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Health See other Health Articles Title: Important Findings in C difficile Infection Editors' Recommendations C difficile: Guidelines to Diagnose, Treat, and Prevent How to Prevent C difficile Infection: A New Guide Dog Sniffs Out Deadly C. diff Infection Important Findings in C difficile Infection Standard teaching is that Clostridium difficile infection (CDI) is a hospital-acquired infection that reflects a failure of infection control, but it may be more closely related to antibiotic control. A recent report from the Centers for Disease Control and Prevention (CDC), based on an analysis of 10,342 cases of CDI in 111 hospitals and 310 nursing homes, showed that 75% of the patients were already colonized with C difficile at the time of admission.[1] Nearly all (94%) of these cases were "healthcare-associated," meaning that acquisition occurred during an outpatient visit, a nursing home stay, the current hospitalization, or a previous hospitalization. Only 25% of patients actually acquired the pathogen in the same hospital where clinical expression of CDI occurred. Clinical relevance. The CDC study suggests that infection control personnel and physicians need to be aware of this association, because this may require changes in infection control practice. The implication is that to prevent CDI, clinicians need to find ways to identify patients who are already colonized to protect them from obvious risks, and also to consider them to be potential sources of infection to others. This could substantially change infection control practice for prevention of CDI. Fidaxomicin Fidaxomicin is the second drug approved by the US Food and Drug Administration (FDA) for the treatment of CDI. The first was oral vancomycin, which was approved in 1978 on the basis of a 16-patient randomized controlled trial.[2] The fidaxomicin trials included approximately 1200 patients randomly assigned to receive fidaxomicin vs oral vancomycin.[3,4] Results showed similar initial response rates (88% vs 86%), but a significantly reduced rate of relapse in fidaxomicin recipients (15% vs 25%).[3] A subsequent trial showed that fidaxomicin was also superior to vancomycin in prevention of a second relapse in patients who had already experienced a relapse of CDI (36% vs 20%).[5] The presumed mechanism for reduced rates of relapse is a less pronounced alteration of the colonic microbiome with fidaxomicin,[6] which is presumed to be the ultimate control of C difficile toxin production. Clinical relevance. It appears that fidaxomicin is a good drug for CDI because it is FDA-approved; similar to oral vancomycin with respect to cure rates; and clearly superior in terms of "global cure" rates, which include initial responses without relapses. Nevertheless, the cost of fidaxomicin (which reflects the high cost of FDA trials) is intimidating. Does the Nose Know? It has long been claimed that nurses can identify patients with CDI by the odor in an infected patient's room or the odor of the stool, although this has not been verified in clinical trials.[7] Because dogs have an olfactory sense that is approximately 300 times that of humans, investigators in The Netherlands[8] trained a beagle to detect the odor of p-cresol (a phenolic compound that results from the fermentation of tyrosine), which is thought to be the source of the odor of C difficile. The dog was taught to sit if the specimen was positive. The beagle's performance in a trial was near perfect. Compared with results of clinical and laboratory studies for C difficile, the dog recognized positive cases in 30 of 30 instances of CDI and identified negative tests in 270 of 270 specimens from patients without CDI. In fact, the dog was even able to recognize a case by exposure to the patient's ward in 25 of 30 cases (83%) and correctly eliminated CDI by the ward walk-through in 265 of 270 negative cases. Clinical relevance. Although the original investigators suggest that dogs could be used in hospitals to "sniff out" CDI if precautions are taken to protect patients, it is unlikely that this method will be widely adopted. Surgical Treatment for CDI A new surgical procedure for CDI has been developed: diverting loop ileostomy with colonic vancomycin lavage. The surgical experience with CDI has previously consisted of colectomy in patients who are critically ill, often with toxic megacolon. Mortality rates are high, and surviving patients suffer the consequences of living without a colon. Surgeons at the University of Pittsburgh had extensive experience in the midst of a CDI epidemic and have subsequently reported a new surgical approach, consisting of a diverting ileostomy in place of colectomy. A retrospective comparison of 42 patients who underwent the new procedure with 42 who had previously had colectomy for refractory CDI showed mortality rates of 19% vs 50% favoring the new procedure.