Kathryn Dvorak, BSN, RN, MSN Student

Alverno College

MSN 621

April 7, 2010

So Your Patient has C-DiffNow What?

Contents – select a choice or hit forward

Treatment

Objectives

What is C-diff?

How does C-diff affect the body?

Age considerations?

Case study

Forward

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Mr. B86 year old gentlemanHospitalized 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/

Case Study

Return

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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

Objectives

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image courtesy of http://images.wellcome.ac.uk/

What could have caused Mr. B to develop C-diff infection? (click on the pills to find out)

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.

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C-diff is considered a nosocomial infection. 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

What is C-diff infection? A brief review.

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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).

What is C-diff infection? A brief review.

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Nosocomial C-diff infection rate has surpassed Staphylcoccus aureus (MRSA) infections.

Out of 28 community hospitals participating in the Duke Infection Control Outreach Network, January 2008 – December 2009: Nosocomial C-diff infection occurred in 847 cases. MRSA infection rate was 680.

(Hitt, 2010).

What is C-diff infection? A brief review.

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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 NauseaFever

How does C-diff affect the body?Pathophysiology

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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

How does C-diff affect the body?Pathophysiology

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Infection by C-diff has many different effects. Did you know all of these can be caused by this infection?

(mouse over for definitions)

Pathophysiology

Leukocytosis

Raised creatinine

Toxic megacolon

Hypo-albuminemia

Death

Relapse

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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 responseChanges in cell-mediated immune reactionsMore susceptible to infections

Altered immune systems cause lymphocytes to become unresponsive (Porth, 2005)

Age Considerations?

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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.

Let’s review the Generalized Stress Response

again.(click on the GSR)

His body is stressed to begin

with.It doesn’t.

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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)

Age Considerations

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Elderly have a higher severity of illnessExisting comorbidities may contribute to this.

Higher peak White Blood Cells (WBC)Often elevated WBC counts in bloodMay 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)

Age Considerations

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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 toxinsThis causes inflammation of the colon

Increase in the WBCs in the colon due to inflammationWhen severe this can cause the tissue to die

(www.webmd.com)

Age & Inflammation

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What could happen as a result of the inflamed colon?

Right again!Inflammation of the abdominal cavity and its

lining

Right!Pseudomembrano

sis colitis is caused by the

dead tissues from the toxins

soughing off

That’s correct!Very dilated or expanded colon

You got it!Hole or leak in

the colon

Toxic Megacolon

Perforated colonPeritonitis

Pseudomembranosis colitis

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Diabetes or end-stage renal disease have been related tin increased susceptibility to nosocomial C-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

Age & Inflammation

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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

Treatment

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What kind of isolation should Mr. B be in? (click on the boxes to see if you are right)

Isolation!!!

Contact precautions should be used

whenever there is a risk of coming into

contact with Mr. B.’s contaminated stool.

Think again. C-diff is spread by having

contact with the spores from the

bacteria. Are they airborne?

Think about it. Are the C-diff spores transmitted by

droplets?

Is Mr. B. receiving chemotherapy

treatment?

Chemotherapy Precautions

Airborne Precautions

Droplet Precautions

Contact Precautions

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But wait! Mr. B has an underlying diagnosis of CKD!

Does the Flagyl dose need to be adjusted for this?

That’s right!

Flagyl is listed as

contraindicated in patients with renal disease.

The dose would need to be adjusted.

NoYes

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Many patients have no further symptoms after treatment

Relapse occurs between 7-10 daysRelapse 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 RifampinCholestyramine

(Aas et.al., 2003)

Treatment

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If Mr. B’s infection kept recurring despite repeated courses of antibiotic treatment, Fecal transplant could be an option.

Donated stool from healthy individual Omeprazole eve before and day of transplantNG tube 25 cc of liquefied stool 25 cc 0.9% NSMay then return home and resume normal activities

and diet

(Aas et, al. 2003).

Treatment

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Thanks to you, Mr. B is healthy again!

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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.

References