with aged. It is also an important cause of diarrhoea amongst inpatient and research shows that the infection has been steadily increasing in recent years. To support this, in the last year the Healthcare Commission (2007) has produce three reports on outbreaks of C. difficile infection that have led to the deaths of hundred of people. The cost of C. difficile - associated diarrhoea can be measured in both human and financial terms (Hall and Horsley 2007). C. difficle causes wide spectrum of disease, from asymptomatic carriage and mild to sever diarrhoea, to life-threatening pseudomembranous colitis (Mcfarland et al 1989). C. diffcile is associated with outbreaks of infection among hospital patients. Infection can occur as a result of environment contamination as well as cross infection (Hall and Hornsley 2007).

C. difficile infection can cause serious illness and hospital outbreaks .It can cause significant financial burden on NHS. It is estimated that the increased length of hospital stay itself can cause an excess of around £4,000 per patient.
Prevention of C. difficile-associated diarrhoea is concern with making sure that the conditions in the healthcare institutions, including patients, staff and environment, are not conducive to the establishment of C. difficile infection (Worsley 1998). The C. difficile spore can adhere to toilet seats, commodes, bedpans, bedsides lockers, beds and floors. The spores are resistant to many types of disinfectants including heat, dryness, alcohol rub, stomach acid and can survive in harsh environment months. In addition, the spores can persist on surfaces such as, electronic thermometer, stereoscopes, skin folds and the hands of a care giver (Hoffman et al 2004).These C. difficile bacteria or spore can be transferred from contaminated hand to mouth and cause infection in susceptible patient and also re-infection. According to Hall and Hornsley (2007), C. difficile spores can grow again when they are reintroduce into more suitable condition thus rigorous cleaning is essential.

The number of death certificates mentioning C. difficile infection in England and Wales fell by 29% between 2007 and 2008 ,after increasing every year since records began in 1999(National Statistics,2008).

According to Weston (2007), Clostridium difficile was first identified in 1935s, but until the late 1970s it was not identified as the cause of pseudo membranous colitis following antibiotic therapy.

C. difficile causes antibiotic - associated diarrhea and it is the spores contained in the feaces that causes HAI. The spores of C. difficile, is frequently found in the stools of newborn infants but rarely causes disease in this group (Johnson and Gerding 2004). Approximately 3% of the adult population carry the organism naturally in their colon (Jenkins 2004), however there is no evidence to suggest that such carriers are sources of cross infection (Hall and Hornsley 2007). It has been stated that once C. difficile enters the colon, the cells do not cause symptoms unless the normal micro flora in alter. However, this mechanism is not full understood but it is thought that the normal flora acts as a protection by using the nutrients to utilising the space available to compete with the C. difficile spores (Hall and Hornsley 2007). It is only when the normal bowel flora is altered or compromised that the organism multiply in the absence of competition and the toxin load increases (Gammon 1995).

C. difficile infection is more common in elderly (over the age of 65). People who have a long stay in health care settings, those who have recently had gastrointestinal surgery and those who have a serious underlying illness that compromises their immune system are also at high risk to get C. difficile infection. In-patients are also at high risk if there are hospital outbreaks.
Infection control precautions need to be implemented according to patient's symptoms and not delayed until the healthcare team can review laboratory test result (AMM 1998). The nurse should explain to the patients why he or she is to be isolated, making it clear that at this time it is a precautionary measure until laboratory test result are available.

Poor infection controls are also an important risk factor.

Causes

Antibiotics are considered as the most important cause for C. difficile infection. Any antibiotic can cause C. difficile infection, but Broad spectrum cephalosporins, broad spectrum penicillin and clindamycin are most frequently implicated. The second most commonly named antibiotic is Co amoxiclav (Health Protection Agency, 2008).

The term 'healthcare associated infections', otherwise referred to as 'nosocomial' infections encompasses any infection by any infectious agent acquired as a consequence of a person's treatment by the NHS or which is acquired by a healthcare worker in the course of their NHS duties. It can also be defined as an infection that was not present or was not in the incubation phase at the time of admission to the hospital (DOH 2005). The prevention and control of HAI is of high priority for all parts of the NHS because it is a UK problem due to the following: 9% of inpatients ended up with HAI, which is equivalent to 100,000 patients; 5% patients have an adverse reaction; it costs the NHS around £1 billion/year and leads to patients mortality and morbidity, hence it is of equal importance for healthcare providers in the independent and voluntary sectors (DOH2007).

