Prevention of Antibiotic-Associated Diarrhea and Clostridium Difficile Infection - Literature review Example

The Prevention and Management of Antibiotic associated Diarrhea and Clostridium Difficile infection Introduction The prevention and control of antibiotic associated diarrhea and clostridium difficile infection Antibiotic-associated diarrhea is a frequent movement of watery bowel (diarrhea) that occurs in response to medications used for treating bacterial infections (antibiotics). It clears up shortly after someone has stopped taking the antibiotics (Dray and Marteau 2006). In some cases, it leads to more severe form of colitis called pseudo-membranous colitis which causes abdominal pain, bloody diarrhea and fever. Clostridium difficile disease is a growing problem in healthcare facilities and occurs when humans ingest spores accidentally in a medical facility. These are diseases that are very threatening in someone’s life and so they need prevention and control especially in elderly patients (Poutanen. and Simor, 2008). Environmental Control to reduce Transmission of C. Difficile According to researchers, Clostridium difficile associated diarrhea is a nosocomial infection that occurs after antimicrobial treatment (Jennie et al, 2001). Affected patients excrete large numbers of clostridium difficile spores. These spores survive for many months in the environment. They cannot be destroyed by hand disinfection and thus persist despite usual environmental cleaning agents. These factors increase the risk of transmission of C. difficile. The researchers (Jennie et al, 2001) did a quantitative study and came up with the results and conclusion to show the part of environmental measures to prevention of AAD and D. Difficile disease. Researchers found out that infection control measures as well as Restrictive antibiotic policies have indicated to reduce Clostridium difficile associated diarrhea (CDAD) incidence among the patients that are hospitalized. It well known that since time memorial, the environmental disinfectants role in reducing nosocomial CDAD rates has not been studied well. Jennie et al, (2001) conducted a study (before and after intervention) whereby patients in 3 units had to be evaluated in order to ascertain if the solution of unbuffered 1:10 hypochlorite was effective in terms of environmental disinfectant in reducing the CDAD incidence. Basing on the results, it was observed that amongst 4252 patients with bone marrow transplant, the CDAD incidence rate decreased substantially from 8.6 to 3.3 cases per 1000 patients-days (in this case, the hazard ratio was 0.37; at 95% confidence interval, 0.19–0.74) after switching of the disinfectants from quaternary ammonium to 1:10 hypochlorite solution in the patients’ room that had CDAD. When it was reverted later to quaternary ammonium solution, the rate of CDAD increased from 8.1 cases per 1000 patient-days. On the other hand, a CDAD rate was observed not to decrease amongst the general medicine patients as well as neurosurgical intensive care unit. In this case, their baseline rates were 1.3 and 3.0 cases per 1000 patient-days, respectively. The study concluded that the solution of unbuffered 1:10 hypochlorite was observed to be effective in reducing the risk of developing CDAD of patients in highly CDAD endemic places. In conclusion, the study confirmed the link between the unbuffered 1:10 hypochlorite solutions with reduced CDAD rates in a unit that has a high prevalence rate. The limitation of the study was that they never took care of confounding factors which can result to significant errors (Polit and Hungler, 1999). In this case, there was no stratification. For instance, gender and age could have a significant influence on the results but this was not considered as it was generalized. The data of groups were not stratified. Therefore, the results could not be very accurate as expected due to the confounding factors that may arise from these (Polit and Hungler, 1999). Another limitation was that the patient proximity with CDAD to each other was not determined beyond the geographical unit- specific location. Nurses should ensure thorough environmental cleaning especially in hospitals because it is very important in an outbreak of C.Difficile. Given its resistance to disinfectants and its long persistence in the environment, there has existed discussion about the importance of different agents in environmental decontamination. It is accepted agreed that some attempt should be made to decrease environmental spore load hence several cases occur and the researchers recommend that nurses should thoroughly clean patients’ beds, surfaces, laboratories and commodes using detergent daily. The researchers did not find any evidence that any disinfectant compatible with routine environment use is more effective than cleaning with soap or detergent in reducing the level of environmental contamination and the nurses sees no role for the routine use of environmental disinfectants in a clostridium difficile outbreak. It is necessary to close and empty the patients’ ward and in these situations, it should be thoroughly surface cleaned before reopening, including wiping fall mattress