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Bobbie
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Articles Written by Posters

Postby Bobbie » Sun Apr 02, 2006 2:00 am

CLOSTRIDIUM DIFFICLE (C. DIFFICLE/C. DIFF.)

By Bobbie S.

In l979, when our four-year-old son developed Clostridium difficle, few people, including doctors, knew about the disease. He was hospitalized in a coma, ill for weeks, and one of the first (and the youngest) patients treated with oral Vancocin. He had a reoccurrence eight years later. I had C. diff. twice in the 1990’s – once for four years.

C. diff. is a bacterial infection with pain, diarrhea, nausea, and fever. It is usually caused by antibiotics that wipe out the “good” bacteria in the GI tract and allow an overgrowth of the C. diff. bacterium. Chemotherapy, possibly anti-acid medications, and exposure to someone with C. diff. are other factors. It can spread rapidly in hospitals, nursing homes, and day care centers, particularly if hygiene is inadequate. If your roommate in a hospital or nursing home has C. diff., you will probably acquire it. Thorough hand washing by both patients and health care providers is one of the best preventatives, but even when health care facilities mandate this, sometimes personnel, including physicians, do not comply.

Treatments are limited. 80% recover with one or two rounds of Vancocin or Flagyl, but others suffer for months or years. C. diff. can be fatal or cause life-long health problems. The mortality rate was originally reported as 1-2.5%, but a few studies report it as high as 15%. C. diff. produces spores that are difficult to eradicate so another course of antibiotics often reactivates it.

Largely due to the widespread use of antibiotics, C. diff. is increasing rapidly. Chicago and Canada had recent outbreaks, and over 2,000 died in Quebec.

Because of the outbreaks and increased cases in young, otherwise healthy people, the media is now interested. Newspapers, including [i]KC Star, Washington Post, Philadelphia Inquirer, Boston Globe, Atlanta Journal & Constitution, Cleveland Plain Dealer,[/i] and papers in Chicago and Canada, have published articles. Prevention is publishing a story. Other publications, including the medical journals [i]JAMA[/i] and [i]The New England Journal of Medicine,[/i] have featured articles. Scotland and other areas of the UK include alerts in health bulletins. [i]The British Medical Journal [/i]is producing an on-line learning module to teach doctors how to diagnose, treat and prevent C. diff. Prominent television and radio shows have aired stories.

When Sam Porter’s wife had C. diff. in l999, he founded http://www.cdiffsupport.com. Three moderators and several other “regulars” answer questions. We are all volunteers and offer support but do not give medical advice. The site has a professional webmaster. We have 632 registered users and add two to six more each day. There is no fee to join. Posters are from the US, Canada, Australia, UK, S. Africa, and other countries. C. diff. authority Dr. Tom Borody and pharmacologist Dr. Kelly Karpa (whose young son had C. diff.), wrote articles for the site. Dr. Clifford McDonald of the CDC, the epidemiologist who tracks cases of C. diff. in the US, made this official statement:

"Authorities at the CDC estimate C. difficile cases have increased by more than 100% relative to rates just 5 years ago (i.e. rates have more than doubled). In addition, cases are no longer confined to elderly patients in hospitals and long term care facilities as C. diff is increasingly reported among healthy young persons living in the community, often resulting in severe disease. Much of this increase in disease incidence and severity appears due to the appearance of a new, more virulent epidemic strain of C. diff responsible for hospital outbreaks in the US, Canada, England, and, most recently, other parts of Europe. However, there may be other reasons for the changing character of this disease that are not yet fully understood. Federal public health authorities in the US, Canada, and Europe are all very concerned about the way this disease is changing and they are actively engaged in public health research to track disease trends, understand causes for the change, and develop and implement new control strategies."

A woman, who started a support group in the UK after her grandmother died of C. diff., said, “…I am trying with my local member of parliament to raise awareness. The Health Care Commission has now realized this is a major problem and has requested that all hospitals monitor cases, number of infected patients, number of deaths etc. . . . We had 43,000 infected cases in the UK in 2004 and this has been rising.”