The use of proton pump inhibitors such as lansoprazole, omeprazole and pantoprazole are also potential risk factor for C. difficile infection (Leonard et al, 2007). The disruption of normal harmless bacteria in the gut, because of antibiotic therapy also allows the C. difficile to multiply to greater number. The bacteria start to produce toxins.
According to the National Audit Office (2000) it has been recommended that infection control teams should carry out observation audits on the wards, to assess staffs competency on hand washing procedure. On the other hand, it could be argued that this is not the most successful method of monitoring staffs hand washing techniques, because staffs have a tendency to perform more competently whilst being assessed by infection control practitioner and this will contribute to poor auditing results.

The antacids suppress the gastric acid secretion and as a result, C. difficile bacteria, including the spores are less likely destroyed. The reason for community associated C. difficile infection was unclear but it is become clear that the reasons for the majority of the infections are associated with antibiotic prescriptions or hospitalisation (Wilcox et al, 2008).

Transmission

The transmission is through faecal-oral route. The infected patients acquire the organisms directly from other patients with diarrhoea.

Hand must be washed with an antimicrobial soap very thoroughly and in order remove C. difficile spores from the skin and to make sure that they are properly cleaned. Although generally beneficial, alcohol-based hand rubs are recommended to prevent the spread of infection such as MRSA it may not be effective at eradicating C. difficile spores (Hoffman et al 2004). Patients' and visitors hands should not be overlooked. Banfield and Kerr (2005) suggests that hand hygiene practice among the public are generally poor and that the case of C. difficile associated diarrhoea, improving patient hand hygiene may have a favourable impact on reducing that transmission of the organism.

The route of transmission may be direct, via the hands of health care workers or via the hands of patients or via the environment. Asymptomatic people who are colonised with C. difficile are also can be able to transmit the disease. About 3% is the colonisation rate in healthy adults, but this increases to nearly 20 % in older people especially in chronic care wards.
Health care aquired infections such as Clostridium difficile associated diahorrea have become a UK problem since the 1990s due to the increase rate of the number of inpatients who caught infection due to cross infection. It is also integral for health care workers to follow the various precaution measures set out according to their hospital policies, procedures and guidelines as this will assist in the prevention of the transmission. The high number of clostridium difficile infection is putting patients' lives and well being at risk and also has significant implication on the NHS finance. For this reason there is a clear need for healthcare workers to work collaboratively to tackle infection such as C. difficile if infection rate are to fall. Improving nurses' knowledge of the cycle of infection in C. difficle is one step in helping to prevent and control this infection. In addition, I strongly believe that more should be done to increase the awareness of Clostridium difficile associated diahorrea to the general public in order to change their behaviour regarding infection control.

The spore form of C. difficile can survive in the environment for five months or more on hard surfaces. It is considered that the primary route of transmission of C. difficile infection via healthcare workers hand.

Clinical features and pathogenesis

The most important clinical feature is sudden onset of offensive smelling diarrhoea during a course of antibiotic or who had antibiotics with in the previous two months. Patients may pass soft or watery stool more than twice daily or in more severe cases more than 20 times accompanied by severe abdominal cramps (Weston, 2007).

During the increase of the toxin loads, C. difficile spores will grow unchecked by normal flora or stomach acid and produces 2 toxins, which are enterotoxin (toxin A) and more potent cytotoxin (toxin B). Toxin A activates macrophages and mast cells, which release inflammatory mediators. The mediators cause disruption of the cell wall junction, resulting in increased permeability in the intestinal wall and subsequent diarrhoea (Gould and Brooker 200). Meanwhile, toxin B causes degradation of epithelial cells in the colon. As the colitis worsens, purulent and necrotic debris accumulates and form characterise ulcers, the pseudomembranes. Similarly, the symptoms of C.difficle associated diarrhoea are testes for when a stool specimen is sent to the laboratory (Hall and Hornsley 2007). The normal microflora of the bowel hosts at least 500 recognised species of bacteria which help to protect the bowel from pathogenic species. This is known as 'colonisation resistance'; however these microfloras resistance can be altered by the uses of broad-spectrum antibiotic therapy, such as ampicillin, clindamycin and cephalosporins (Kelly and Lamont 1998). These antibiotics mentioned can disturb and alter the lining of the intestine, and when this happens, C difficile in some cases becomes harmful and cause infections (Ayliffe et al 2000).

