The worst of the nationwide Clostri-dium difficile epidemic is yet to come. The current, highly virulent NAP1/027 strain has reached all 50 states and Canada, with a total burden estimated at more than 500,000 annual cases.1

The economic burden associated with managing C. difficile-associated disease (CDAD) in Massachusetts hospitals over a two-year period was estimated at $51.2 million and associated with 55,380 inpatient days.2 A retrospective review (n=3,692) identified a mean cost per stay for a first hospitalization with a primary CDAD diagnosis at $10,212. This was associated with a mean length of stay (LOS) of 6.4 days. For patients with a secondary CDAD diagnosis, the LOS was estimated at 15.7 days, most likely due to time spent in the intensive-care unit (ICU) and not likely related to CDAD management. The CDAD-related increased LOS in these patients was estimated to be an additional 2.95 days, with an additional cost of $13,675.

More recently, CDAD-associated costs were noted to be more than $7,000 per case, according to data from 439 cases evaluated by two statistical methods.3

Bacillus Background

C. difficile is a spore-forming, gram-positive, anaerobic bacillus that has become one of the most significant causes of hospitalization-associated diarrhea in adults.4 The number of infections occurring with the more virulent strain is disquieting. It is associated with a spectrum of illnesses, which include uncomplicated diarrhea presenting as mild, watery stools, life-threatening pseudomembranous colitis, and toxic megacolon, leading to sepsis and death.

CDAD might be an unrecognized and under-reported cause of death in the U.S.5 From 1999 to 2004, CDAD was reported as a cause of death for 24,642 people and an underlying cause of death for an additional 12,264 people.6 The median patient age was 82.

As an aside, CDAD is the older terminology for what is now being referred to as C. difficile infection (CDI).

CDI is predominantly seen as a nosocomial or long-term-care facility concern, although community-acquired infections have been reported.7 Risk factors include previous antimicrobial use, particularly with clindamycin, fluoroquinolones, cephalosporins, ampicillin, or ß-lactams. Other risk factors include use of immunosuppressants or chemotherapeutic agents, advanced age, surgery, exposure to gastric acid suppressants, host immunity, and serious underlying illnesses or comorbidities.8,9 Gastric acid suppressant use outside a healthcare facility might be a significant risk factor for outpatient CDI.

Prevention

Healthcare-facility-based CDI prevention strategies include discontinuing any suspected antibiotic, as this alone has been known to resolve CDI in up to 25% of patients. C. difficile spores are resistant to bactericidal effects of alcohol and most hospital disinfectants. Therefore, additional prevention measures should include:

• Meticulous and proper hand hygiene for healthcare workers, patients, and visitors;
• Utilizing soap and water and avoiding alcohol-based rubs that are not sporicidal;
• Environmental cleaning with sporicidal cleaning agents;
• Placing patients under contact isolation infection control procedures until resolution of the diarrhea; and
• Adopting antibiotic restriction policies to limit excessive antimicrobial use.

Two additional principles include not giving prophylactic antimicrobials for patients at high risk of developing CDI and not treating or attempting to decolonize asymptomatic C. difficile carriers. The Centers for Disease Control recently developed a patient-safety initiative to assist healthcare facilities in dealing with multidrug-resistant organisms (MDRO) and CDAD.10

Management

General management strategies for CDI patients include:

• Discontinuing all unnecessary antimicrobials or utilizing lower-risk agents when able;
• Monitoring volume status and electrolytes and appropriately replete when necessary;
• Avoiding anti-diarrheal agents, such as loperamide, atropine, or diphenoxylate, as these agents do not allow the toxin to be excreted and can worsen symptoms and lead to serious complications;
• Encouraging patient hand hygiene through use of soap and water;
• Possibly avoiding the use of lactose-containing foods;
• Possibly discontinuing proton pump inhibitors and other acid suppressants; and
• Administering specific anti-Clostridial antibiotics, if necessary, based on infection severity.