1. Clostridium Difficile BY: KELSEY COMBS AND ROSA CORDOVA

2. What is C. diff? Clostridium difficile is a bacterium that causes inflammation of the colon, a disease called colitis. The bacterium is not always unpleasant. In fact, 5% of the population has C. diff living as their normal flora in their colon, but do not experience any signs or symptoms. When things go wrong, is when a person is treated with antibiotics for an extended amount of time. This leads to our normal colonic bacteria being suppressed and that allows the C. difficile is free to multiply quickly, causing colitis.

3. History Timeline of C. difficile  1893: First Pseudomembranous colitis was described  1935: 1st isolated from stool of healthy infant by Hall and O’Toole  1978: George and colleagues found that C. diff was responsible for most cases of antibiotic- associated diarrhea  Today: C. diff is the leading cause of hospital acquired illness in the United States

4. Quick Facts about C. difficile!  Each case of C. diff is estimated to cost the person an extra $3600 in health care  Approximately 500,000 cases per year occur in the United States  The mortality rate has seen a 20-fold increase  15,000-20,000 patients die every year from C. diff  42% of meat sampled from supermarkets contained C. diff bacteria  C. diff can be spread by a simple handshake

5. Case Study of Clostridium difficile Infection A woman (Patient P), is 50 years old and has a history of rheumatoid arthritis and diverticulitis. Patient P is a nurse, therefore, she is extra cautious about hand washing and reminds others around her to do the same. She had recently undergone a temporary colostomy and then got it removed. As she was attempting to get back into normal dietary activity, she was never fully healthy. Patient P never gained any weight back and developed a watery diarrhea. After multiple times back into the surgeons office, he did not look too much into it and suggested she consider counseling for the symptoms and that she should visit her primary care doctor.

6. Patient P continued searching for results and requested a test for C. difficile, which tested positive for the infection. At the time, she had minimal pain and estimated that she had 8-10 loose or watery stools per every 24 hours. The first medication they gave her was metronidazole. She took 500 mg every 8 hours for 10 days. She improves greatly, and after one week, Patient P had 1 to 2 formed stools a day and has an improved appetite.

7. Two weeks after she finished the first medication treatment, her diarrhea returned and she was then treated with vancomycin. Patient P took 125 mg every 6 hours for 14 days, followed by a slow tapered dose over the next three weeks. Six weeks after starting the vancomycin, she had fully formed stool, regular bowel habits, increased appetite, and her sense of well- being had been restore. It is unknown if Patient P had been an asymptomatic carrier of C. diff prior to admission, such as just a byproduct of her work exposure, or if she had picked up the infection due to her recovery time she spent in the hospital.

8. C. diff Characteristics Bacterium Gram positive Anaerobe Rod- shaped Heterotroph Reproduces by binary fission Moves by evenly spread flagella covering the cell Requires five amino acids for energy metabolism Can exist in a vegetative or spore form

9. Spore form of C. difficile Can survive in harsh environments Withstands sterilization techniques Resistant to high temperatures, ultraviolet light, and strong chemicals Survives against antibiotics, which allows it to remain in the gastrointestinal tract for long periods of time

10. Virulence Factors 1. Produce A and B toxins that do several things Cause diarrhea Leads to colitis Disrupts the actin cytoskeleton 2. Has fimbriae which is used for attachment in the gut 3. It has many flagella to increase its motility. 4. Can produce capsules that make it hard to be eliminated 5. Also produce heat-resistant spores when located outside the body

11. Pathophysiology The following chain of events results in C. diff  A disruption in the normal bacterial flora of the colon  Colonization with C. difficile  Release of toxins that cause mucosal damage and inflammation

12. Signs and Symptoms Symptoms are usually present after 5-10 after taking antibiotics Strong smelling stool Watery/frequent stool Stomach or abdominal pain Fever Loss of appetite Weight loss Nausea

13. Mode of Transmission Clostridium difficile is spread through feces. Any surfaces that become contaminated with fecal matter serves as a reservoir for the C. diff spores, which therefore, are transmitted, most commonly, by the hands of medical staff that have touched a contaminated area.

