Recently, the spread of Clostridium difficile infection among hospitalized patients in the United States has increased significantly. As a result, patients and other populations are at risk of developing diseases caused by C. difficile, including diarrhea and colitis. The problem is exacerbated by the fact that the current strains of C. difficile can be resistant to treatment in many cases, an aspect that negatively affects the management of diseases caused by this infection (Ofosu, 2016). This situation has led to worsening epidemic levels in the United States related to the spread of C. difficile and to increased mortality rates. The purpose of this paper is to describe the problem in detail while focusing on symptoms and appropriate measures; identify the population at risk, laboratory tests, and treatment options; and discuss nursing interventions, medications, and outside impacts.
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Description of the Problem
C. difficile is a Gram-positive, anaerobic, spore-forming bacterium. American scientists first identified it in healthy infants’ fecal material in 1935. They found that the bacterium is typical of the gut flora of some people; it became known as Bacillus difficilis because this particular bacterial organism was difficult to isolate. In 1978, researchers found that the bacterium is pathogenic, producing toxins that caused antibiotic-associated diarrhea in some patients in the 1970s (Kenneley, 2014). The name of the bacterium was changed to Clostridium difficile, and today, it is viewed as the cause of C. difficile infection or C. difficile-associated diarrhea.
C. difficile causes diarrhea in more than 25% of hospital cases that are associated with surgery and prolonged hospitalization, and today, it is a factor in more complications than previously. The population at risk includes hospitalized male patients older than 65 years who take antibiotics. Mortality rates among these patients are high (Goudarzi, Seyedjavadi, Goudarzi, Mehdizadeh Aghdam, & Nazeri, 2014). However, women and children are also considered to be at risk since C. difficile has become more resistant, and it causes more fatality cases nowadays.
Signs and Symptoms
The first signs of C. difficile infection can be observed during or following antibiotic therapy. Signs and symptoms include watery diarrhea and nausea. The spores of this bacterium are transmitted using the oral-fecal route and are resistant to antibiotics. These spores cannot live in an open environment, but they are able to grow in the stomach. Symptoms occur when bacterial growth causes the production of such toxins as an enterotoxin and a cytotoxin, among others, that damage the intestinal crypts (Leffler & Lamont, 2015). The active production of these toxins leads to inflammation and diarrhea symptoms. As the disease progresses, the symptoms worsen, and it is possible to observe an increased white blood cell count and the development of pseudomembranous colitis, which is characterized by watery diarrhea observed about 10–15 times a day, nausea, blood in the stool, abdominal tenderness, and fever (Goudarzi et al., 2014). Increasing inflammation can also lead to sepsis and shock. Surgery can be required to manage bowel perforation in this case.
In order to effectively manage C. difficile infection, it is important to isolate a patient who is showing the first symptoms of diarrhea if this infection is suspected. Additional laboratory tests are required to prove the diagnosis. Spores of C. difficile can be found on equipment in hospitals, on the hands of staff members, and in bathrooms. Therefore, it is necessary to use soap and sanitizers to reduce the number of spores on different objects. Precautionary measures also include the use of gloves and gowns by healthcare providers who work with patients in isolation from other individuals (Kenneley, 2014). It is also possible to use probiotics to decrease the risk of spreading the infection and to address the risks associated with using antibiotics.
Fecal samples are used to diagnose C. difficile infection. In order to isolate the bacterium, it is necessary to use cycloserine cefoxitin-fructose agar. The results of this test are known in 48–96 hours. The next step is a toxin assay, conducted with the help of the cell culture neutralization assay and immunoassay tests (EIA and GDH). These tests are highly sensitive and specific; while they demonstrate the presence and growth of C. difficile, they require some time and resources to be performed. It is also possible to use nucleic acid amplification tests effective in determining specific toxin genes (Smits, Lyras, Lacy, Wilcox, & Kuijper, 2016). Blood tests are important to demonstrate the severity of the disease. When WBC < 15,000 cells/mm3 and SCr < 1.5, mild diarrhea is diagnosed. Severe diarrhea is diagnosed with WBC > 15,000 cells/mm3 and SCr > 1.5 in relation to the baseline (Leffler & Lamont, 2015). An additional step includes endoscopy when laboratory tests do not support the assumed diagnosis.
Population at Risk
Hospitalized patients are at the highest risk of developing C. difficile infection. This population specifically includes persons who are older than 65 years, predominately males, and individuals who stay in a hospital for a long period of time. A more important factor is that persons at risk of developing the disease use antibiotics. These patients can also be diagnosed with bowel disease, kidney disease, or immunodeficiency, or they can be receiving chemotherapy (Kenneley, 2014). The reason for identifying this population is that antibiotic treatment provokes the growth of C. difficile along with the related production of toxins. The use of cephalosporins and clindamycin is most challenging in this case. In addition, hospitalizations and contact with patients and healthcare providers in hospitals are also risk factors for the progress of C. difficile infection when hygiene principles are neglected since the disease is spread through the oral-fecal route (Goudarzi et al., 2014). Additionally, as already mentioned, children and women have been recently added to the category of patients who are at risk of C. difficile infection.