Abdominal distension, fever and dehydration may also be present in more severe cases. Unless C. difficile is diagnosed, the patients can be miss- diagnosed with irritable bowel syndrome. C. difficile infection is a major health problem worldwide that leads to increased morbidity and mortality. Healthy adults carry around 500 species of bacteria in the colon, 90% of which are harmless (Weston, 2007).
Evidence base literature will be use to support key aspects discussed throughout and this will end with a conclusion that will summarise the main issues which has being discussed or analysed. The rational for choosing this infection control issue is due to the fact that C. difficile has been a common occurrence in clinical setting. In addition doing the topic will improve my knowledge and understanding of the infection including.

C. difficile colitis results from the disruption of normal colonic flora and C. difficile colonises in the oxygen deficient areas of intestine. The spores are able to replicate and produce toxins that can lead to mucosal damage and inflammation.
Vaishnavi, C. (2010, April). Clinical spectrum & pathogenesis of Clostridium difficile associated diseases. Indian J Med Res 131, pp. 487-499.

In a healthy adult the normal colonic flora inhibit the growth and colonisation by C. difficile. The antibiotic therapy may disrupt the normal flora and allow the C. difficile to colonise very rapidly. After colonisation the organism's produces two protein exotoxins( Toxin A, an enterotoxin and Toxin B , a cytotoxin) in to the colonic lumen.
Clostridium difficile is a gram-positive spore-forming obligate anaerobic bacterium. Its pathogenicity factors are exotoxins that cause cytopathic and enterotoxic effects. The C. difficile bacterium has two major forms of existence: an active or it is also called ‘infectious’ form that cannot survive in the environment for a long time; and a noanactive or ‘noninfectious’ form, when spore can survive in the environment for prolonged periods. Thus, it is obvious that C. difficile can persist for a long time in the environment and its spores are resistant to many types of various disinfectants, heat treatment, and dryness. The spores may persist for a long time, even months on different surfaces such as different commodes, stethoscopes, bed rails, electronic thermometers etc. C. difficile has a natural resistance to most antibiotics and the spores can provoke disease in people at high risk for Clostridium difficile-associated disease.

These are responsible for diarrhoea and colitis. Toxin A binds to the receptors in the intestine and cause extensive tissue damage, inflammation and oedema. Both toxins posses cytotoxic activity against cultured cells by same mechanisms but they differ in cytotoxic potency, toxin B is generally 1000 times more potent than toxin A and to play a major role in activating inflammatory repose (Weston, 2007).
Treatment of intestinal infection caused by C. difficile primarily includes the suspension of the antibiotic therapy - if this is justified from a medical point of view - and filling a huge loss of fluid and electrolytes. In most cases, these measures are enough to relieve symptoms. Anastaltic drugs are prohibited in these cases, because they contribute inhibition of bacterial toxins in the gastrointestinal tract. In severe disease may require antibiotics of narrow effect, such as vancomycin and metronidazole, because they are effective against C. difficile. However, to avoid the emergence of resistance to certain antibiotics, these drugs should be used only in cases when the patient’s clinical condition makes the use of antibiotics therapy absolutely necessary.

Toxin B is more important than toxin A in the pathogenesis of C. difficile infection in man.

According to lab test reports there are 100 different types of c difficile stains. The most recognised epidemic types is ribotype 027.

In recent years has significantly increased the number of infections associated with Clostridium difficile. It is observed an increase in the number of serious diseases that are associated with a high rate of complications and deaths. Nowadays, Clostridium difficile is the main causative pathogen of nosocomial diarrhea that connected with the use of antimicrobials. In the present essay the following topics are observed in details: the etiology and epidemiology of Clostridium difficile-infection, method of transmission, risk factors, symptoms, treatment and impact on human population.