14. Prevention If transmission of the infection is by touching contaminated things, then best way to prevent it is by…WASHING YOUR HANDS! Do it often and remind others around you to do the same

15. Diagnosis of C. difficile Diagnostic strategies have been improving drastically over the years. There are different ways to test for the infection.

16. Possible Forms of Treatment If a person has a strong suspicion that they have C. diff, it is strongly advised that they begin treatment right away, and do not wait for the test results. Recommended Treatments oDiscontinue any antimicrobial agents oLimit use of anti-peristaltic agents oTake one of the following: oMetronidazole 500 mg orally three times a day for 10 days (If a patient does not respond to this after 5-7 days, or they are pregnant/breastfeeding, then resort to Vancomysin) oVancomycin 125 mg four times daily for 10 days o If there is a third occurrence after pulsed vancomycin regiment, fecal microbiota transplant should be considered

17. Number of Cases in Oregon

18. Importance of Studying the Disease? Clostridium Difficile is extremely important to study for many different reasons. The main reason being that many of us have goals of being in the healthcare field and this infection directly affects the medical staff if the proper precautions are not taken. C. diff is the leading cause of hospital-acquired diarrhea in both the United States and Europe. C. difficile is also a serious re-emerging pathogen, so beating it once is not good enough. We must follow procedures and learn techniques to prevent it all together. Learning prevention begins with becoming more educated on the disease as a whole.

19. Information References Bartlett, J. and Gerding, D. (2008). Clinical infectious diseases. Retrieved on July 13, 2015 from http://cid.oxfordjournals.org/content/46/Supplement_1/S12.full Ciaran, P. K. (1994). Clostridium difficile colitis. Retrieved July 13, 2015 from http://www.nejm.org/doi/pdf/10.1056/NEJM199401273300406 Kumm, J. (2009). General characteristics of Clostridium difficile. Retrieved on July 13, 2015 from http://bioweb.uwlax.edu/bio203/s2009/kumm_jakl/growth&ad apt.htm Rodriguez, J. (2008). Clostridium difficile. Retrieved on July 13, 2015 from http://www.austincc.edu/microbio/2704v/cd.htm Vedantam, G. (2012). Clostridium difficile infection. Retrieved July 13, 2015 from http://www.ncbi.nlm.nih.gov/pubmed/22555464

20. Picture References http://static.guim.co.uk/sys-images/Guardian/Pix/pictures/2013/2/18/1361197461368/Clostridium-difficile- C-d-013.jpg http://w3.chabad.org/media/images/355/zLee3551098.jpg https://classconnection.s3.amazonaws.com/554/flashcards/618554/jpg/peritrichous1327193029852.jpg http://www.biologycorner.com/resources/fission.jpg https://classconnection.s3.amazonaws.com/899/flashcards/1256899/jpg/b2200531- clostridium_perfringens_bacterium_with_spore-spl1330649924267.jpg https://www.google.com/search?q=person+with+abdominal+pain&biw=1366&bih=627&source=lnms&t bm=isch&sa=X&ei=2sigVa67IofxoASbsYuICg&ved=0CAYQ_AUoAQ#imgrc=ayL3YParhGzvhM%3A http://www.greenaircleaningnyc.com/wp-content/uploads/Flu-Sick.jpg http://manhattan.myhomecareblog.com/files/2014/06/bigstock-Sick-older-woman-trying-to-eat- 34022006-300x200.jpg http://imagefriend.com/vicomycin.shtm http://www.123rf.com/photo_17811638_contagious-virus-infection-with-children-hands-holding-and- touching-spreading-dangerous-infectious-g.html http://www.cdc.gov/vitalsigns/hai/stoppingcdifficile/ http://www.bioquell.com/en-us/home-page-highlights/microbiology-homepage-highlights/clostridium- difficile/ http://www.cnhsa.com/hand-washing.aspx http://www.theamericannurse.org/index.php/2011/02/02/the-go-to-nursesfinding-ways-to-keep-long- time-rns/ http://www.alere.com/us/en/product-details/c-diff-quik-chek-complete.html