Transcript So Your Patient has C-Diff Now What?

Kathryn Dvorak, BSN, RN, MSN Student
Alverno College
MSN 621
April 7, 2010
Case study
How does C-diff affect the
body?
Objectives
Age considerations?
What is C-diff?
Treatment
Forward
 Mr. B
 86 year old gentleman
 Hospitalized 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/
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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 Cdiff infection rate and effects.
 Learner will consider the various treatments for C-diff
to get Mr. B healthy again
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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.
image courtesy of http://images.wellcome.ac.uk/
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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
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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).
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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).
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 What symptoms might Mr. B present with? (click on Mr. B.
to see his symptoms)
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Mild to moderate diarrhea (may be bloody)
Lower abdominal cramping
Nausea
Fever
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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
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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)
Toxic
megacolon
Leukocytosis
Raised
creatinine
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Hypoalbuminemia
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Death
Relapse
 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 response
 Changes in cell-mediated immune reactions
 More susceptible to infections
 Altered immune systems cause lymphocytes to
become unresponsive
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(Porth, 2005)
Forward
Right!
Mr. B’s existing diagnosis
CKD continually
Hisofbody
is stressed to
stresses his body. The
begin
with.
continued
stress
leads to
increased susceptibility
to disease.
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Let’s review the
Generalized
Stress
It doesn’t.
Response again.
(click on the GSR)
Forward
 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)
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 Elderly have a higher severity of illness
 Existing comorbidities may contribute to this.
 Higher peak White Blood Cells (WBC)
 Often elevated WBC counts in blood
 May 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)
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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 toxins
 This causes inflammation of the colon
 Increase in the WBCs in the colon due to inflammation
 When severe this can cause the tissue to die
(www.webmd.com)
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What could happen as a result of the
inflamed colon?
Right!
Pseudomembranosis
Pseudomembranosis
colitis is caused by
the deadcolitis
tissues from
the toxins soughing
off
That’s correct!
Toxic
Very Megacolon
dilated or
expanded colon
Right again!
Inflammation of the
Peritonitis
abdominal cavity
and its lining
You got it!
Hole
Perforated
or leakcolon
in the
colon
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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
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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
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 What kind of isolation should Mr. B be in? (click on
the boxes to see if you are right)
Contact precautions
should be used whenever
there
is a risk
of coming
Contact
Precautions
into contact with Mr. B.’s
contaminated stool.
Is Mr. B. receiving
Chemotherapy
chemotherapy
Precautions
treatment?
Think again. C-diff is
spread by having
contact
Airborne
with
Precautions
the spores
from the bacteria. Are
they airborne?
Contents
Think about it. Are the
C-diff spores
Droplet Precautions
transmitted by
droplets?
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 But wait! Mr. B has an underlying diagnosis of CKD!
 Does the Flagyl dose need to be adjusted for this?
Flagyl is listed as
contraindicated in
patients with renal
No
disease. The dose
would need to be
adjusted.
That’s
Yesright!
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 Many patients have no further symptoms after
treatment
 Relapse occurs between 7-10 days
 Relapse 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 Rifampin
 Cholestyramine
 (Aas et.al., 2003)
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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 transplant
 NG tube 25 cc of liquefied stool
 25 cc 0.9% NS
 May then return home and resume normal activities and diet
 (Aas et, al. 2003).
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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.
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