The impact of clostridium difficile associated diarrhoea

The aim of this theoretical assignment is to discuss and analyse the impact of clostridium difficile-associated diarrhoea; how it is spread and the prevention measures. Before introducing the organism C. difficile in clarity, the term healthcare associated infections will be looked at to demonstrate that C. difficile associated diarrhoea is one of those infections that can be acquired in the hospital environment. There will be a focus on hand hygiene, the type of patients that are likely to develop C. difficile and the importance of compliance with infection control.

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Evidence base literature will be use to support key aspects discussed throughout and this will end with a conclusion that will summarise the main issues which has being discussed or analysed. The rational for choosing this infection control issue is due to the fact that C. difficile has been a common occurrence in clinical setting. In addition doing the topic will improve my knowledge and understanding of the infection including.

The term ‘healthcare associated infections’, otherwise referred to as ‘nosocomial’ infections encompasses any infection by any infectious agent acquired as a consequence of a person’s treatment by the NHS or which is acquired by a healthcare worker in the course of their NHS duties. It can also be defined as an infection that was not present or was not in the incubation phase at the time of admission to the hospital (DOH 2005). The prevention and control of HAI is of high priority for all parts of the NHS because it is a UK problem due to the following: 9% of inpatients ended up with HAI, which is equivalent to 100,000 patients; 5% patients have an adverse reaction; it costs the NHS around £1 billion/year and leads to patients mortality and morbidity, hence it is of equal importance for healthcare providers in the independent and voluntary sectors (DOH2007).

Organisms responsible for HCAIs includes MRSA, Pseudomonas aeruginosa, S. aureus, Enterococcus species, S. epidermis and Clostridium difficile but according to Department of Health (2007) Clostridium difficile is a particular problem because, unlike other infections, patients become vulnerable to it through the antibiotics used to treat their underlying illness.  The rates of Clostridium difficile have gone up dramatically from 1000 in the early 1990s to 44,448 in 2004 (Health protection agency 2007). In the UK, there is a growing concern at the increased incidence of Clostridium difficile-associated diarrhea (Health commission 2005). In January 2004 the Department of Heath (DOH) introduced mandatory surveillance of C. difficile in patients over the age of 65. The total number of reports of C. difficile-associated diarrhea over the period of January to December 2004 in England and Wales was 44,488, rising to 51,690 in 2005, an increase of 16.2 % (Health Protection Agency 2007). The risk that C. difficile poses to the public health is now considered as fundamental as meticillin resistant staphylococcus aureus (MSRA), and it is thought to have contributed to more deaths than MRSA in England, Wales and Northern Ireland in 2003 (Healthcare Commission 2006). Coupled with the fact that the number of cases reported is increasing, this suggests that further controls are required to limit the spread of infection.

Clostridium difficile is the name given to a family of bacteria which has more than 80 strains (Wilson 2006). For example, some of the species includes Clostridium perfingens, which causes gas gangrene, others including clostridium tetani and Clostridium botulinum (Hall and Hornsley 2007). Its morphology depicts a rod shaped, which is normally prevalent in soil and a size of 0.5 to 1 microgram in diameter (Gould and Brooker 2000). Clostridium difficile is a commensal gram positive anaerobic bacterium that produces spores (reproductive structure that is adapted for dispersal and survives for extended periods of time in unfavorable conditions). It has been stated that gram positive bacteria was identified through a system invented in 1884 named gram stains (the cells were stained with a dye in order to distinguish between gram positive and gram negative organisms). Gram positive cells absorbed dark blue dye and appeared blue under the microscope, while gram negative appears pink (Gould and Brooker 2000). Bacteria which produces spores can tolerate extreme conditions that active bacteria does not and because of this C. difficile has the pathogenicity to spread and causes outbreaks. In fact, it has been mentioned that this spore-bearing organism can survive in the environment for some considerable time and be potential reservoir of the infection. Outbreaks associated with Type 027, a hypervirulent strain which has recently been recognised, produces higher levels of toxins than other strains which produces 16 times more toxins A and 23 times more toxin B (Warny et al 2005).