covers and horizontal surfaces and laundering of curtains. It is also very necessary for nurses to ensure that all equipment that comes into close contact with patients is disinfected or sterilized properly. Autoclave is the best form of equipment sterilization, but instruments that ill not survive moist heat sterilization should be disinfected by exposure to two percent alkaline buffered glutaraldehyde for ten minutes. Single use equipment is preferable for patients with clostridium difficile infection and in which they are not a cohort nursed. The nurses should ensure clothes of patients and linen are bagged according to the local policy for infected laundry. Laundering process of normal hospitals is effective at removing clostridium difficile contamination. Health guidance department on arrangements for dealing with foul or infected linen is contained in health circular 87/30. This process is currently in revision and will be re-issued as health service guidance. If nurses apply these practices in the hospitalized patients, they will help in prevention and control of antibacterial associated diarrhea together with clostridium difficile infection (Polit and Hungler, 1999) Hand hygiene Hand hygiene is the act of cleaning hands with the use of water or with the use of soap for the resolution of removing microorganisms or dirt. According to research, it is clearly evident that Health care associated infections are the key problem causing about 5000 deaths each year globally (World Health Organization 2005). The current guidelines have noted that expert opinion is the degree of evidence for hand washing as the activity of reducing infections. Sheree (2008) conducted a review in order to ascertain the most effective hand –cleansing and hand-washing practice that might be employed in the primary care. This was a systematic review, whereby publications on hand cleansing ,hand washing studies, practice and policy based documents had to be sought through searching various databases. According to the review, it was found out that there were limited articles that explored about hand-washing technique in detail as well as there were some publications which only referred to either the British and European Standards or CDC statement in relation to hand washing. The key discrepancies are related to water flow direction as well as hand position were determined. There were also various methodological problems identified and limited studies were carried out in the primary care. In conclusion, it was found out by the review that there is no enough evidence for hand washing techniques being carried out in practice today. Basing on the hand washing techniques study findings, it is clearly evident that the findings were inconclusive and methodological issues are seen to be there. Hence, this resulted to in sparse reliable evidence (Polit and Hungler, 1999). In this case, it can be noted that an urgent need is required to carry out hand washing technique methodological sound studies to be applied in the primary care practice that is ever expanding (Polit and Hungler, 1999). The information of the review could be relevant for clinical practice because the evidence for hand cleansing and hand washing techniques could inform the health care professional practice and this could contribute to the general management of the infections such as CDAD control in the primary care Nurses play a very important role in preventing clostridium difficile transmission. Excreted spores are transmitted from one patient to another through improperly sanitized hands and also through the use of contaminated shared equipment. Meticulous hand hygiene using soap and water and strict adherence to isolation protocols should be put into consideration when in the control even when the cessation of CDI symptoms of which they are capable of shedding spores long after clinical symptoms subside. It is very critical for nurses to communicate with their staff of epidemiology to determine the length of time for isolation. Nurses should be very careful on cleaning equipments that are shared between patients and partner with housekeeping services to efficiently clean areas of experience contamination. Because regular active cleansing ingredients do not kill spores despite being used in hospitals as in disinfectants, the (CDC) centers for disease control recommends nurses to use hypochlorite-based germicides for cleaning C. difficile contaminated environmental surfaces and equipment. Viruses’ persistence on the hands has been investigated mainly on fecal and respiratory tract viruses. Hands artificial contamination with HAV has led to an immediate recovery rate of 70.5%. Direct contact with blood puts one at risk and thereby with blood borne viruses is variable. Nurses should wear protective gloves if contact with blood is expected. Hands are the main entry point during transmission of blood-borne, fecal and respiratory tract viruses. Due to this, nurses should thoroughly wash their hands using water and disinfectants after patients care and dispose of ensure the equipments used are meticulously prior to use on another patient. Through this C. difficile transmission will be prevented. The Effect of