Saturday, May 2, 2015

Nursing care

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

  1. Testing is done on diarrheal stool
  2. 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
  3. Minimize antibiotic use
  4. Do not use probiotics

Here is the right contact isolation sigh for patients with C. Diff: 

Nursing Diagnosis

This week I will be talking about nursing diagnosis. Here are some of 5 nursing diagnosis I think are the most important and relevant:

  1. Diarrhea related to side effects of antibiotics & c. diff infection
  2. Acute pain related to inflammation and abdominal cramping
  3. Deficient fluid volume related to excessive losses through normal routes (this can be evidenced by frequency of artery stools) 
  4. Imbalanced nutrition due to insufficient intake and excessive output
  5. 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.
Nursing InterventionsRationale
 Maintain adequate hydration, increase fluid intake. To prevent dehydration & maintain hydration status.
 Provide frequent oral care To prevent from dryness
 Administer Intravenous fluids as prescribed To deliver fluids accurately and at desired rates.
 Determine effects of age. Very young and extremely elderly individuals are quickly affected by fluid volume deficit
 Restrict solid food intake, as indicated To allow for bowel rest and to reduced intestinal workload.
 Discuss individual risk factors/ potential problems and specific interventions To prevent or limit occurrence of fluid deficit.


The nursing diagnoses information can be found for more information here

Wednesday, April 22, 2015

Treatment options

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:


Saturday, April 4, 2015

Clinical Manifestations


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.



ALWAYS WASH YOUR HANDS! 

Diagnosis of C. Diff

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 negative unless 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. 

So remember, ALWAYS WASH YOUR HANDS. 

Sunday, March 29, 2015

Pathophysiology of C. diff colitis

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: 
  1. C. diff enters the gut usually through from consumption of fecal matter (which can occur unnoticeably) 
  2. 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. 
  3. Toxin A and Toxin B work to cause inflammation (colitis) and to inflict mucosal damage, respectively. 
  4. 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

Saturday, March 28, 2015

Who is at risk?

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. 

C. Diff defined

Clostridium difficile, or more commonly known as a C. diff, is one of the 1000 types of bacteria that resides in the human gut. The bacteria in our gut help to keep us healthy by aiding in digestion of our food and preventing bad bacteria from taking over our intestines. People who have other illnesses or a prolonged use of antibiotics can have an altered bacterial composition in the gut. During this time patients can get a C. diff infection, where the otherwise harmless bacteria takes over the gut and grows out of control.  This can cause symptoms of diarrhea, belly pain and tenderness and can ultimately lead to Clostridium difficile colitis and possibly sepsis (blood infection). I will discuss these points in later weeks.

C. diff bacteria that does not require oxygen to survive. It takes two forms -- a vegetative and a spore form. It is a fastidious bacteria in its vegetative state, actively releasing toxins. Outside the gut, it lives in a spore form. In this form, the bacteria is resistant to heat, acid, and antibiotics and can live for a very long time. It may be found on things in the environment such as bed linens, bed rails, bathroom fixtures, and medical equipment.  It is a bacteria that is found in feces. Patients get infected when they touch items or surfaces with contaminated feces and then touch their mouth or mucous membranes. It can also spread from person-to-person on the hands of doctors, nurses, and other healthcare providers and visitors. 

Upon diagnosis of C. diff, patients in hospitals are put into "isolation rooms", although some institutions will isolate patients who are suspected of having C. diff until test results come back negative. Placing patients in isolation rooms ensures that healthcare providers and visitors where gloves and gowns to prevent transmission. Studies have shown that spores may be difficult to remove from hands even with hand washing!

Below is a video with more information about C. diff, although I will provide you more details as the weeks go on.



Also, remember:

ALWAYS WASH YOUR HANDS