The changing face of Clostridium difficile in critical care
ABSTRACT
Clostridium difficile, a Gram-positive, spore-forming, anaerobic bacillus, has been a common healthcare-associated infection since at least the 1970s. At that time it caused diarrhea and occasionally a more severe manifestation of pseudomembranous colitis. The disease usually affected frail older adults who'd recently undergone antibiotic treatment. The characteristics of the disease changed in the early 2000s, and it's now associated with more severe manifestations, including pseudomembranous colitis that may require a colectomy, sepsis, toxic megacolon, bowel perforation, and death. The demographics of those infected have changed from frail, hospitalized older adults to young, healthier patients, including postpartum women.1-4 C. difficile infection (CDI) contracted outside the hospital-either in the community or in other care facilities-is also increasing.5CDI is estimated to cost as much as $3.2 billion annually in the United States, with 333,000 cases and 15,000 to 20,000 deaths per year.6 If CDI progresses to pseudomembranous colitis, the mortality is estimated to be between 6% and 30%.7Medicine's reliance on (and sometimes inappropriate use of) antibiotics has caused increasingly resistant and difficult-to-treat infections. Transmission can be reduced by stressing optimal infection control practices and antibiotic stewardship. By 2013, all hospitals participating in the Centers for Medicare and Medicaid Services' Inpatient Prospective Payment System Quality Reporting Program will be required to report all CDIs to qualify for the program.8Along with antibiotic resistance, mutations in C. difficile's toxin genes have caused more virulent strains. In critically ill patients who depend on lifesaving antibiotic therapy, C. difficile and the treatment necessary to control it can often be a deadly complication. Because the severity of CDI has increased so dramatically, patients who were hospitalized for less severe illnesses can progress to the need for critical care.
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