C. diff causes concern in primary care, other outpatient settings

Primary care practices and other outpatient facilities have long been considered largely beyond the reaches of Clostridium difficile infections, according to the Centers for Disease Control and Prevention. Finding ways to curb transmission of this potentially fatal bacterial illness that causes diarrhea has been seen as a hospital problem for years — but not anymore.

A recent CDC study shows that prevalence of C. diff infections and mortality have reached historic highs, and the condition is spreading in inpatient and outpatient care facilities.

“C. difficile should no longer be considered just a hospital problem,” said Clifford McDonald, MD, a medical epidemiologist at the CDC. “These infections are now a patient safety concern everywhere medical care is given.”

Ninety-four percent of all C. diff infections reported in 2010 were associated with receiving health care, according to the study in the March 9 Morbidity and Mortality Weekly Report. Of those cases, 75% first showed symptoms in nursing home patients or people who recently received care in an outpatient doctor’s office or clinic. Only 25% of infections first presented in hospital patients.

Although the proportion of infection onset is relatively low in hospitals, these facilities remain at the core of prevention efforts, because many patients with C. diff are transferred to hospitals for care, which increases the risk of spreading the disease there, Dr. McDonald said.

Primary care physicians’ most significant role in the spread of the illness is their misuse or overuse of antibiotics, Dr. McDonald said. The CDC estimates that half of all antibiotics prescribed are not needed.

Antibiotics destroy good bacteria that protect people from infection, meaning that individuals taking such medications are more susceptible to infections, Dr. McDonald said.

Contributing to the problem is that C. diff spores can spread quickly from person to person because they are not easily killed. For example, hand sanitizer alone does not kill the spores, and even vigorous hand washing with soap and water does not completely clean hands of the bacteria, Dr. McDonald said.

The CDC recommends that physicians wear gloves and a gown when caring for a patient they suspect has the infection.

“We agree that antibiotics are lifesaving, but every doctor in the outpatient setting needs to think about the risks associated with prescribing antibiotics, particularly among older people,” he said.

C. diff is linked to about 14,000 U.S. deaths a year, according to the MMWR study. More than 90% of those deaths occur in people 65 and older. In 1999-2000, the infection was related to about 3,000 deaths a year, data show.

Consider C. diff as a diagnosis

West Virginia family physician Gregory Juckett, MD, MPH, encourages primary care physicians to consider C. diff as a possible diagnosis for patients who have chronic diarrhea. He recommends that doctors isolate such individuals from other patients, use gloves during an exam, test the person for the infection and advise the office’s cleaning crew to clean that exam room with disinfectant approved to kill C. diff spores.

Dr. Juckett also recommends that doctors refrain from shaking hands with patients they suspect might have C. diff.

“It’s hard when people do extend their hands to decline, but you have to do so with a smile and an explanation,” said Dr. Juckett, a professor of family medicine at West Virginia University School of Medicine in Morgantown. “I just explain to patients that I don’t usually shake hands, but that’s only because we don’t know what you have yet. I try to make a joke out of it. Usually, people laugh and no offense is taken.”

The number of hospitalized patients with C. diff increased from about 139,000 people in 2000 to 336,600 in 2009, according to the MMWR study. During the same period, other health-care-associated infections declined.

Much of the recent increase in the incidence and mortality of C. diff is attributed to the emergence and spread of a hypervirulent, resistant strain, the study authors write.

For the study, researchers examined C. diff infection data from the Emerging Infections Program and the National Healthcare Safety Network Multidrug-Resistant Organism and Clostridium difficile Infection module for laboratory-identified events. They also assessed the early results of state-led programs in Illinois, Massachusetts and New York in which hospitals collaborated to prevent health-care-associated infections.

Researchers found that the hospital-onset rate of C. diff declined about 20% at the three hospitals, decreasing from 9.3 cases per 10,000 patient days to 7.5 cases per 10,000.

“C. difficile harms patients just about everywhere medical care is given. [But] illness and death linked to this deadly disease do not have to happen,” said CDC Director Thomas R. Frieden, MD, MPH.