The most important feature of ribotype 027 is hypertoxin production, 10 to 20 times more toxin than other stains. The C. difficile infection caused by ribotype 027 are more likely to be severe with increased complications such as renal impairment, severe colonic dilatation and sepsis (Freeman et al, 2007).The clinical features include increased severity of illness, failure to respond to antibiotics ,abdominal distension.
Nurses have responsibility to safeguard and promote the interest of individual patients and clients (NMC 2004). This responsibility includes ensuring that his or her knowledge and competence in commensurate with the task being undertaken. Infection are responsible for increased morbidity and mortality, thus a comprehensive knowledge of infection control precautions and basic microbiology should be the fundamental requirement of the NMC, other statutory bodies, and the legal system NMC (2004). Research has shown, however, that despite the provision of a specific care plan, together with guidance on it use, the documentation of appropriate care for infection control remain inadequate. Infection control affects every aspect of health care and every nurse, irrespective of the setting with which they work should ensure that their practice incorporates a sound knowledge and understanding of basic infection control.

Raised CRP and rising WCC particularly in patients who may have appeared to respond to antibiotics and deterioration in condition and appears to have higher mortality rate.

Diagnosis

Laboratory studies of stool sample will help to detect c difficile infection. Stool culture will help to detect the presence of difficile with toxin production.

Standard infection control procedures, including barrier nursing, are important in the prevention of spread and should be re-enforced by early diagnosis of C. difficile. Healthcare worker should maintain barrier nursing when providing care for patients with C. difficile as infection can contaminate staffs uniforms which can be transferred to susceptible patients. It has been stated that the use of protective clothing appears to be an area of confusion for many. Staffs often need correcting for not wearing apron when making beds and sometimes respond that they were not aware they need to wear apron. Clearly the use of protective clothing is an important area in infection control and needs to be covered thoroughly during infection control lectures. The Royal College on nursing booklet, 'Guidance on uniforms and clothing worn in the delivery of patient care' (2005) makes coherent of when protective clothing must to be worn. In addition the RCN booklet also state 'staff must change out if their uniforms promptly at the end of each shift as infection can found on uniform.

Stool enzyme immunoassay (ELISA)will detect both of the toxins ( A or B). For toxin B Stool cytotoxicity assay will be positive.Endoscopy may demonstrate ,but it is the least sensitive for diagnosing C. difficile as compared to stool assays., Sigmoidoscopy alone may not reveal any abnormality if the disease is confined to the right colon. Colonoscopy is more useful. Because of the risk of perforation Sigmoidoscopy and Colonoscopy is contraindicated in patients with colitis (Weston, 2007).
Literature illustrates that doctors and nurses are falling to comply with basic hand hygiene rules between patients intervention (Shuttleworth et al 2004). Poor staff and patient hand hygiene may also account for how the organism enters the patient's digestive system. Infection can be spread on the hand of health care workers who have come into contact with infected patient or health-care environment (Jenkins 2004). Once C. difficile is established in the environment, the most common method to spread the infection is via the hand (Wilson 2005). Healthcare workers hand hygiene is one of the six main factors noted in saving lives; which is a delivery programme to reduce health associated infection including MRSA (DOH and NHS Modernisation Agency 2005). This illustrates that hand hygiene is a crucial factor in the control of infection because hands can easily transfer micro organisms from one patient to another or from one area to another. Despite strategies implemented to promote hand hygiene such as the clean your hands campaign which was launched in 2005 in trust nation wide and hygiene code, there still seems to be difficulty in persuading staff to adopt good practice (Shuttleworth 2004). There is recognition that hand hygiene among staffs remains generally poor (Jenkins (2004) and Tailor (1978) demonstrated that even when staff did perform hand hygiene 89% missed some part of their hands.

Treatment

The treatment of C. difficile infection depends on the severity of the illness. At my work place, the patient is closely monitored and isolated. A stool chart is maintained using Bristol Stool Chart.

According to Cunha (1998), “C. difficile is acquired from the environment or from the stool of other colonized or infected people by the fecal-oral route. Intestinal colonization rates in healthy neonates and young infants can be as high as 50% but usually are less than 5% in children older than 2 years of age and in adults. Hospitals, nursing homes, and child care facilities are major reservoirs for C difficile. Risk factors for disease are those that increase exposure to organisms and those that diminish the barrier effect of the normal intestinal flora, allowing C difficile to proliferate and elaborate toxin(s) in vivo.” Household transmission of C. difficile with a variety of factors creates a serious risk of nosocomial infections, especially in patients treated with massive antibiotics. The cohorts at risk of developing severe nosocomial Clostridium difficile-infections are also young children with weakened organism, as well as patients who stay in the hospital for rather long time.

