C. difficile Infections Hit All-Time High

The recent alarm by the Centers for Disease Control and Prevention which reports on the increasing incidence and burden of Clostridium difficile infections (CDI) in the United States is drawing attention to a phenomenon which is already well- known to gastroenterologists and infectious Ddisease physicians worldwide. In fact, the sweeping changes in the epidemiology of CDI – with reports of increasing rates, outbreaks, and elevated morbidity and mortality since 2002 originally in parts of Canada and the United States – has now been described in almost every developed country which keeps statistics on this infection.

The only fact which is even more alarming in the CDC’s report is that there has not been any “leveling off” or abatement in this health care–associated complication in the U.S. Although GI and ID physicians, hospitalists, and many other health care providers around the globe have been aware of the disquieting rise in CDI since 2002, the hoped-for stabilization or reduction in its incidence due to aggressive infection prevention and control (IPC) techniques, as has been seen in the U.K., has not materialized in the U.S. and central Canada.

Why is it so difficult to control CDI? Because it requires the accomplishment of multiple simultaneous aggressive IPC maneuvers – all of which must be done correctly -– in order to overcome this infection on an institutional level:

- Appropriate antimicrobial use and stewardship

- Rapid testing, isolation, and treatment of any patient with diarrhea who has recently received antibiotics, while awaiting test results
- Rigorous hand-washing and appropriate use of personal protective equipment when in contact with suspected or confirmed cases
- Meticulous and frequent environmental cleaning with sporicidal agents which are tolerable to patients and personnel
- Attention to cleaning and disinfection of the innumerable shared pieces of medical equipment, like blood pressure cuffs, thermometers, bladder scanners, and the like
- High level of scrutiny for quickly detecting and treating recurrences, which occur in 15%-40% of CDI patients
- Real-time surveillance to detect outbreaks and effect heightened measures, when necessary.

The “new CDI” has demonstrated itself to be an unforgiving infection in health care facilities. Any lapse in one or more of the above IPC interventions is enough to cause a rise in the incidence or complication rate.

It is unclear exactly why the “new CDI” is behaving as it does. Certainly, the appearance of a new hyper-virulent strain with additional fluoroquinolone resistance (on top of C. difficile’s “usual” multi-drug resistance), a mutation in the toxin regulator gene, and a seemingly greater propensity to sporulate (and thus resist disinfection) appears to be the event which has coincided with the re-emergence of this disease during the past 10 years.

However, not all of the clinical aspects of this “new CDI” can be explained by these findings alone. For instance, the rapid progression from diarrhea to fulminant colitis in the elderly and the immunocompromised, the high recurrence rate (compared with historical controls) and the elevated morbidity (i.e., colectomy and need for intensive care) and mortality remain unnerving manifestations without a real explanation.

The number of scientific publications describing the new epidemiology, pathogenesis, and prophylactic or treatment options has risen impressively over the past several years in order to gain an understanding of this relentless bacterium.

Medical journals are not the only place for CDI-related news, however. The internet and social media sites are rife with stories of personal tragedies from this affliction. Typical stories like a healthy grandfather undergoing uncomplicated elective surgery but then dying from antibiotic-induced CDI during or soon after his hospitalization are too commonly detailed in surveillance data and in personal blogs.

Sites dedicated to and run by patients who have suffered from CDI compete with other sites established by the all-too-commonly depressed individuals who have had to undergo a therapeutic colectomy or who are suffering multiple recurrences of this disease and are searching for centers offering a fecal transplant.

There is no doubt that the true tragedy of CDI, a health care complication with an attributable mortality of almost 15% in the frail elderly over 85 years of age, is the fact that it is more likely to kill than the primary cause of hospitalization (such as a pneumonia, cellulitis, or hip fracture) in this population.

At a time when CDI is clearly overcoming our ability to control it in many parts of the world, it remains puzzling why the U.S. and many European countries do not yet have a true, real-time local and national CDI surveillance network for tracking the number of cases.

Using hospital discharge data or disease coding has been shown to be inaccurate and too late to be of immediate use. Real-time local, state, and national CDI surveillance is essential in telling us where we are, where we are going, and what we have to do to control this affliction. There is clearly a battle going on between health care providers and CDI in many countries, including the U.S. and Canada. We need to use as many tools and tricks as possible to gain control. This is one war we cannot afford to lose.

MARK MILLER, M.D., FRCPC, is Chief, Infectious Diseases, and Head, Infection Prevention and Control Unit, Jewish General Hospital, Montreal.