So Your Patient has C-Diff Now What?

1. So Your Patient has C-DiffNow What? Kathryn Dvorak, BSN, RN, MSN Student Alverno College MSN 621 April 7, 2010

2. Contents – select a choice or hit forward Treatment Case study How does C-diff affect the body? Objectives Age considerations? What is C-diff? Forward

3. Case Study • Mr. B • 86 year old gentleman • Hospitalized for pneumonia • Treated with Levaquin • Existing diagnosis of Chronic Kidney Disease (CKD) • Developed Clostridium-difficile (C-diff) infection Click on Mr. B’s name throughout the tutorial to return to this page then on the return button to return to the tutorial • Image courtesy of http://images.wellcome.ac.uk/ Return

4. Objectives • Learner will be able to identify what C-diff infection is and how Mr. B presented with this infection. • Learner will gain an understanding of how the C-diff infection affects Mr. B’s body (pathophysiology). • Learner will explore if Mr. B’s age has an effect on C-diff infection rate and effects. • Learner will consider the various treatments for C-diff to get Mr. B healthy again

5. What could have caused Mr. B to develop C-diff infection? (click on the pills to find out) image courtesy of http://images.wellcome.ac.uk/ Antibiotics not only work against the bacteria causing his pneumonia, they also affect other bacteria within the body. Some bacteria is helpful. The colon contains normal protective bacterial flora . By killing the good bacteria off, the disease-causing bacteria can overgrow.

6. What is C-diff infection? A brief review. • C-diff is considered a nosocomialinfection. It is spread by spores in the stool that can live on surfaces within patient rooms for months. • Cleaning with bleach is the only way to completely remove these spores. • Hand washing! Hand sanitizers are not effective. • C-diff is spread by the oral-fecal route. This means that if the patient touches a surface contaminated by C-diff spores and then touches the mucous membranes of their mouth they have potentially infected themselves. • Hitt, 2010

7. What is C-diff infection? A brief review. • A gram-positive, spore forming bacillus • Is part of the normal intestinal flora in 1-3% of people • Despite the decline in the rate of C-diff associated diarrhea it remains one of the most common nosocomial infections. (Gouliouris, Forsyth, Brown, 2009).

8. What is C-diff infection? A brief review. • NosocomialC-diff infection rate has surpassed Staphylcoccusaureus (MRSA) infections. • Out of 28 community hospitals participating in the Duke Infection Control Outreach Network, January 2008 – December 2009: NosocomialC-diff infection occurred in 847 cases. MRSA infection rate was 680. • (Hitt, 2010).

9. How does C-diff affect the body?Pathophysiology • What symptoms might Mr. B present with? (click on Mr. B. to see his symptoms) • Mild to moderate diarrhea (may be bloody) • Lower abdominal cramping • Nausea • Fever

10. How does C-diff affect the body?Pathophysiology • C-diff toxins damage the intestinal lining or mucosa. This can cause hemorrhage, inflammation, and necrosis. • It can lead to a life-threatening condition, Pseudomembranous colitis (click for review on this condition) • Image used with permission from www.gihealth.com

11. Pathophysiology • Infection by C-diff has many different effects. Did you know all of these can be caused by this infection? • (mouse over for definitions) Leukocytosis Toxic megacolon Death Raised creatinine Hypo-albuminemia Relapse

12. Age Considerations? • Because Mr. B is elderly, he has a decreased ability to adapt to environmental stresses. • Generalized Stress Response can weaken his body’s defenses (click for a review of the GSR) • There is a decline in his immune response • Changes in cell-mediated immune reactions • More susceptible to infections • Altered immune systems cause lymphocytes to become unresponsive (Porth, 2005)

13. How would having an existing diagnosis of CKD change in his stress response affect Mr. B’s ability to fight his C-diff infection? Right! Mr. B’s existing diagnosis of CKD continually stresses his body. The continued stress leads to increased susceptibility to disease. His body is stressed to begin with. Let’s review the Generalized Stress Response again. (click on the GSR) It doesn’t.