[9] Clinical relevance. It is hoped that diverting loop ileostomy procedure will replace colectomy as the standard surgical procedure for most patients with severe CDI who require surgery. n has become a relatively common method to manage the patient with multiple relapses of CDI. This technique was initially attempted in the early 1980s for CDI, with multiple reviews showing good results. Meta-analyses of these studies, including approximately 300 reported cases, generally showed cure rates of 85%-90% with minimal morbidity.[10] One of the problems with this strategy (besides the "yuck" factor) has been the anecdotal nature of the published reports. A controlled trial was finally conducted in The Netherlands to clearly substantiate the benefit of stool transplantation and silence the critics,[11] with results that were already clear to those who were using this treatment. More recently, the FDA decided that stool used in this fashion was a "drug," and required the massive paperwork that accompanies an application for an investigational new drug. However, they have subsequently repealed this requirement. Stool transplant cannot be considered new, because the procedure actually goes back to 1958. A variation of this procedure is the recent attempt to achieve the same goal by implanting not human stool, but cultured organisms that dominate the normal microbiome.[12] The product is called "RePOOPulate" and has been tested in 2 patients, with good results.[12] Clinical relevance. Stool transplants are highly effective, and physicians who see patients with multiple relapses need to be aware of local resources with expertise in this procedure. RePOOPulate is interesting and has nothing to do with probiotics, because it is composed of the dominant colonic bacteria that require special handling. This treatment will require substantial testing before it can become available in the marketplace. Poster Comment: Nearly all (94%) of these cases were "healthcare-associated," meaning that acquisition occurred during an outpatient visit, a nursing home stay, the current hospitalization, or a previous hospitalization. A good reason to maintain a state of good health so you avoid these infection sources. Post Comment Private Reply Ignore Thread Top • Page Up • Full Thread • Page Down • Bottom/Latest Begin Trace Mode for Comment # 1.
#1. To: Tatarewicz (#0)
On the forefront here of the C diff battle. Nurses CAN smell the infection, it is very distinctive. I start therapies frequently based on my sniffer. The fecal donor situation would be a lot easier if the donor would be covered. The donor costs can run $2000 to $6000 and most insurance does not cover. You have to make sure the donor does not pass any other diseases or parasites to the recipient that worsen the situation. Out of control C diff pretty much can cause the colon wall to rot and rupture leading to big surgery. I have big respect fot this organism. Much of the problem comes from over vigilent "clinical pathway" enforcement. If a patient rolls into the ER sick and someone even thinks pneumonia, the "Pneumonia Pathway" kicks in and antibiotics must be given with in 4 hours. This meets mandatory quality control measures and prevents a loss of hospital revenues for delivering substandard care. Hospitals are proud of %100 pathway compliance. Deviation from the pathway is punished. Meanwhile, the patient may later turn out to have only bronchitis or heart failure or asthma or emphysema. Pneumonia is NOT a clearcut diagnosis. Doctors disaggree all the time over infiltrates on chest xray. Pneumonia is easy for an ER doc to diagnose and gets someone who they can't figure out into the hospital to become another doctors problem. The end result is over use of broad spectrum antibiotics, and a deadly epidemic of C diff.
#2. To: octavia (#1)
X-ray the only way of detecting pneumonia? Perhaps you have an opinion on another medical matter. Had a massive bladder stone removed but during recovery bladder sprung a leak; infection developed beneath six-inch stapled area. During another week in hospital drainage stopped seemingly after I began drinking water one sip every five minutes. Infection was no longer visible on wound packing after a few days of cipro and clindamycin. Packing changed daily, then every second day. Now Family Doc wants alternate days free of packing. My question: is packing still necessary now that there is no drainage or infection? Packing necessary for upward healing? Tunnel ends appear to be shortening from original two and three inches from central hole. Urologist a few days ago was satisfied with progress; said don't make packing as deep as before. Meantime awaiting appointment for cystogram to check on possible fistula (which was theorized as cause for urine drainage through wound).
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