Most states do not mandate reporting cases of C. diff. Several, including Ohio, Connecticut, and Pennsylvania, have some reporting regulations. Although Kansas requires that healthcare facilities report over 50 infectious diseases to the Kansas Department of Health and Environment, C. diff. is not included. Reportable status:

• Equals lower infection rates. This means a huge reduction in health care costs associated with C. diff. in the US -- an estimated 1.1 billion dollars each year;
• Allows epidemiologists to effectively step up research for new ways to combat the bacteria;
• Raises awareness for physicians who are uneducated about the "new face of C. diff." and thus actually contribute to the problem.

It will take cooperation and a massive JOINT effort between healthcare providers, health insurers, and legislators to work together to control this organism. Reportable status is the first step.

There are 186 confirmed human cases of bird flu worldwide, most directly linked to bird handlers. There are an estimated 3 million new cases of C. diff. in the US alone each year based on voluntary reporting (the actual number is probably double), and the most common cause is a frequently prescribed medication. C. diff. is already a “pandemic.” The next time you take an antibiotic, you could develop C. diff. or perhaps your young son or daughter will be the victim.


Attachments: Articles by Dr.Tom Borody (Sydney, Australia), Dr. L. Clifford McDonald (CDC), and Dr. Kelly Karpa (PhD, RPh, Hershey, PA)


C. diff. Support Site Administrator/Co-Moderator Lauren D. &. Co-Moderator Allison M. contributed research and suggestions, and Dr. McDonald and Dr. Karpa provided statistics. Dr. Borody contributes to the support site frequently. Dr. Mark Allen (KC, MO) controlled my C. diff. with his innovative “broth” procedure.



03-31-06
Last edited by Bobbie on Thu Jul 31, 2014 2:23 am, edited 3 times in total.
Reason: updating

Bobbie
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Posts: 12140
Joined: Sat Aug 06, 2005 8:00 pm

Clostridium Difficle Infection

Postby Bobbie » Sun Apr 02, 2006 2:06 am

Posted: Fri Jan 13, 2006 6:07 pm by RN092504

One of our frequent contributors, RN092504, wrote a paper during her studies. Although she is a nurse, she is not submitting this as someone in the medical profession but as a C. diff. sufferer. She is NOT offering medical advice but is reporting her investigation of the disease and what happend to her personally because of it. Thanks, RN for an excellent synopsis.

Clostridium Difficile Infection:
An emerging epidemic
By RN092504
*** College
Women’s Health Nursing

C.diff facts

 Discovered in the 1970s to cause infection in humans
 Transmission primarily in healthcare setting, acquiring it from the community is rare
 Historically low rate of severe infection (3%) until recently
 Increase to 26% infection rate in patients discharged in 2001(U.S.)
 Recent outbreak in Quebec with mortality of 17%
 Estimated that $3,600 more per individual case is used to treat the infection today
 Estimated that the cost may exceed one billion dollars annually in the U.S.
 Not specifically addressed in Healthy People 2010

The New Strain
 Recently identified in cases in the U.S. and believed to cause the epidemic last year in Canada
 Found within the UPMC Health-system
 Known as B1/NAP1, it is more virulent and resistant to certain antibiotics (fluoroquinolones)
 Produces more toxins that causes more severe symptoms
 Affecting populations previously thought as low risk, mainly younger, healthier patients with minimal health care exposure
 Associated with 15-20% relapse rate and is more challenging to treat

Mechanisms of Infection
 Gram positive, anaerobic, spore-forming bacillus
 Naturally occurs in 1.5-3% of population
 Found in 20-40% of hospitalized patients
 Spores can live outside the human body, on inanimate objects for up to 40 days.
 Spores in the environment only destroyed with bleach

Mechanisms of Infection
 Spores enter the mouth via contact of hands or other items with the contaminated environment
 Stomach acid does not destroy all spores
 Spores settle in large intestine
 Normal gut flora can keep growth of c.diff in check
 When normal gut flora is destroyed by antibiotics, the c.diff bacteria flourishes and causes infection via production of toxins


Symptoms
 Incessant watery-diarrhea, unresponsive to treatment with anti-diarrheals
 Up to and beyond 20 stools per day
 Severe abdominal pain and cramping
 High fever may or may not be present
 Poor appetite
 Chronic infection and relapses can lead to weight loss, fatigue, muscle aches

Diagnosis
 Standard stool tests used today can detect Toxins A & B
 New strain may produce toxins that tests cannot detect
 Colonoscopy can reveal inflamed mucosa as well as plaques found in psudomembranous colitis, a severe complication