14. Age Considerations • While not a lot of information is available on differences in how C-diff affects the elderly • The 30 day mortality rate for elderly with C-diff is 68% higher than the younger age groups. • (Zilberg, Shorr, Micek, Doherty, Kollef, 2009). • In Pennsylvania the rate of patients over age 65 hospitalized for C-diff infections was 19.3 cases per 1000. • (Reed, Edris, Eid, Molitoris, 2009)

15. Age Considerations • Elderly have a higher severity of illness • Existing comorbidities may contribute to this. • Higher peak White Blood Cells (WBC) • Often elevated WBC counts in blood • May also have elevated WBC counts in stool • Higher risk for leukocytosis • (Zillberg et.al, 2009). • The elderly tend to have a decreased thirst mechanism. This can contribute to dehydration, especially during illness • (Porth, 2005)

16. Age & Inflammation • C-diff infection causes inflammation, however, it is not known if a pre-existing inflammatory condition predisposes a person to C-diff infection • C-diff bacteria in its infectious state releases toxins • This causes inflammation of the colon • Increase in the WBCs in the colon due to inflammation • When severe this can cause the tissue to die (www.webmd.com)

17. What could happen as a result of the inflamed colon? Right! Pseudomembranosis colitis is caused by the dead tissues from the toxins soughing off Pseudomembranosis colitis That’s correct! Very dilated or expanded colon Toxic Megacolon Right again! Inflammation of the abdominal cavity and its lining Peritonitis You got it! Hole or leak in the colon Perforated colon

18. Age & Inflammation • Diabetes or end-stage renal disease have been related tin increased susceptibility to nosocomialC-diff infection (Hitt, 2010) • Inflammatory bowel disease (IBS) may predispose an individual to C-diff infection (click to learn about IBS) • (Morris & Lopez, 2009) • This could indicate a potential genetic connection

19. Treatment • How is Mr. B being treated for his C-diff infection? (click on Mr. B to find out) • Discontinue antibiotic treatment, as directed by MD • Metronidazole (Flagyl) • Probiotics • Isolation

20. Isolation!!! • What kind of isolation should Mr. B be in? (click on the boxes to see if you are right) Is Mr. B. receiving chemotherapy treatment? Chemotherapy Precautions Contact precautions should be used whenever there is a risk of coming into contact with Mr. B.’s contaminated stool. Contact Precautions Think again. C-diff is spread by having contact with the spores from the bacteria. Are they airborne? Airborne Precautions Think about it. Are the C-diff spores transmitted by droplets? Droplet Precautions

21. But wait! Mr. B has an underlying diagnosis of CKD! • Does the Flagyl dose need to be adjusted for this? That’s right! Yes Flagyl is listed as contraindicated in patients with renal disease. The dose would need to be adjusted. No

22. Treatment • Many patients have no further symptoms after treatment • Relapse occurs between 7-10 days • Relapse rather than re-infection • Each subsequent relapse results in a higher chance of another relapse • Treated with another course of Flagyl or Vancomycin • Combo Flagyl or Vancomycin with Rifampin • Cholestyramine • (Aas et.al., 2003)

23. Treatment • If Mr. B’s infection kept recurring despite repeated courses of antibiotic treatment, Fecal transplant could be an option. • Donated stool from healthy individual • Omeprazoleeve before and day of transplant • NG tube 25 cc of liquefied stool • 25 cc 0.9% NS • May then return home and resume normal activities and diet • (Aas et, al. 2003).

24. Thanks to you, Mr. B is healthy again!

25. Additional Resources • If you enjoyed this tutorial and wish to see more like it please visit: • http://faculty.alverno.edu/bowneps/index.html

26. References • Aas, J., Gessert, C.E., Bakken, J.S. (2003). Recurrent Clostridium-difficile colitis: Case series involving 18 patients treated with donor stool administered via a nasogastric tube. CID, 36, 580-585. • Anthony, D.M., Reynolds, T., Patton, J., Rafter, L. (2009). Serum albumin in risk assessment for Clostridium-difficile. Journal of Hospital Infections, 71 (4), 378-379. • Gouliouris, T., Forsyth, D.R., Brown, N.M. (2009). Clostridium-difficile associated diarrhoea [sic](CDAD): New and continuous issues. Age & Ageing, 38, 497-500. • Hitt, E. (2010). C Difficile. surpasses MRSA as the leading cause of nosocomial infections in community hospitals. Medscape Medical News. Retrieved April 1, 2010, from http://www.medscape.com/viewarticle/719053. • Morris, J.D., Lopez, F.A. (2009). Clostridium-difficile: An old player with a new hand in the game. Emergency Medicine, 41(11), 12. • Pagana, K.D., Pagana, T.J. (2002). Mosby’s manual of diagnostic and laboratory tests. (2nd ed.). St. Louis, MO: Mosby, Inc. • Porth, C.M. (2005). Pathophysiology: Concepts of altered health states. (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins • Reed , J. III, Edris, B., Eid, S., Molitoris, A. (2009). Clostridium difficile: The new epidemic. Internet Journal of Infectious Diseases. 7(1), 9. • www.healthline.com. • www.webmd.com • Zillberg, M.D., Shorr, A.F., Micek, S.T., Doherty, J.A., Kollef, M.H. (2009). Clostridium-difficile associated disease and mortality among the elderly critically ill. Critical Care Medicine, 37(9), 2583-2589.