In order to manage C. difficile infection, healthcare providers will first stop any current antibiotic treatment. When mild‑to‑moderate or severe C. difficile infection is observed, treatment includes medicines as well as hospitalized patients. The use of metronidazole, vancomycin, or fidaxomicin is prescribed, depending on disease severity (Kenneley, 2014). It is important to guarantee hydration and regular monitoring of a patient’s state (Leffler & Lamont, 2015). Risks of reinfection are high, and in such cases, vancomycin and fidaxomicin are mainly used. Complicated cases can require surgery, and it is used when fulminant colitis is diagnosed, or when a patient does not respond to antibiotic treatment.
In order to prevent the development of the disease and help patients cope with C. difficile infection, nurses should teach those patients who are at risk of infection how to focus on hygiene and to report any changes in their stool. Nurses are also responsible for the availability of clean hygiene tools and products. Patients who show the first symptoms and signs of C. difficile infection should be educated by nurses not to leave their rooms. Nurses are also responsible for organizing a private room for a patient with C. difficile infection or one suspected to have this infection (Kenneley, 2014). It is also important to monitor changes in a patient’s state and educate the individual regarding the necessity of reporting abdominal tenderness, skin irritation, reactions to medicines, and other signs.
To prevent the growth of C. difficile, medical organizations recommend using metronidazole and vancomycin as well as fidaxomicin. Oral metronidazole (500 mg three times per day) is used to address mild‑to‑moderate C. difficile infection because of minimal adverse effects and appropriate levels of absorption. In severe cases, it is appropriate to use oral vancomycin (500 mg four times per day; Goudarzi et al., 2014). Fidaxomicin (200 mg twice per day) is a more advanced type of antibiotic that was developed to address this infection. Adverse effects usually include headaches, nausea, taste disturbance, and peripheral neuropathy as a severe effect (Ofosu, 2016). When these symptoms are observed, nurses should inform physicians and choose another antibiotic.
The transmission of C. difficile infection is possible because of certain outside factors. These include the uncontrolled overuse of antibiotics, such as ampicillin, clindamycin, amoxicillin, and fluoroquinolones, among others. External factors also include ignoring hygienic principles while using proton pump inhibitors and other equipment in healthcare facilities that have many patients who have had gastrointestinal surgery or patients who need to stay in a hospital over a long period of time (Smits et al., 2016). Longer stays in hospitals and nursing homes are directly associated with the risk of developing C. difficile infection. If norms of hygiene and sanitation are not followed in a facility, and healthcare providers do not use gloves, the risk of spreading C. difficile infection increases.
Importance of the Problem
The current spread of C. difficile infection in hospitals in the United States and other countries is a problem that requires an effective solution because the resistance of C. difficile to antibiotics is increasing, and more cases are being classified as severe and leading to complications or patients’ deaths. Therefore, this problem needs to be addressed. However, it is also important to note that an epidemic of C. difficile infection in hospitals can be prevented by following certain precautionary measures and focusing on hygiene standards (Kenneley, 2014). The spread of C. difficile infection demonstrates the necessity of prescribing adequate antibiotic therapies with probiotics and following hygiene standards in hospitals as simple steps to prevent the rise of C. difficile infection in healthcare facilities.
The paper has presented an analysis of C. difficile infection, providing a description of the disease and a discussion of preventive measures, treatment, and appropriate medications. It is important to note that C. difficile infection is a common problem for healthcare facilities. Thus, the possible complications of the resulting diarrhea are causing researchers and practitioners to pay more attention to identifying effective measures to prevent any outbreak of an epidemic. It is possible to decrease the mortality rates associated with C. difficile infection with the help of providing nurses more information about signs of the disease and effective precautionary procedures, as well as interventions to apply in hospitals.
Goudarzi, M., Seyedjavadi, S. S., Goudarzi, H., Mehdizadeh Aghdam, E., & Nazeri, S. (2014). Clostridium difficile infection: Epidemiology, pathogenesis, risk factors, and therapeutic options. Scientifica, 2014, 1-9.
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Kenneley, I. L. (2014). Clostridium difficile infection is on the rise. The American Journal of Nursing, 114(3), 62-67.
Leffler, D. A., & Lamont, J. T. (2015). Clostridium difficile infection. New England Journal of Medicine, 372(16), 1539-1548.
Ofosu, A. (2016). Clostridium difficile infection: A review of current and emerging therapies. Annals of Gastroenterology: Quarterly Publication of the Hellenic Society of Gastroenterology, 29(2), 147-154.
Smits, W. K., Lyras, D., Lacy, D. B., Wilcox, M. H., & Kuijper, E. J. (2016). Clostridium difficile infection. Nature Reviews Disease Primers, 2, 1-20.