Treatment
 Flagyl is considered first-line medication, is cheaper, but has side effects like nausea and vomiting. Some patients cannot tolerate Flagyl
 Flagyl may not be as effective against the new strain
 Vancomycin has been used since 1979
 Oral Vancomycin is only form effective, since it is poorly absorbed in the gut
 Oral Vancomycin is extremely expensive, up to $1,400 per two week supply
 Oral Vancomycin can be used long-term, sometimes years, without toxicity seen with IV Vancomycin
 Oral Vancomycin is generally well tolerated with few side effects

Treatment
 Severe symptoms of c.diff can lead to hospitalization to manage pain, dehydration and electrolyte loss
 In cases of extreme infection that causes toxic megacolon, colectomy has been required
 A technique of fecal transplantation has been shown to ‘cure’ chronic c.diff infection in some individuals.
 Studies using IV Immunogammaglobulin, milk with antibodies to c.diff (MucoMilk) and a vaccine for c.diff are currently being conducted, some within the UPMC Health-system in Pittsburgh.
 New studies have indicated that new treatment modalities need to be developed.

Women and C.diff infection
 Women of all ages, health status, ethnicity and economic background can be affected
 Older women are more at risk due to increased contact with healthcare environment, and comorbidities associated with aging
 Younger women are at risk due to surgeries associated with maturing, such as wisdom teeth removal in their 20s.
 Women are frequently prescribed antibiotics for UTIs and other infections, often without culture for sensitivity
 Women have increased contact with healthcare, during childbirth, minor surgery, caring for sick family members
 Healthcare personnel are predominantly female

Global Epidemic
 In the U.S., cases have been found from coast to coast, New England to Oregon
 Also found in Australia, where new treatments have been developed
 Many studies have been completed on this infection in Europe, including Germany and Great Britain
 Increasing ‘globalization’ has led to patients being infected in the U.S. and Canada, and then traveling to other countries, such as South Africa

Impact of Infection
 Individual: symptoms can devastate entire lifestyle. Frequent trips to the bathroom can lead to patient secluding themselves at home. Fatigue and pain can interfere with completing tasks associated with motherhood, being a wife, and keeping employment
 Families suffer due to loss of function of key member, and the cost of medications, hospitalization and other treatments
 Communities are at risk due to spreading of new strain
 Society is affected through the amount of money needed to combat this infection, the use of healthcare resources, and possible fear of infection from using healthcare.

Strategies to combat infection
 Education of healthcare personnel and the public in the importance, signs and symptoms and ways to decrease contracting the infection
 Increasing identification and reporting of infection by nurses can help patients receive prompt and correct treatment, as well as tracking trends in the U.S.
 Increased compliance with strict infection control can decrease the rate of transmission in hospitals.

Specific Nursing Measures
 Always wash your hands before and after patient contact with soap and water, alcohol-based gels and foams are not effective against c.diff
 Always wear provided protective equipment whenever contact occurs with patient or environment, including gowns and gloves, and if you’re just going in the room to check an IV pump
 Keep patient in strict isolation, devote commonly used equipment to use by that patient only, i.e. stethoscopes, bp cuffs, thermometers
 A 1:10 dilution of bleach and water is the only cleaner known to kill spores, and should be used to clean the room and shared equipment (i.e. stretchers)
 Monitor for inappropriate use of antibiotics, question orders



My Personal Experience
 Worked in ICU since March 2004
 Diagnosed in July 2005 while being treated with multiple antibiotics for otitis media (Augmentin, Avelox)
 Two hospitalizations, three relapses
 Lost 30 pounds, led to development of fibromyalgia
 Through this project I have learned how prevalent this infection is becoming, and how women are uniquely affected
 I have learned more about infection control in hospitals, and how all members of a healthcare team have to work together to combat this infection
 I have made many friends who are helping me through this on http://www.cdiffsupport.com