All antibiotics that are not required are stopped. This will help the normal bacteria to thrive again in the gut. If any patient develops C. difficile infection at my work place, we conduct a thorough investigation for the causes and we notify the antibiotic management team to review the patient. The team will review the patient in the ward (rounds Wed/Fri) or via the phone.
Patient have a right to clean and safe treatment whenever they are treated by the NHS. Safety in the healthcare is a top priority for the NHS, and this must be an essential element for procedure in the NHS so that patients have the confidence they need in the care they receive. Furthermore, clean environments are extremely important in their own right, and are central to patients receiving comfortable reassuring and welcoming care. This is why deep cleaning of every hospital in the country is so important (DOH 2008).

There will be a root cause analysis to find why the patient developed C. difficile infection? In some patients fluid and electrolyte replacement and nutrition review may also be necessary. In mild cases of C. difficile infection, patients are monitored for 48 hrs before starting antibiotics. In severe cases, antibiotics may need to be administered immediately.
Infection with C. difficile can be carried out by exogenous (transfer from outside sources) and by endogenous (activation of own microflora) ways. However, there is no doubt that the preexisting endogenous reservoir of C. difficile is not a prerequisite for the development of symptomatic forms of infection, and in most cases the agent enters the body from the environment.

Metronidazole and Vancomycin are the two preliminary antibiotics used in the treatment of the infection (Weston, 2007). Usually a 7 to 10 day of therapy is required. Oral metronidazole 400mgs eight hourly for seven to ten days is the first line of treatment. It is contraindicated in women who are pregnant or who are breast feeding.
Effective staff education programs can result in a significant reduction in infection rate. Recommendation includes hand hygiene education and on going audit and mandatory surveillance on C. difficile which as being established by the Health Protection Agency in 2007 reports that all acute NHS trust in England are required to report all cases of CDAD in patients aged 2 years and over. Previously, reporting had been limited to patients aged 65 and over (Hall and Horsley 2007). Infection can also be reduce if nurses get tougher on infection control measures in their ward area, by becoming assertive and through adopting collaborative working. All health care workers as well as the general public need to change their behaviour regarding infection control.

The most recognised side effects of the metronidazole are an unpleasant metallic taste, nausea, vomiting, diarrhoea, abdominal pain, headache, pruritus, rashes, dizziness and reversible neutropenia.

Vancomycin is known to cause the spread of vancomycin resistant bacteria.

In addition there is one issue which is very personal in infection prevention and control, which is staff wearing rings. Ayliffe et al (2000) have shown that the wearing of rings carries greater risks of transferring infection because it prevents good hand washing technique. The study found that there are high numbers of organism present on the hand of staff wearing rings (Ayliffe et al 2000). It is therefore pivotal for staff to refrain for wearing ring whilst on duty in order to fight against the spread of micro-organism and HCAIs.

Vancomycin is used for severe, life threatening cases of C. difficile infection. It is also used for patients unable to tolerate metronidazole and failed treatment with metronidazole. Vancomycin is expensive. Oral vancomycin is not completely absorbed or metabolized in the gut and is excreted in the stool unchanged. This is ideal in the treatment of C. difficile infection. The recommended oral vancomycin doses for adults are either 125mg or 500mg four times daily.
Patients with toxin-producing strains of C, difficile in their faeces should be isolated while they have diarrhoea. Isolation is the physical separation of symptomatic patients from other vulnerable patients to limit the spread of infection. Furthermore the (DOH 2007) stipulates that isolation of patients with suspected or confirmed infection in a side room is strongly recommended, and where isolation facilities are not available, patients should be cohoted. Hence Farrington and Pascoe (2001) recommended the need for more side rooms in hospitals.

The use of a rectal vancomycin enema (500mg diluted in 1000ml of 09% sodium chloride injection) is also an alternative. A recurrence of symptomatic disease with re infection occurs in 5-20% cases. Management of repeated relapses is more difficult. The options include slow tapering of vancomycin or metronidazole over a period of six weeks and vancomycin combined with rifampicin for seven days. There are also case reports of successful treatments with intravenous immunoglobulin which contains antibodies to c difficile toxins.
Wilcox and Fawley (2000) found that C. difficile produce more spores when exposed to cleaning products that did not contain chlorine. Therefore, the DOH (Donald and Beasley 2005) recommended that there should be enhanced environment cleaning using chlorine-based disinfectants in areas where there are patients with C. difficile-associated diarrhoea.

