C. diff danger spreads

`Simple little operation' that's a success can evolve into a deadly infection

By Tracy Wheeler

Beacon Journal medical writer

In March 2004, Christine Falkenberg underwent surgery to repair a fractured hip.

Three months later, she was dead, the victim of an infection she caught while in rehabilitation.
``It's really sad when a person goes in for a simple little operation and ends up dying,'' said Falkenberg's daughter, Teddy West of Mantua. ``It makes you really leery to go into any facility to have something done.''
The bacterium that took Falkenberg's life -- Clostridium difficile, or C. diff -- is being blamed for an increasing number of infections and deaths nationwide.
In Ohio, the number of deaths caused by C. diff has risen nearly 325 percent, from 112 deaths in 2000 to 473 in 2005, according to the Ohio Department of Health.
The total number of diagnosed C. diff infections doubled between 1996 and 2003, according to the U.S. Centers for Disease Control and Prevention, which is urging doctors to be aware of the increased risks and make efforts to prevent spread of the disease.
This year, the state department of health began tracking C. diff cases for the first time, with the data showing that long-term care hospitals are the most likely places to see higher rates of the infection, though the pathogen is found in hospitals, rehab facilities, long-term care facilities, and nursing homes.
C. diff is a bacterium commonly found in the intestinal tract, but it can gain strength and cause severe illness -- diarrhea and colitis -- when antibiotics are used. Deadly outbreaks in Canada and an increasing number of severe and deadly cases in the United States have drawn new attention to the infection.
65 and older at risk
Those 65 and older are at greatest risk, accounting for 92 percent of the deaths in Ohio.
Falkenberg, at 93, fell into that high-risk category.
However, West said, ``when she went in for the hip repair, she was in perfect health. Sharp as a tack. She was just as perfect as you and I. She could do everything and anything.''
While Falkenberg managed to kick the infection once after surgery, she couldn't overcome it when the bacterium returned during a nursing home stay that was supposed to help her recover. During that second bout, ``she just went downhill,'' her daughter said. ``She was so thin, it was just awful... Her downfall really was the C. diff. It just debilitated her.''
West estimates that her mother lost 30 pounds by the time she died, ``and she couldn't have weighed more than 95 when she went into the hospital. She was nothing but skin and bones.... Even three days before she died, she shook her head and said, `I'm not getting any better.' She just quit eating and that was it.''
C. diff is one of those illnesses most people never hear about until they or a loved one suffers from it. But, West said, health-care consumers deserve to know how their hospital or rehab facility stacks up.
``I'm sure none of the hospitals, none of the facilities, really want the information out,'' she said. ``On the other hand, something needs to be done.''
State gathering reports
The monthly reports being gathered by the Ohio Department of Health are available on the agency's Web site, www.odh.state.oh.us/.
With nine months of data collected, ``I can say that C. difficile is indeed found in health-care facilities in Ohio, at a rate of 7 to 8 per 10,000 patient days,'' said Dr. Forrest Smith, ODH's state epidemiologist. ``That's something we did not know before this.''
The goal behind the state tracking system is to establish benchmarks that will identify typical levels of C. diff across the state and within individual institutions, Smith said. Once benchmarks are established, outbreaks will be easier to recognize.
While local hospitals show monthly averages ranging from 1.1 to 15.1 cases per 10,000 patient days, long-term care hospitals saw average monthly rates as high as 45 and 53 per 10,000 patient days.
Health-care officials warn that using these numbers to compare one facility to another is problematic, though.
The monthly numbers do not take an institution's patient characteristics into account, Smith said. Some facilities have patients with more severe health problems than others.
Long-term care facilities, for instance, tend to have older patients, patients recovering from surgery, and patients with complex, multiple health problems, said Martie Allen, director of nursing and clinical services at the Edwin Shaw Hospital for Rehabilitation.
``The population that comes to our facility are really very major traumas -- horrific auto accidents, brain injuries, multiple fractures, people who are literally at death's door,'' she said. ``We also get a very large number of elderly people, most of whom don't have the physical reserves that young people do.''
Antibiotics are trigger
The vast majority of these patients are on extensive antibiotics regimens -- the No. 1 risk factor for C. diff infections.
Among the local long-term care hospitals, Edwin Shaw has the lowest C. diff rate, at 19 cases per 10,000 patient days per month. Select Specialty Hospital of Canton, which leases space inside Mercy Medical Center, has the highest rate at 53.8.
Another difficulty with the numbers is that C. diff does not lend itself to a simple cause-and-effect situation, said Dr. Gary Bollin, chief of infectious disease at Akron General Medical Center. Just because someone becomes ill with C. diff during a hospital stay, that doesn't mean that the patient caught the bug while in the hospital. In fact, he said, it's possible that the patient brought the bug with them in their intestinal tract, only to have a course of antibiotics allow it to take over.
C. diff is carried in 1.5 percent to 3 percent of healthy adults but increases to 20 percent to 40 percent in hospitalized patients. The intestinal tract is populated with friendly bacteria. But antibiotics can kill off these good bacteria, allowing C. diff -- a bad bacterium -- to colonize the gastrointestinal tract, leading to severe, watery diarrhea.
In many cases, Bollin said, patients are given antibiotics before they enter the hospital. So the question is, are these truly hospital-acquired infections or infections that happen to sprout while a person is in the hospital? The answer isn't clear.
Still, he said, there is some value in tracking the infections, especially for facilities with rates much higher than the average. In such cases, those facilities could use the tracking numbers to figure out whether the infections are coming from certain hospital floors or certain surgical procedures.
How to combat C. diff
Research has shown that the most effective way to combat C. diff in hospitals is hand washing with soap and water (not alcohol-based hand sanitizers). Other recommendations, presented at the 2005 annual meeting of the Infectious Disease Society of America, include:
Wearing gowns and gloves when treating patients who are suspected to have a C. diff infection.
Cleaning with 1-to-10 dilution of household bleach.
Isolation of infected patients for the entire length of stay.
Permit nurses to order C. difficile lab tests because they often know when patients have diarrhea one to two days before doctors do.
Limit use of C. diff-associated antibiotics (clindamycin, ceftriaxone, and levofloxacin).
Policies and procedures can make a difference, said Sherri Rhodes, director of infection control at Edwin Shaw. After seeing an increase of cases in June and July, the staff was educated about hand washing and ``contact precautions,'' which include wearing gowns and gloves, as well as guidelines on removing those protective items before leaving the patient's room so the C. diff bacterium doesn't leave the room either.
Procedures also include not allowing the patient to leave the room, even for therapy which is performed in the room for those with C. diff infections.
After having three cases in June and four in July, Rhodes said Edwin Shaw has had none since.
http://www.ohio.com/mld/ohio/living/health/16106284.htm
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