As a nurse it is important to put the patient on contact isolation and teach the patient, family, and visitors about the importance of hand hygiene. Prevention is the best medicine, but if your patient has C. diff, he/she is t greater risk of getting a second round of C. Diff.
Here is a video approved by W.H.O. about how to properly wash your hands.
CDC has published a report setting up clinical guidelines for the management of C. diff. While not nursing specific here are some of the key points that related to nursing
Testing is done on diarrheal stool
Infection management:
Appropriate hand hygiene for healthcare workers and visitors
Contact precautions while awaiting for results and continued if C. diff positive
Appropriate cleaning of supplies -- Bleach must be used
This week I will be talking about nursing diagnosis. Here are some of 5 nursing diagnosis I think are the most important and relevant:
Diarrhea related to side effects of antibiotics & c. diff infection
Acute pain related to inflammation and abdominal cramping
Deficient fluid volume related to excessive losses through normal routes (this can be evidenced by frequency of artery stools)
Imbalanced nutrition due to insufficient intake and excessive output
Risk for secondary infection related to broad antibiotic medicatio
In an acute setting the priorities of the nurse would be to manage the pain and excessive diarrhea and the side effects of the diarrhea (poor nutrition and fluid deficits) while preventing further or second infection of the C. diff. Fluid management can be maintained through I.V. fluids, while appropriate nutrition can be managed through high caloric food options, such as Ensure. Pain can be managed through I.V. meds (meds by mouth may not be absorbed in the intestines). Also consider non-pharmaceutical options such as warm compress on the abdomen or positional changes.
Here I elaborate on the the third nursing diagnosis:
Deficient Fluid Volume
Rapid propulsion of intestinal contents through the small bowels may lead to a serious fluid volume deficit. The body would want to expel the foreign objective as much as possible thus it doesn’t undergo its “normal” speed, with that, the digestive system organs are not able to absorb the excess fluids that are usually absorbed by the body.
Assessment
Patient may manifest
passage of loose watery stool
vomiting
abdominal cramping
dehydration
nausea
fatigue
weakness
nervousness
confusion
weight loss
decreased skin turgor
decreased urine output
dry mucous membrane
fever
Outcomes
Patient will report understanding of causative factors for fluid volume deficit
Patient will maintain fluid volume at functional level AEB well hydrated, intake is equal as output, and normal skin turgor.
Ironically, the first line of treatment after diagnosis of C. diff is more ... ANTIBIOTICS! The type of antibiotic used varies on the severity of infection. For mild to moderate infections flagyl is used. For more severe infection or for recurrent infections vancomycin is used. Surgery is the last resort for those who have suffered from organ failure or severe inflammation that damaged the lining of the GI tract. The damaged part of the tract is then removed.
Unfortunately, up to 20% of patients with C. diff will get sick again. This may be do to the fact that the initial infection never went away or because the patient was reinfected with another strain of the bacteria after the first round of antibiotics. This is called recurrence. Recurrence of a new infection is about 20% and after the first recurrence the chance of continual recurrence is up to 65! Certain populations are at greater risk for recurrence than others. These are:
An older adult (65+)
Are taking other antibiotics for a different condition while being treated with antibiotics for C. diff
Have severe underlying medical disorder such as chronic kidney failure, inflammatory bowel disease or chronic liver disease
Treatment for recurrent disease can include more antibiotics, which can pretty much just start this vicious cycle. Increasingly, hospitals are looking towards fecal microbiota transplant as a a form of treatment for patients with recurrent episodes, though it has yet to be approved by the FDA. Fecal microbiota transplant (FMT) is also known as a stool transplant. FMT restores health intestinal
bacteria by placing another individual's stool in our colon using a colonoscope or nasogastric tube. Donor stools are carefully and repeatedly screened for parasites, viruses, bacteria and certain antibodies before being used for FMT. Below is a video with more information from Mayoclinic:
The video above describes the most common C. diff infection symptoms. About 20% of hospitalized adults are C. diff carriers. Those who have diarrhea with colitis, can have watery diarrhea up to 10-15 times daily with lower abdominal pain and cramping, low grade fever, and leukocytosis.
Someone can also develop protein losing enteropathy with hypoalbuminemia. What this means is that the bowel wall becomes so inflamed, albumin (a protein in the blood) begins to leak out. With the albumin, water also follows. Patients can develop ascites (fluid buildup in the stomach) and peripheral edema, as a result.
Below is a video of a woman who contracted C. diff. She explains how she got it, what her symptoms were, and how it impacted her life. It is a little longer than the one above, but I found it to be excellent to hear about it from a patient's perspective.
Every nurse, new and seasoned, will tell you that you can diagnose C. diff by the noxious, pungent smell. While memorable, this is NOT the way to diagnosis a patient! If I could, I would emirate the odor across the inter webs, because truly, it is an unforgettable smell. Below is the clinical way to diagnose C. diff.