Age on Treatment outcome in CDI Basing on the literature, it is known that advancing age has been determined to be the risk factor for contracting CDI. Recurrent burden of CDI, sporadic outbreaks as well as the emergence of more virulent strains have initiated the efforts of determining new therapies. Despite metronidazole continues to be recommended for moderate and mild disease, it is until of recent when vancomycin was the only antibiotic approved by Food and Drug Administration. In this case, it is a drug recommended for severe disease (Belmares et al., 2008).There was a study carried out by Thomas et al. (2013) to ascertain the advancing age impact on the clinical outcomes of Clostridium diffile (CDI) treatment. This was a randomized study whereby the participants were randomly put into the studies of Europe, Canada and United States. There was a regression model of results from 2 double blind randomized multicenter studies on the primary treatment as well as CDI first cases that were recurrent to examine the age impact and study drug on cure outcomes(diarrhoea resolution),cure without recurrence, recurrence and complete successful cure within four weeks. The participants were 999 in number and they were toxin-positive CDI. In this case, they were randomized in order to receive vancomycin (125mg 4 times every day) or fidaxomicin(200mg twice every day) for a period of 10 days. The impact of the advancing age in the given age between 18 to 40 years was measured and in 10 years later it was examined. The results of this study was that the model was seen to predict 17% greater recurrence, 17 % lower clinical cure and 13% lower clinical response that is sustained through the decades as compared to those younger than 40 years (p value was less than 0.01).Clinical cure was observed to be similar in the vancomycin and fidaxomicin with a relative risk of more than 50% for recurrence as compared to vanomycin. The regression model indicated that risk factors accounted for outcomes that were poorer with advancing age. The study concluded that progressive and measurable deterioration in the treatment of CDI outcomes was experienced with the advancing age of above 40 years. This indicated the need for treatment and prevention strategies. Despite the P values were less than 0.05 indicating statistically significant statistics (Polit et al., 2001). The co-llinearity between the independent variables was not put into consideration to really determine the exact influence of these variables on the dependent variable in the regression model (Polit et al., 2001). Another limitation was that randomization was not quite enough to take care of the confounding factors (Polit et al., 2001). This is because there are other factors that were left out that can result to confounding. In this case, stratification of the data was not done. For instance, gender could have a big influence on the drug therapy outcome but it was not considered (Polit et al., 2001). Oral rehydration therapy From 2004, there have been some significant improvements in our knowledge base regarding the treatment of c. difficile infections. Casburn-Jones and Farting (2004) study on management of infectious diarrhea concluded that nurses use oral rehydration that has remained important despite introduction of hypotonic solutions and there is early evidence that the resistant starch may be the substrate of the future. This was a systematic review whereby the researchers explored different aspects related to management of infectious diarrhoea (Polit et al., 2001). In the review, the limitation was that they never covered a big range of diarrhoea types and the specific treatment of the disease was not indicated. The search for anti-secretor drugs has been on for a long time. This has seen the introduction of new class of drugs (the enkephalins inhibitors). Nurses should use recommended oral replacement fluids which are glucose electrolyte solutions known collectively as oral rehydration solutions (Farthing, 1998). This solution has been a life saving therapy for many patients with severe diarrhea. The rationale and scientific research principle for this treatment are based on active carrier mediated sodium glucose contra-sport (“International Study Group on Reduced-Osmolality ORS Solutions,” 1995). The WHO (1999) has recommended an oral rehydration therapy containing 90mmol/l of sodium. A lower concentration of sodium of 50 – 60 mmol/l is effective. Glucose has always been the main substrate of ORT (oral rehydration therapy) though the possibility that the effectiveness may be increased by using complex substrates like cereals or defined glucose polymers, which have been explored widely for the last few decades (Gore et al., 1992). Replacement of glucose with a glucose polymer, such as rice starch has a dual benefit of producing low osmolality solution while providing good substrate. Cereal based oral rehydration solution has only a significant benefit in cholera but not in other diarrheal states (Gore et al., 1992).. Electrolyte and fluid replacement through the oral route is commonly sufficient unless the patient is vomiting and or losses are very extreme. According to researchers, dehydration