C. difficile causes antibiotic – associated diarrhea and it is the spores contained in the feaces that causes HAI. The spores of C. difficile, is frequently found in the stools of newborn infants but rarely causes disease in this group (Johnson and Gerding 2004). Approximately 3% of the adult population carry the organism naturally in their colon (Jenkins 2004), however there is no evidence to suggest that such carriers are sources of cross infection (Hall and Hornsley 2007). It has been stated that once C. difficile enters the colon, the cells do not cause symptoms unless the normal micro flora in alter. However, this mechanism is not full understood but it is thought that the normal flora acts as a protection by using the nutrients to utilising the space available to compete with the C. difficile spores (Hall and Hornsley 2007). It is only when the normal bowel flora is altered or compromised that the organism multiply in the absence of competition and the toxin load increases (Gammon 1995).

During the increase of the toxin loads, C. difficile spores will grow unchecked by normal flora or stomach acid and produces 2 toxins, which are enterotoxin (toxin A) and more potent cytotoxin (toxin B). Toxin A activates macrophages and mast cells, which release inflammatory mediators. The mediators cause disruption of the cell wall junction, resulting in increased permeability in the intestinal wall and subsequent diarrhoea (Gould and Brooker 200). Meanwhile, toxin B causes degradation of epithelial cells in the colon. As the colitis worsens, purulent and necrotic debris accumulates and form characterise ulcers, the pseudomembranes. Similarly, the symptoms of C.difficle associated diarrhoea are testes for when a stool specimen is sent to the laboratory (Hall and Hornsley 2007). The normal microflora of the bowel hosts at least 500 recognised species of bacteria which help to protect the bowel from pathogenic species. This is known as ‘colonisation resistance’; however these microfloras resistance can be altered by the uses of broad-spectrum antibiotic therapy, such as ampicillin, clindamycin and cephalosporins (Kelly and Lamont 1998). These antibiotics mentioned can disturb and alter the lining of the intestine, and when this happens, C difficile in some cases becomes harmful and cause infections (Ayliffe et al 2000).

The Health Protection Agency (2005) reports that C. difficile typically infects patients who receive broad-spectrum antibiotics and can be common in older people owing to factors such as underlying chronic illness and weakened immune systems. In addition there, is mounting evidence that the immune system plays a fundamental part in defending against colonisation by C. difficile (Kyne et al 2001). Equally Wilson (2006) points out that, C. difficile is now the predominant enteric pathogen amongst the over 65s this maybe due to the fact that the normal microbial population of the colon diminished with aged. It is also an important cause of diarrhoea amongst inpatient and research shows that the infection has been steadily increasing in recent years. To support this, in the last year the Healthcare Commission (2007) has produce three reports on outbreaks of C. difficile infection that have led to the deaths of hundred of people. The cost of C. difficile – associated diarrhoea can be measured in both human and financial terms (Hall and Horsley 2007). C. difficle causes wide spectrum of disease, from asymptomatic carriage and mild to sever diarrhoea, to life-threatening pseudomembranous colitis (Mcfarland et al 1989). C. diffcile is associated with outbreaks of infection among hospital patients. Infection can occur as a result of environment contamination as well as cross infection (Hall and Hornsley 2007).

Literature illustrates that doctors and nurses are falling to comply with basic hand hygiene rules between patients intervention (Shuttleworth et al 2004). Poor staff and patient hand hygiene may also account for how the organism enters the patient’s digestive system. Infection can be spread on the hand of health care workers who have come into contact with infected patient or health-care environment (Jenkins 2004). Once C. difficile is established in the environment, the most common method to spread the infection is via the hand (Wilson 2005). Healthcare workers hand hygiene is one of the six main factors noted in saving lives; which is a delivery programme to reduce health associated infection including MRSA (DOH and NHS Modernisation Agency 2005). This illustrates that hand hygiene is a crucial factor in the control of infection because hands can easily transfer micro organisms from one patient to another or from one area to another. Despite strategies implemented to promote hand hygiene such as the clean your hands campaign which was launched in 2005 in trust nation wide and hygiene code, there still seems to be difficulty in persuading staff to adopt good practice (Shuttleworth 2004). There is recognition that hand hygiene among staffs remains generally poor (Jenkins (2004) and Tailor (1978) demonstrated that even when staff did perform hand hygiene 89% missed some part of their hands.