The studies shows oral administration of limited bacteria or yeast helps to reconstitute the gut flora and there is a potential to prevent infection.The ability of these organisms to colonize and also to prevent and treat the c.difficile is unclear. (Department Of Health, 2009). Surgery may be needed for small number of cases especially if C. difficile infection progress to fulminant colitis and perforation. Loperamide (anti diarrhoea drug) is contraindicated for C. difficile infection because this will slow down the clearing of toxic bacteria (Weston, 2007).

Prevention & Control

Preventing the spread of C. difficile can be challenging as hospitals tend to have an increasing population of elderly, debilitated and susceptible persons, which naturally increases the number susceptible hosts within the environment.

Isolation

Isolation should be implemented in conjunction with the infection prevention and control measures to minimise the risk of spread to other vulnerable groups. Private room/side room is recommended, especially for patients who are fecally incontinent.

Isolating patients has some element of psychological risks, for example anxiety, depression and feeling of loss of choice (Gammon 1998) and is something that the nursing staffs need to be aware of and assess regularly. The patients need to be updated regularly and if he or she is found to have an infection the nurse must to keep up to date with patient progress.

Cohort symptomatic C. difficile associated disease patients only with other symptomatic C. difficile infected patients, to minimise environmental contamination. Patients with C. difficile infection may be moved to other rooms or bays when the diarrhoea ceases (no diarrhoea at least 48 hours) (Department Of Health, 2009 and Health Protection Agency, 2009).

Hand washing & Barrier nursing

Contact precautions should be used for C. difficile infected patients with diarrhoea. Proper hand washing is essential.

In most cases it could be fair to say this is not due to laziness or lack of care but to barriers such as time constriction. For example when call bells are ringing nursing staff can feel the pressure to get these answered quickly and hand washing in these circumstances can be forgotten and also the lack of access to hand hygiene agents can also be another barrier. In addition study by Parkers (1999) states that the work pressure may also reduces opportunities to frequently wash hands in between procedures or patient handing. Furthermore it could be argued that the pressure at work has led to lack of time for senior nurses to act as role models for junior staffs and to supervise their hand hygiene performance (Ayliffe et al 2000). This in turn has contributed to the increase in the spread of infection.

Alcohol-based hand gels are not effective in reducing the spread of the organism and are not recommended. Disposable gloves and aprons should be worn when caring for the patients. It is recommended that not to share the equipments between the patients.
Effective drying of hands after washing is an essential part of hand hygiene, because wet surface transfer micro- organism more effectively than dry one (Elliott 1989). Hence, a paper towel should be use to turn off the faucet and hands should be washed before and after contact with a patient and after gloves removal. This technique must be taught to family member as a well as patient to reduce the risk of spreading the infection.

It is a good practice to inform healthcare workers and visitors that a patient is on contact precautions, such as labelling the door of the room, without disturbing patient's privacy. Last year we (My work place) spent £1,280.
The incidence of nosocomial diarrhea connected with C. difficile, varies greatly in different regions and even hospitals and departments. C. difficile infection is officially recognized as nosocomial. The vast majority of C. difficile cases are provoked by exogenous infection in patients during the hospital stay. Hospital-acquired cases of C. difficile infection can have both sporadic and epidemic character. Vaishnavi (2010) stated that in the event of outbreaks of Clostridium difficile-associated diseases in hospitals or nursing homes it can be covered from 16 to 29% of all hospital patients.

32 for soap, alcohol, gel and moisturiser.

Environmental Cleaning

The environment of a patient with C. difficile infection should be cleaned thoroughly at least twice per day. An approved hospital disinfectant-detergent should be used for all environmental cleaning.

Evidence suggests that the organism is endemic in the hospital setting, with between 20% and 70% of sampled sites being contaminated with C. difficile (Wilson 2005). In addition studies have found more bacteria in the environment of patient with C. difficile associated diarrhoea than those who do not have the infection (DOH 2007).