occurs quicker in children and infants hence early administration of oral rehydration solution is advised to prevent acute dehydration and acidosis. In extreme dehydration, in young children and infants, nurses require to use intravenous fluid. In adults, formal oral rehydration therapy is needed withered oral fluids with, for example, soups which are salty, fruit juices and carbohydrates to provide glucose for the glucose-sodium contra sport (Margaret, 2008) Antimicrobial Researcher (Loeb et al, 2001) suggests that nurses should educate the hospitalized patients infected by clostridium difficile so as to manage it. The aim of the study carried out by Loeb et al., (2001) was to ascertain the variability and incidence of the antibiotic use in the facilities that provide chronic care. They also wanted to know how often clinical criteria related to infection are met in case of antibiotic prescription in these facilities. There were 22 facilities which were considered in the study and these facilities were known to provide chronic care in the South western Ontarion. This was a cohort study (Polit et al., 2001) that was conducted within a period of 12 months. 9,373 antibiotic courses were prescribed in total. The antibiotic prescriptions incidence in the facilities had a range of 2.9 -13.9 antibiotics course per 1000 patients-days. The study conclusion was that the use of antibiotics is frequent and highly variable between patients under chronic care. Antibiotic prescription reduction for asymptomatic bacteria is a representative of a critical way of optimizing the use of antibiotic in this population. The limitation of the study was that there was no randomization of the treatment and this could lead to the sample being not the representative of the population (Polit et al., 2001). Another factor that was also not considered is the taking care of confounding factors that could have effects on the data analysis (Polit et al., 2001). For instance, stratification could have been done to take care of this. Nurses should wear gloves and do a thorough washing of hands where necessary. Better compliance with isolation is also another effort to prevent CDAD. According to the researchers, inappropriate antimicrobial use is of concern, but not easily fixed as empirical use is general, based on clinical impressions and often without decision-influencing data such as the results of laboratory investigations. With all products of pharmaceutical, use is based on a risk-benefit ratio and if the perceived or known benefit is such that the product is used, risk associated with product use are accepted as part of the patient management. CDAD is recognized as a potential risk following antimicrobial exposure, so is the potential for secondary infection with drug-resistant organism, fungal infections and drug-associated side effects. C. difficile represents a significant health service burden, and outbreaks are extremely costly, affecting lengths of stay and eventually, disrupting services and patient care. According to the researcher, it is clear that the most successful measure for reducing the incidence of symptomatic disease has been a restriction of the use of antimicrobial agents from the available evidence. Nurses should treat patients if they are debilitated, specifically with malignancy, immune-suppressed, have an abnormal cardiovascular system, have orthopedic prostheses or vascular, have hemolytic anemia or are extremely young or old. Nurses should advise treatment for those with prolonged symptoms and those who relapse. In situations here there is doubt the effectiveness of antibiotics, it may not have a correlation with the potency of antibiotic but also to the design of the study. Antibiotic administration may be delayed after the onset of symptoms. If given late in the natural history of the disease, additional benefits of treatment could be missed. References Belmares J, Gerding DN, Tillotson G et al. (2008). Measuring the severity of Clostridium difficile infection: Implications for management and drug development. Expert Rev Anti Infect Ther;6: 897–908. Casburn-Jones A.C and Farthing M.J. (2004). Management of infectious diarrhea. International journal of gastroetelogy and hepatology. 53(2): 296–305. Dray X, and Marteau P.( 2006). Acute diarrhoea in the adult (with treatment). Journal of gastroetelogy and hepatology. ;56 (16):1811-6. Farthing MJG.(1998). Dehydration and rehydration in children. In: Arnaud MJ, ed. Hydration throughout life. Paris: John Libbey Eurotext,:159–73. Gore SM, Fontaine O, Pierce NF.(1992). Impact or rice-based oral rehydration solution on stool output and duration of diarrhoea: meta-analysis of 13 clinical trials. BMJ; 304:287–91. International Study Group on Reduced-Osmolality ORS Solutions (1995). Multicentre evaluation of reduced-osmolality oral rehydration salts solution. Lancet;346:282–5. Loeb M, Simor AE, Landry L et al, (2001). Antibiotic use in Ontario facilities that provide chronic care. J Gen Intern Med; 16:376-383. Margaret A. W. (2008). Infection control and prevention of Clostridium difficile infection. Journal of Antimicrobial Chemotherapy 41, Suppl. 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