In most cases it could be fair to say this is not due to laziness or lack of care but to barriers such as time constriction. For example when call bells are ringing nursing staff can feel the pressure to get these answered quickly and hand washing in these circumstances can be forgotten and also the lack of access to hand hygiene agents can also be another barrier. In addition study by Parkers (1999) states that the work pressure may also reduces opportunities to frequently wash hands in between procedures or patient handing. Furthermore it could be argued that the pressure at work has led to lack of time for senior nurses to act as role models for junior staffs and to supervise their hand hygiene performance (Ayliffe et al 2000). This in turn has contributed to the increase in the spread of infection.

According to the National Audit Office (2000) it has been recommended that infection control teams should carry out observation audits on the wards, to assess staffs competency on hand washing procedure. On the other hand, it could be argued that this is not the most successful method of monitoring staffs hand washing techniques, because staffs have a tendency to perform more competently whilst being assessed by infection control practitioner and this will contribute to poor auditing results.

Hand must be washed with an antimicrobial soap very thoroughly and in order remove C. difficile spores from the skin and to make sure that they are properly cleaned. Although generally beneficial, alcohol-based hand rubs are recommended to prevent the spread of infection such as MRSA it may not be effective at eradicating C. difficile spores (Hoffman et al 2004). Patients’ and visitors hands should not be overlooked. Banfield and Kerr (2005) suggests that hand hygiene practice among the public are generally poor and that the case of C. difficile associated diarrhoea, improving patient hand hygiene may have a favourable impact on reducing that transmission of the organism.

Effective drying of hands after washing is an essential part of hand hygiene, because wet surface transfer micro- organism more effectively than dry one (Elliott 1989). Hence, a paper towel should be use to turn off the faucet and hands should be washed before and after contact with a patient and after gloves removal. This technique must be taught to family member as a well as patient to reduce the risk of spreading the infection.

In addition there is one issue which is very personal in infection prevention and control, which is staff wearing rings. Ayliffe et al (2000) have shown that the wearing of rings carries greater risks of transferring infection because it prevents good hand washing technique. The study found that there are high numbers of organism present on the hand of staff wearing rings (Ayliffe et al 2000). It is therefore pivotal for staff to refrain for wearing ring whilst on duty in order to fight against the spread of micro-organism and HCAIs.

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Isolation

Patients with toxin-producing strains of C, difficile in their faeces should be isolated while they have diarrhoea. Isolation is the physical separation of symptomatic patients from other vulnerable patients to limit the spread of infection. Furthermore the (DOH 2007) stipulates that isolation of patients with suspected or confirmed infection in a side room is strongly recommended, and where isolation facilities are not available, patients should be cohoted. Hence Farrington and Pascoe (2001) recommended the need for more side rooms in hospitals.

Infection control precautions need to be implemented according to patient’s symptoms and not delayed until the healthcare team can review laboratory test result (AMM 1998). The nurse should explain to the patients why he or she is to be isolated, making it clear that at this time it is a precautionary measure until laboratory test result are available.

Isolating patients has some element of psychological risks, for example anxiety, depression and feeling of loss of choice (Gammon 1998) and is something that the nursing staffs need to be aware of and assess regularly. The patients need to be updated regularly and if he or she is found to have an infection the nurse must to keep up to date with patient progress.

Personal Protective equipment

Standard infection control procedures, including barrier nursing, are important in the prevention of spread and should be re-enforced by early diagnosis of C. difficile. Healthcare worker should maintain barrier nursing when providing care for patients with C. difficile as infection can contaminate staffs uniforms which can be transferred to susceptible patients. It has been stated that the use of protective clothing appears to be an area of confusion for many. Staffs often need correcting for not wearing apron when making beds and sometimes respond that they were not aware they need to wear apron. Clearly the use of protective clothing is an important area in infection control and needs to be covered thoroughly during infection control lectures. The Royal College on nursing booklet, ‘Guidance on uniforms and clothing worn in the delivery of patient care’ (2005) makes coherent of when protective clothing must to be worn. In addition the RCN booklet also state ‘staff must change out if their uniforms promptly at the end of each shift as infection can found on uniform.

