Opinion Former Article

MRSA Action UK: Using fingerprinting and testing for toxin positive patients is key to reducing Clostridium difficile

Care homes and hospitals need to take advantage of their local Health Protection Units in the use fingerprinting to check for cross infection. New evidence that shows fewer than a quarter of cases can be linked to other patients makes diagnosis and effective treatment absolutely essential if deadly strains are to be halted from becoming endemic in our care facilities.

Targeting patients with tests that will be able to identify who is vulnerable to the toxigenic type of disease that is more likely to cause severe illness and higher mortality remain important interventions.

Lab detection is fundamental to tackling Clostridium difficile infection, it is therefore important that the best test is used to give the patient the best chance of overcoming the illness, and to help to control the risk of cross-infection. 10-20% of adults aged over 65 can be colonised with the bug that might produce toxins. Colonisation will last 4-6 weeks in 56% of patients in an environment where Clostridium difficile infection is endemic.

A clearer picture of the disease both in and out of hospital is needed as there is too much variation in testing currently. Where there are outbreaks either in hospital or in care homes, use of fingerprinting is essential to establish if there is cross infection. Toxin positive patients are more likely to die, so it's important to identify potential Clostridium difficile carriers.

Metronidazole and Vancomycin are currently used to treat Clostridium difficile. Patients with a raised white cell count, which is one of the symptoms of more severe disease, do better on Vancomycin.

Fidaxomicin will be licensed for use in the UK from June 2012, trials show the recurrence of Clostridium difficile infection is less frequent with Fidaxomicin than with Vancomycin. Fidaxomicin costs one and a half thousand pounds for a 10 day course, so there will be a need to assess which patients are at higher risk of recurrent C diff. The frail elderly are more likely to benefit. Resistance has not been detected, although there was a need to increase levels during trials. We need surveillance to check this is not a clinical problem as it will be 4-5 years minimum before a fourth and fifth antibiotic for the treatment of Clostridium difficile will be available. Patients should be isolated within 2 hours of unexplained diarrhoea.

The deadlier strain 027 has significantly reduced, and 027 has kept others at bay, 078 is increasing and there are similar risks associated with this strain. We need to resolve this before patients start dying.

Environmental and air sporicidal spread is significant. Research has shown that toilet facilities in healthcare settings vary widely, but patient toilets are commonly shared and do not have lids. When a toilet is flushed without the lid closed, aerosol production leads to surface contamination within the toilet environment. Lidless conventional NHS toilets increase the risk of C. difficile environmental contamination, their use should be discouraged in settings where C.diff occurs.

Patients are infectious for about a week. Less than a quarter can be matched to other cases, there is little evidence of long term ward transmission, but we need to keep on top of the diagnosis of the deadlier toxigenic strains to stop deadly strains in their tracks, and to use a common sense approach to keep fighting Clostridium difficile.

Derek Butler
MRSA Action UK
Tel: 07762 741114 

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