Terminal cleaning (stage cleaning) of ward area is essential after the discharge or transfer or death of a patient with C. difficile infection. (My ward)

Decontamination of equipment

Do not share equipments among patients to prevent cross infection. Commodes and bedpans are heavily contaminated with spores and are considered as vehicles of cross infection in C. difficile outbreaks. It is ideal that symptomatic patients have their own commodes or toilet facilities.

Summarizing the above stated information it is possible to conclude that C. difficile has great impact on human population at present time. Such situation has a place, because nosocomial infection usually overrides the existing disease, always burden existed state, and often becomes the last page in the history of the disease. Thus, it is necessary to remember about prevention measures. The main prevention measure includes strict compliance with the rules of personal hygiene, as well as the strict implementation of all requirements for compliance with sanitary-epidemiological regime in hospitals. Moreover, increase of sanitary culture among population and the increasing professionalism of health workers will help to overcome C. difficile and help patients to become healthier.

Proper disinfection must be essential.

Transfer of Patients

Transfer of patients with C. difficile infection or disease to another ward, unit, or to the long term care facility must be informed prior to the transfer that the patient has C. difficile infection. Same notice must accompany transfer of patients with C. difficile infection to a long term care facility (Department Of Health, 2009). It is not necessary to have absence of diarrhoea or negative stool cultures before the transfer of a C. difficile patient to a long term care facility. On the patients discharge, we need to notify the primary care physician (My ward).

Rectal Thermometers

Since the outbreaks C. difficile in hospitals and long term care facilities, rectal thermometers are restricted to use. For the routine use Electronic tympanic thermometers are recommended (Department Of Health, 2009)

Education

Ward should conduct training programmes to the health care staff. Ensure that patient / family information leaflets are given out.

Cunha, B. A. (1998). Infectious Diseases in Critical Care Medicine (Infectious Disease and Therapy). Informa Healthcare.

Anti microbial management team

It is the responsibility of the hospital trust to develop anti microbial management team. That should consist of a consultant microbiologist, pharmacist and prescriber. The trust also needs to develop restrictive antibiotic guidelines.

Clostridium difficile is often found in the environment and can be isolated from soil. To isolate C. difficile is often used nutrient medium, prepared on the basis of egg yolk and containing cycloserine and cefoxitin as selective components that inhibit the growth of other microorganisms, as well as fructose. The above described medium is both selective and differential diagnostic that allows to determine C. difficile in the examined material, on the assumption of the density of microbial population not less than 6 x 1010 bacteria in 1 g of faeces.

These guidelines specifically need to address to avoid the use of broad spectrum cephalosporin, broad spectrum penicillin and clindamycin especially in elderly and minimise the use of fluroquinolones, carbapenems,that we follow in my work place.
Aktories, K. and Wilkins, T. D. (2000). Clostridium difficile (Current Topics in Microbiology and Immunology). Springer.

It is also a good practice to have an infection control link nurse to each and every ward. It is their responsibility to do proper training for staffs and auditing the clinical area.

Outbreaks of C. difficile infection in Long Term Care Facilities

An outbreak of C. difficile infection is defined as three or more cases of symptomatic C. difficile infection mainly in the same area of the hospital ward within a period of seven days. Infected patients should be placed in isolation room or cohorted.

The most important exogenous sources of C. difficile are people with manifest forms of infections and asymptomatic carriers of the causative agent, who emits them in the environment. Infection in most cases occurs in a hospital, where medical personnel and patients are likely sources of infection. In this regard, as it was already mentioned, C. difficile infection is considered to be predominantly nosocomial.

Patient(s) can be removed from precautions if there is no diarrhoea .There is no need to wait for negative stool culture to remove the patent from precautions. An education program regarding C. difficile infection and its transmission and prevention should be conducted to all health care workers. Need to highlight the use of gloves and aprons and moreover proper hand washing. The health care facility need to monitor for any significant episodes of C. difficile infection, and then need to liaise with local health department for further assistance (Walker K et al, 1993).

