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Clostridium difficile: Trouble for adults and children

Snow, Michelle MSHR, MSPH, RN

doi: 10.1097/01.NURSE.0000399594.28533.35

Clostridium difficile

Michelle Snow is the president of Michelle Snow Enterprises in Kaysville, Utah.

CLOSTRIDIUM DIFFICILE infections (CDIs) aren't new. Historically, CDIs were diagnosed in older adults who were taking antibiotics, had gastrointestinal surgery or manipulation, were hospitalized for long periods, had a serious underlying illness, or were immunocompromised.1

What is new, however, is a recent study that shows the rate of hospital-acquired CDI in children almost doubled (from 7.24% to 12.80%) from 1997 through 2006.2 But in contrast to trends in adults, the researchers found no increasing trend in the severity of CDI in children.3

Other studies have identified a decrease in nosocomial CDIs and an increase in community-acquired CDIs in adults. More adult patients with CDIs hadn't previously received prescribed antibiotics, suggesting that C. difficile can now be found outside of the hospital setting.2–5

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Take a closer look

C. difficile is a Gram-positive anaerobic spore-forming, toxin-producing bacillus that commonly causes antibiotic-associated diarrhea. The major reservoirs are infected patients, both symptomatic and asymptomatic, and items or surfaces contaminated with feces. C. difficile is often transferred to patients via the hands of healthcare personnel who have direct contact with infected patients or who have touched a contaminated surface or item.1 Signs and symptoms of CDI include watery diarrhea, fever, anorexia, nausea, and abdominal pain. Untreated, CDIs may lead to pseudomembranous colitis, toxic megacolon, colonic perforation, sepsis, and, rarely, death.1

A CDI is diagnosed through history and physical assessment, stool cultures, and polymerase chain reaction (PCR) assays. Unfortunately, stool culture results may not be available for 48 to 96 hours. PCR assays can be run with a high degree of sensitivity within 1 to 2 hours. If stool specimens won't be processed or picked up by the lab within 2 hours, they must be refrigerated because the toxins rapidly deteriorate at room temperature.1

According to the CDC, 20% of CDIs resolve after discontinuation of the antibiotic that inadvertently created the bacterial imbalance. For the remaining 80%, antibiotic therapy is necessary. Children with moderate-to-severe illness or persistent diarrhea after the inducing antibiotics have been stopped should receive antimicrobial treatment.7 Oral vancomycin and metronidazole are most commonly used.8

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Unique risk for children

The increasing trend of CDIs in young children may be the result of a new hypervirulent strain of C. difficile that is resistant to quinolones. Hospitalized children with medical conditions such as inflammatory bowel disease and immunosuppression or conditions that require antibiotics are at a higher risk for CDI.3,6

Young children are also at an increased risk of contracting and spreading CDIs due to oral exploration of their environment, hand-to-mouth behaviors, limited experience with hand washing, and poor elimination hygiene. Diaper-changing stations may be another source of infection, especially if protective coverings aren't available and surfaces aren't sanitized after each use. Childcare centers are another reservoir for community-acquired CDIs. Toys, toileting, and changing facilities as well as caregivers' hands may all contribute to inadvertent CDI transmission.

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Reduce the risk

Some steps you can take to lower the risk of spreading CDIs in your facility include the following.

  • Move patients who need contact precautions into a single-patient room if possible. If not, consult with infection control personnel to assess the risks associated with having another patient in the room. Separating beds by 3 feet or more can help reduce sharing of items.9
  • Wear a gown and gloves for all interactions that may involve contact with the patient or possible contaminated areas in the room. Put them on when entering the patient's room and discard them before leaving.7
  • Follow hand hygiene protocol before and after patient care and after removing gloves. Alcohol rubs aren't effective with C. difficile because they're not sporicidal. Use soap and water and vigorously scrub to clean hands.7
  • Clean and disinfect nondisposable equipment with sodium hypochlorite diluted 1:10 with water.7 Use equipment dedicated to the patient whenever possible.
  • Make sure toys provided for pediatric patients aren't plush or porous.
  • Visit for specific health facility cleaning guidelines.
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Patient education

Educate patients and caregivers on the importance of frequent and proper hand hygiene. Teach patients and caregivers that soap, water, and vigorous scrubbing for at least 15 seconds is the best method for getting rid of bacteria on hands.1

Emphasize the importance of perineal care after toileting, incontinence, or diaper changing. Tell parents to wash toys and air dry them daily with sodium hypochlorite (household bleach) diluted 1:10 with water.7

Advise patients and parents of children who've been diagnosed with a CDI to take antibiotics as prescribed and to avoid antidiarrheal medications because they may prolong a CDI. Supportive care includes maintenance of hydration and nutritional status.7 Remind them to contact their healthcare provider if the diarrhea persists or returns.

The recent increase in CDIs in children emphasizes the need for additional education in proper hygiene for these younger patients. Taking extra steps to prevent CDIs in your facility can help avoid complications.

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1. Centers for Disease Control and Prevention. Frequently asked questions about Clostridium difficile for healthcare providers .
2. Zilberberg MD, Tillotson GS, McDonald LC. Clostridium difficile infections among hospitalized children, United States, 1997–2006. Emerg Infect Dis. 2010;16(4):604–609.
3. Nylund CM, Goudie A, Garza JM, Fairbrother G, Cohen MB. Clostridium difficile infection in hospitalized children in the United States. Arch Pediatr Adolesc Med. 2011;165(5):451–457.
4. Benson L, Song X, Campos J, Singh N. Changing epidemiology of Clostridium difficile-associated disease in children. Infect Control Hosp Epidemiol. 2007;28(11):1233–1235.
5. Centers for Disease Control and Prevention. Surveillance for community-associated Clostridium difficile—Connecticut, 2006. MMWR. 2008;57(13): 340–343.
6. Cooperstock MS. Clostridium difficile infection in children: microbiology, pathogenesis, and epidemiology .
7. Cooperstock MS. Clostridium difficile infection in children: treatment and prevention .
8. The Nebraska Medical Center, Clarkson and University Hospital: clinical pathway for Clostridium difficile infection .
9. Centers for Disease Control and Prevention. Management of multi-drug resistant organisms in healthcare settings, 2006 .
© 2011 Lippincott Williams & Wilkins, Inc.