References
 Aspisarnthanarak, A., Khoury, H., Reinus, W. R., Crippen, J. S., & Mundy, L. M. (2002). Severe clostridium difficile colitis: The role of intracolonic vancomycin? The American Journal of Medicine, 112(4), 328-329. Retrieved December 11, 2005, from Elsevier Science Direct via HSLS: http://www.hsls.pitt.edu
 Bartlett, J. G. (2002). Antibiotic-associated diarrhea. The New England Journal of Medicine, 346, 334-339. Retrieved December 11, 2005, from Health Sciences Library System: http://www.hsls.pitt.edu
 Bartlett, J. G. (2005, November 21). Highlights of the Infectious Diseases Society of America 43rd Annual Meeting (2nd ed., Vol. 7). Message posted to Medscape: http://www.medscape.com
 Borody, T. (2002). Infection with Clostridium Difficile. In Approach to Patients with Chronic C. Difficile Infection. Retrieved October 12, 2005, from Clostridium Support Group/Foundation: http://www.cdiffsupport.com/members/drbappch.htm
 Boylard, E. A., Tablan, O. C., Williams, W. W., Pearson, M. L., Shapiro, C. N., & Deitchman, S. D.. Guideling for infection control in health care personnel, 1998. Retrieved December 13, 2005, from CDC: http://www.cdc.gov/ncidod/dhqp/pdf/guid ... trol98.pdf
 Centers for Disease Control. (2005, July). Information about a new strain of clostridium difficile. In FAQs. Retrieved December 12, 2005, from CDC: http://www.cdc.gov/ncidod/dhqp/id_cdiff ... train.html
 Centers for Disease Control.. Clostridium Difficile causing severe diarrhea in low-risk patients. Morbidity and Mortality Weekly Report: CDC Surveillance Summary 2005, 54(6), 1201-1205. Retrieved December 11, 2005, from Medscape: http://medscape.com
 Fabregas, L. (2005, October 29). 'Superbug' infecting area patients. Pittsburgh Tribune-Review.
 Lem, S. (2005, September 26). Deadly Bug may Spread. The Toronto Sun.
 Levine, D. P. (in press). Vancomycin: A history. Clinical Infectious Disease, 42(1). Retrieved December 11, 2005, from Health Sciences Library System: http://www.hsls.pitt.edu
 McDonald, L. C., Killgore, G. E., Thompson, A., Owens, R. C., Kazakova, S. V., Sambol, S. P., Johnson, S., & Gerding, D. N. (2005). An Epidemic, Toxin Gene-Variant Strain of Clostridium difficile. The New England Journal of Medicine, 353(23), 2433-2441. Retrieved December 11, 2005, from Health Sciences Library System: http://www.hsls.pitt.edu
 Muto, C. A., Pokrywa, M., & Shutt, K.. A large outbreak of Clostridium difficile-associated disease with an unexpected proportion of deaths and colectomies at a teaching hospital following increased fluoroquinolone use. Infection Control Hospital Epidemiology, 26, 273-280. Retrieved December 11, 2005, from Health Sciences Library System: http://www.hsls.pitt.edu
 The Original Clostridium Difficile Support Group. (2005).. Messages posted to http://www.cdiffsupport.com
 Pepin, J., Saheb, N., Coulombe, M., Alary, M., Carrlueau, M., Authier, S., Leblanc, M., Ruiard, G., Bettez, M., Primeau, V., Nguyen, M., Jacob, C., & Lanthier, L. (2005). Emergence of floroquinolone as the predominant risk factor for Clostridium difficile-associated diarrhea: A cohort study during an epidemic in Quebec. Clinical Infectious Disease, 41(6), 1254-1260. Retrieved December 11, 2005, from Health Sciences Library System: http://www.hsls.pitt.edu
 Pepin, J., Valiquette, L., & Cossette, B. (2005). Mortality attributable to nosocomial Clostridium difficile-associated disease during an epidemic caused by a hypervirulent strain in Quebec. Canadian Medical Association Journal, 173. Retrieved December 11, 2005, from Health Sciences Library System: http://www.hsls.pitt.edu
 Pothoulakis, C. (2001, Fall). Clostridium Difficile Infection. In Participate. Retrieved October 12, 2005, from http://www.aboutibs.org/Publications/CDifficile.html
 Siemann, M., Koch-Dorfler, M., & Rabenhorst, G. (2000). Clostridium difficile-associated diseases. The Clinical Course of 18 fatal cases. Intensive Care Medicine, 26(4), 416-421. Retrieved December 11, 2005, from Health Sciences Library System: http://www.hsls.pitt.edu
 Stein, R. (2005, December 2). Deadly Hospital Germ is Spreading in U.S. The Washington Post, p. A08.
 Stobbe, M. (2005, December 2). A dangerous bacterial illness appears to spread, US reports. The Boston Globe.

