The long-term care setting sees many cases of Clostridium difficile (C-diff) each year, which places elderly residents at a very high risk for other complicating factors such as dehydration and skin breakdown. As such, the protocols in my long-term facility call for stool sampling if a resident has had three or more loose stools with no identifiable cause (such as lactulose, milk of magnesia, etc) in a 24 hour period or less. While the stool sample is being tested, the patient is placed on contact precautions until the results are returned. Unlike the acute care setting, rooms are often not available to separate the resident from other residents, and in our facility, the toilets are set up in a Jack-and-Jill manner in which two rooms (four people) share one toilet. Therefore, a bedside commode is provided to the affected resident, a personal protective equipment caddy is hung on the door and signage asking visitors and staff to check with a nurse before entering is placed on the doorframe. Once the resident has been cleared from the C-diff and the contact precautions are discontinued, the environmental services staff will clean the room in accordance with C-diff decontamination protocols.
There are three widely used tests to determine if the stool is positive for C-diff – GDH, glutamate dehydrogenase test, the NAAT, nucleic acid amplification test and the enzyme immunoassay toxin test (McDonald, et al., 2018). It is recommended that at least two of these tests be combined to determine if a stool sample is positive for C-diff. This will help eliminate false positive results.
Determining what, if any, pathogen is causing a patient to have symptoms is likely the most important and primary step in reducing the risk of developing C-diff. When a patient begins to have signs/symptoms of an infection, it is important to make every effort to identify the cause or pathogen, so that a specific course of treatment can be provided. When a provider is unsure of what specific pathogen is at the root of problem, he/she is likely to prescribe a broad spectrum antibiotic. Additionally, a broad spectrum antibiotic may or may not halt the pathogen. If a patient is treated for C-diff without the proper testing, there is a chance that the wrong course of treatment may be prescribed, adding to the problem or failing to address it at all.
In regards to antibiotic stewardship, my facility is struggling to wrap its arms around the process. While the staff, especially the nurses, are on board with working to make sure that antibiotics are not over prescribed to carried out too long, there has been a lot of interference and push back from residents and their family members. Some of the protocols in place for the antibiotic stewardship program include following recommended guidelines for diagnosis of infections such as urinary tract infections and wound infections by waiting for laboratory results to be returned before prescribing. Additionally, our facility requires that the physician or prescriber provide a stop date for any antibiotics. Lastly, residents that are known to have colonized bacteria are not arbitrarily re-tested for the same infection as it can prompt a provider to prescribe unnecessary and ineffective courses of antibiotics (Beerepoot & Geerlings, 2016).
As C-diff is often a result of over usage of antibiotics, and many strains of C-diff are reported as being resistant to multiple antibiotics, alternative methods are being explored in the treatment of C-diff. Some of these alternative treatments include the development of human antibodies (such as bezlotoxumab) to prevent the development of clostridial toxins necessary to develop C-diff (Peng, et al., 2018). Other strategies include fecal microbiota transplant (Lin, et al., 2018) and the use of bacteriophage proteins to control C-diff infections (Wang, et al., 2015).
Beerepoot, M., and Geerlings, S. (2016). Non-antibiotic prophylaxis for urinary tract infections. Pathogens. 5(2), 36-38.