Preventing cross-infection environment

Patient have a right to clean and safe treatment whenever they are treated by the NHS. Safety in the healthcare is a top priority for the NHS, and this must be an essential element for procedure in the NHS so that patients have the confidence they need in the care they receive. Furthermore, clean environments are extremely important in their own right, and are central to patients receiving comfortable reassuring and welcoming care. This is why deep cleaning of every hospital in the country is so important (DOH 2008).

Prevention of C. difficile-associated diarrhoea is concern with making sure that the conditions in the healthcare institutions, including patients, staff and environment, are not conducive to the establishment of C. difficile infection (Worsley 1998). The C. difficile spore can adhere to toilet seats, commodes, bedpans, bedsides lockers, beds and floors. The spores are resistant to many types of disinfectants including heat, dryness, alcohol rub, stomach acid and can survive in harsh environment months. In addition, the spores can persist on surfaces such as, electronic thermometer, stereoscopes, skin folds and the hands of a care giver (Hoffman et al 2004).These C. difficile bacteria or spore can be transferred from contaminated hand to mouth and cause infection in susceptible patient and also re-infection. According to Hall and Hornsley (2007), C. difficile spores can grow again when they are reintroduce into more suitable condition thus rigorous cleaning is essential.

Evidence suggests that the organism is endemic in the hospital setting, with between 20% and 70% of sampled sites being contaminated with C. difficile (Wilson 2005). In addition studies have found more bacteria in the environment of patient with C. difficile associated diarrhoea than those who do not have the infection (DOH 2007).

Wilcox and Fawley (2000) found that C. difficile produce more spores when exposed to cleaning products that did not contain chlorine. Therefore, the DOH (Donald and Beasley 2005) recommended that there should be enhanced environment cleaning using chlorine-based disinfectants in areas where there are patients with C. difficile-associated diarrhoea.

The role of the nurse

Nurses have responsibility to safeguard and promote the interest of individual patients and clients (NMC 2004). This responsibility includes ensuring that his or her knowledge and competence in commensurate with the task being undertaken. Infection are responsible for increased morbidity and mortality, thus a comprehensive knowledge of infection control precautions and basic microbiology should be the fundamental requirement of the NMC, other statutory bodies, and the legal system NMC (2004). Research has shown, however, that despite the provision of a specific care plan, together with guidance on it use, the documentation of appropriate care for infection control remain inadequate. Infection control affects every aspect of health care and every nurse, irrespective of the setting with which they work should ensure that their practice incorporates a sound knowledge and understanding of basic infection control.

Recommendation

Effective staff education programs can result in a significant reduction in infection rate. Recommendation includes hand hygiene education and on going audit and mandatory surveillance on C. difficile which as being established by the Health Protection Agency in 2007 reports that all acute NHS trust in England are required to report all cases of CDAD in patients aged 2 years and over. Previously, reporting had been limited to patients aged 65 and over (Hall and Horsley 2007). Infection can also be reduce if nurses get tougher on infection control measures in their ward area, by becoming assertive and through adopting collaborative working. All health care workers as well as the general public need to change their behaviour regarding infection control.

CONCLUSION

Health care aquired infections such as Clostridium difficile associated diahorrea have become a UK problem since the 1990s due to the increase rate of the number of inpatients who caught infection due to cross infection. It is also integral for health care workers to follow the various precaution measures set out according to their hospital policies, procedures and guidelines as this will assist in the prevention of the transmission. The high number of clostridium difficile infection is putting patients’ lives and well being at risk and also has significant implication on the NHS finance. For this reason there is a clear need for healthcare workers to work collaboratively to tackle infection such as C. difficile if infection rate are to fall. Improving nurses’ knowledge of the cycle of infection in C. difficle is one step in helping to prevent and control this infection. In addition, I strongly believe that more should be done to increase the awareness of Clostridium difficile associated diahorrea to the general public in order to change their behaviour regarding infection control.