Bobbie
Administrator
Posts: 12140
Joined: Sat Aug 06, 2005 8:00 pm

ONE TOUGH BUG

Postby Bobbie » Sat Feb 03, 2007 12:26 pm

ONE TOUGH BUG by Christina S.

After 17 months of being near death (or at least feeling like it!), 10 times, I believe I have finally won one of the biggest battles of my 36 years of life so far. That battle was with the nasty, sometimes fatal bug, Clostridium difficile, a.k.a. C-diff.

I am cured, although there is no official cure for this disease to date. For now, what us fellow c-differs call "The Beast", is asleep. No cure means that, at 36, if I take an antibiotic again I will be at high risk for a recurrence of c-diff. In short, “The Beast” may awaken. There is a chance, however, that it may never come back again but the risk is a pretty scary thought considering I have a long life (hopefully) ahead of me.

Clostridium difficile is a gram-positive spore forming anaerobic bacteria that resides in the colon and intestines of those unfortunate enough to have it inside of them. Only a small percentage of people naturally carry this bacterium in their normal gut flora. The rest have been unfortunate to have somehow ingested a spore via hand to mouth, most likely by touching an infected surface. These spores then need a "trigger" to set off an actual clinical infection. Antibiotics are the culprit. By taking an antibiotic, not only does the bad bacterium get wiped out, but also the good, which would help to keep C-diff in check. Since C-diff is resistant to antibiotics, the bacteria then flourish and grow out of control colonizing the intestinal tract producing lethal toxins and causing clinical disease which results in severe sickness.

The symptoms of C-diff can range anywhere from mild to life-threatening, and include, but are not limited to: stomach cramps; abdominal pain; elevated white blood cell count; extreme nausea; and bloody, mucous-filled diarrhea. Some severe cases may have 30 or more bouts of diarrhea per day. This can also lead to Pseudomembraneous Colitis, the worst form of C-diff, which is characterized by yellow or off white plaques in the colon that are detected through either a colonoscopy or sigmoidoscopy. It can also rarely cause toxic mega colon, which can be fatal, characterized by a severely dilated colon, abdominal distention, fever, abdominal pain and sometimes shock.

Ironically, C-diff is presently treated with antibiotics, usually Flagyl and/or Vancomycin. Non-antibiotic treatments are soon to come as they are currently in clinical trials.

My C-diff infection was very resilient having survived two rounds of Flagyl and so many rounds of Vancomycin, I lost track. I was on and off the Vancomycin for a year. I also tried many probiotics to try to re-populate my gut with good flora, but these proved ineffective for me. Probiotics are dietary supplements containing potentially beneficial bacteria and yeast.
A stool transfer was attempted at a Minnesota clinic which has been done as a last resort when all else fails. A donor stool, taken from a carefully screened family member, is injected into the stomach by means of a nasogastric tube in hopes that the good bacteria will overcome the C-diff infection and cause it to go into remission. Supposedly, the cure rate for this procedure is 97%. This procedure failed as well, and I became part of the 3% failure group. At this point, I was very discouraged and losing hope that my nightmare would ever end.

I then moved on down my list of treatment options, which was now almost depleted. I carefully made my choice for the next plan of attack. My Doctor ordered 3 rounds of IVIG (IV immuglobin) to be spaced three weeks apart. The theory behind this was to bide time by giving my immune system extra antibodies to hold off the C-diff long enough so that my body might naturally replenish my good bacteria. It was to be rough for me for weeks to come. I was taken off the Vancomycin immediately following the first IVIG and relapsed 3 times while still testing positive during this time period.

Eventually, with patience (what was left) and lots of encouragement, my system began to respond over time. The diarrhea finally stopped and my other symptoms gradually began to improve. Something finally clicked and the battle was won!!

With continued support and love from my family and friends, the constant help from the most intelligent and compassionate Doctor, who never stopped believing and re-assuring me that I would beat it - - and a courage and determination I never knew I had, I have survived one of the most challenging epidemics facing the health care system today.
As for me, I am heading back to college in January to hopefully one day pursue my new passion for medical research. I am also enjoying catching up on spending time with my husband and children. These are the reasons why I fought so hard.

For those still suffering from recurrent C-diff, it eventually really does go away.


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