Before you do any testing on your patient, there needs to be present a clinically significant amount of diarrhea or a pause in your GI motility (lack of peristalsis, medically known as ileus). There are diagnostic procedures that can be used to test for C. diff. One of which can be a endoscopic finding of "pseudomembranous colitis". Here is a video to exhibit what an endoscopy would look like and what this colitis is and looks like through a camera lens.
What is the preferred method for diagnosis is lab testing of the diarrhea. Because the diarrhea is tested for a positive C. difficile toxin, which degrade at room temperature, it is critical that collected swabs are kept at 4 degrees Celsius after collection. The stool that is collected is used in a number of tests including:
Polymerase chain reaction (PCR) : Detects Toxin A and B genes; tests are highly sensitive and specific. Results are quick, but because of the sensitivity of the tests, false positive results. This test is usually favored for initial diagnosis, while the doctors wait for secondary results that take longer to produce.
Enzyme immuno assay (ELISA) for C. diff glutamate dehydrogenase (GHD): GDH antigen is an enzyme produced by all C. diff bacterial types. Unfortunately this enzyme is produced by all toxin producing and non-toxin producing C. diff.
ELISA for C. diff toxins A and B: Most C. diff strains produce both these toxins. Sensitivity is about 75%, but can be as specific as high as 99%. What this essentially means is that there is relatively high false negativeunless a lot of the bacteria has been collected. This is inexpensive and results are within hours.
Cell culture cytotoxic assay: This is the gold standard. It is performed by adding a prepared stool sample to a petri dish with a layer of cells. If the C. diff toxin is present, the first layer if cells begins to change shape from a long stretched on cell to a round cell. This test is expensive and takes time.
Early diagnosis is key here in order to ensure patient safety of the individual diagnosed but other individuals on a hospital floor. Immediate isolation is required. In some cases, patients are put into isolation while results are pending.
This week I will be writing about the pathophysiology of C. diff colitis. Basically, what that means is -- what does the little bugger do to make life so horrible?
Here is a visual with some scientific wording to help you understand if you are a visual learner.
Basically what is happening is the following:
C. diff enters the gut usually through from consumption of fecal matter (which can occur unnoticeably)
Without other gut flora to keep C. diff in check, the bacteria proliferates uncontrollably. As the bacteria grows, toxins are released. Most pathogenic C. diff strains release Toxin A and Toxin B.
Toxin A and Toxin B work to cause inflammation (colitis) and to inflict mucosal damage, respectively.
Destruction of the lining ultimately prevents absorption in the gut, leading to the diarrhea that is commonly seen in patients. Prolonged infection can ultimately lead to sepsis (infection of the blood), which can cause systemic organ failure.
It is thought that there is a hyper-virulent strain named NAP/BI/027. This strain is thought to cause more severe symptoms and faster acting, in terms of damaging the colon.
Interestingly, neonates, who are often carriers are the C. diff toxin,are aysmptomatic. It is believed that in addition to acquiring maternal antibodies in utero against the C. diff toxins, the immature gut cells of a neonate may lack the intestinal receptors for the C. diff toxins altogether. This prohibits the toxins from eliciting the immune response that ultimately destroys the mucosal lining of the gut.
Need I remind you? ALWAYS WASH YOUR HANDS! References Lamont, T. J. (2015). Clostridium difficile in adults: epidemiology, microbiology, pathophysiology. Uptodate. Retrieved from uptodate.com/home
Before I begin to bore with you with numbers and facts, here is an image from the CDC discussing some key facts about the spread of C. diff.
According to the CDC the populations at greatest risk for acquiring C. diff are patients with:
antibiotic exposure
proton pump inhibitors (usually used for patients with GERD --gastroesophageal reflux disorder) -- this reduces the acidity of the stomach, which is essential for destroying pathogenic bacteria, such as certain strains of C. diff.
gastrointestinal surgery or manipulation
long length of stay in a healthcare setting (including nursing homes)
a serious underlying illness
immunocompromising conditions (eg: transplant patients, HIV patients)
advanced age (65+)
Based in a 2008 study also published by the CDC the following impact of C. diff was determined:
Hospital acquired, hospital onset of C diff: 165,000 cases were reported resulting in $1.3 billion in excess costs and ultimately leading to 9.000 deaths annually
Hospital acquire post discharge (up to 4 weeks): 500,000 cases were reported resulting in $0.3 billion in excess costs and leading to 3,000 deaths annually
Nursing home onset: 263,000 reported cases, $2.2 billion in excess costs and 16,500 deaths annually
These numbers are astounding! Patients and health care providers need to pay better attention to preventing episodes of C. diff as treatment is difficult. While old age and serious illnesses are not always risk factors that can be altered, limiting antibiotic exposure and preventing C. diff exposure can great reduce transmission!
Don't forget folks, ALWAYS WASH YOUR HANDS! References Center for Disease Control and Prevention. (2015). Clostridium difficile infection. Retrieved from: http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html.