Possible Solution

Conducting education programmes and workshops for health care workers and public to increase the awareness of C. difficile infection can contribute a major role in reducing the number of C. difficile infection cases within the healthcare system. Need special attention to personal hygiene. The primary route transmission is via the hands of healthcare workers and other patients and residents. It is very important to perform proper hand washing and barrier nursing (gloves, gowns). Environmental hygiene is also very important factor in controlling C. difficile infection. Regular and proper cleaning of patient rooms with anti bacterial cleaning agents is essential as C. difficile toxins can stay in the environment for several months.

Changing the way doctors prescribe antibiotic therapy is also an important strategy in control the C. difficile infection. Because C. difficile infection is always associated with the use of antibiotics, It is also recommended to have an antimicrobial management team for each hospital (Department Of Health, 2009).

In cases of recurrent C. difficile infection experts agree that the non antibiotic treatment have a positive impact. The use of toxin binders neutralises the effect of toxin producing stains and to helps the intestinal flora to restore .Tolevamer, developed by Genzyme Corporation is the first non antibiotic treatment approved for C. difficile infection (wwwmediscape.com).

Mandatory surveillance of C. difficile infection in the United Kingdom

When looking at surveillance reports, many of the hospitals in the UK have been affected with outbreaks of C. difficile. We can see that the large increase in the number is between 2000 and 2007.It is the responsibility of the hospitals in the UK has to measure and report to the Department of Health.

Clostridium difficile (C. difficile) is an acute infectious disease characterized by the development of diarrhea, pseudo-membranous colitis and enterocolitis. The true number of cases of acute infectious diarrhea does not coincide with the officially recorded sickness rate and order of magnitude is greater than the number of medical consultations in this regard. However, the number of reported cases of C. difficile infection is by tens of thousands to several million per year in different countries. It is precisely this fact that explains the necessity to observe C. difficile as a separate issue requiring careful consideration and control.

The surveillance should include the number of positive cases, number of severe infections, the number of required surgery cases and number of deaths.

The surveillance of C. difficile infection is taking to get a target for 30% reduction from 2007/2008 numbers by 2010/2011. In 2007-2008, there were 55,498 cases reported across England. In 2008-2009, the cases reported dropped to 36,095. i.e., cases dropped by 35%. Last year our target (My hospital and my community) was 180. The number of cases reported was 171, 98 of which are from hospital (7 cases from my ward).This year, the target is 155.

Social, economic and political issues.

C. difficile infection is expensive to the NHS. The total identifiable increased cost of C. difficile infection causes an excess of £4000 per case. Such high costs can be used to justify expenditure on personnel and/or other control measures to reduce the incidence of this hospital-acquired infection.

Johnson, S. and Gerding, D. N. (2004). Clostridium difficile. Hospital epidemiology and infection control, 3 rd ed. Philadelphia: Lippincott Williams &Wilkins.

There are notable outbreaks of c. difficile infection worldwide since 2003.Outbreaks was reported in Montreal, Quebec and Calgary, Alberta, in Canada. Approximately 1400 cases affected, death count 36 - 89.A similar outbreak reported at Stoke Mandeville Hospital in the United Kingdom between 2003 and 2005, in which 33 patients died. In 2007 Maidstone and Tunbridge Wells NHS Trust was heavily criticized by the Commission, have heightened media and made public awareness. In 2009, four deaths reported at Our Lady of Lourdes Hospital in Ireland also thought to have links to Clostridium difficile infection. The prevention and control of C. difficile infection in health care settings is become a global public health challenge.(Health Protection Agency 2009)

Conclusion

C. difficile infection is a major problem in hospitals that is associated with the use of antibiotics. C. difficile infection also recognised as one of the major health care associated infection. It is estimated that C. difficile infection affects between 40000-60000 people in the UK every year. The prevention and control of C. difficile infection is very important.

The three main elements of prevention are:

Need to restricted use of antibiotics;

Strict isolation precautions and barrier nursing when looking after patients with diarrhoea and

Through cleaning of clinical areas.

Poor hand washing is known to play a key role in the spread of infection. Hand washing facilities in the hospitals such as the number of hand washing sinks and their position, and type of taps are also need to be inspected. Hand washing protocols is low in many hospitals. C. difficile infection needs treatment only if it is symptomatic. Most of the people make full recovery and in rare cases the infection can be fatal. Infection control teams need to develop education programmes to improve compliance and regular auditing. It is everybody's business to participate to prevent and control C. difficile infection with in the health care system. The health care workers need to follow the hospital infection control policy.

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