In recent years, there has been a significant increase in the number of infections associated with Clostridium difficile. It is observed an increase in the number of serious diseases that are associated with a high rate of complications and deaths. Nowadays, Clostridium difficile is the main causative pathogen of nosocomial diarrhea that connected with the use of antimicrobials. In the present essay the following topics are observed in details: the etiology and epidemiology of Clostridium difficile-infection, method of transmission, risk factors, symptoms, treatment and impact on human population.
Clostridium difficile (C. difficile) is an acute infectious disease characterized by the development of diarrhea, pseudo-membranous colitis and enterocolitis. The true number of cases of acute infectious diarrhea does not coincide with the officially recorded sickness rate and order of magnitude is greater than the number of medical consultations in this regard. However, the number of reported cases of C. difficile infection is by tens of thousands to several million per year in different countries. It is precisely this fact that explains the necessity to observe C. difficile as a separate issue requiring careful consideration and control.
Etiology and Epidemiology of Clostridium difficile-infection
Clostridium difficile is a gram-positive spore-forming obligate anaerobic bacterium. Its pathogenicity factors are exotoxins that cause cytopathic and enterotoxic effects. The C. difficile bacterium has two major forms of existence: an active or it is also called 'infectious' form that cannot survive in the environment for a long time; and a noanactive or 'noninfectious' form, when spore can survive in the environment for prolonged periods. Thus, it is obvious that C. difficile can persist for a long time in the environment and its spores are resistant to many types of various disinfectants, heat treatment, and dryness. The spores may persist for a long time, even months on different surfaces such as different commodes, stethoscopes, bed rails, electronic thermometers etc. C. difficile has a natural resistance to most antibiotics and the spores can provoke disease in people at high risk for Clostridium difficile-associated disease.
Clostridium difficile is often found in the environment and can be isolated from soil. To isolate C. difficile is often used nutrient medium, prepared on the basis of egg yolk and containing cycloserine and cefoxitin as selective components that inhibit the growth of other microorganisms, as well as fructose. The above described medium is both selective and differential diagnostic that allows to determine C. difficile in the examined material, on the assumption of the density of microbial population not less than 6 x 1010 bacteria in 1 g of faeces.
The incidence of nosocomial diarrhea connected with C. difficile, varies greatly in different regions and even hospitals and departments. C. difficile infection is officially recognized as nosocomial. The vast majority of C. difficile cases are provoked by exogenous infection in patients during the hospital stay. Hospital-acquired cases of C. difficile infection can have both sporadic and epidemic character. Vaishnavi (2010) stated that in the event of outbreaks of Clostridium difficile-associated diseases in hospitals or nursing homes it can be covered from 16 to 29% of all hospital patients.
Method of Transmission
Infection with C. difficile can be carried out by exogenous (transfer from outside sources) and by endogenous (activation of own microflora) ways. However, there is no doubt that the preexisting endogenous reservoir of C. difficile is not a prerequisite for the development of symptomatic forms of infection, and in most cases the agent enters the body from the environment.
The most important exogenous sources of C. difficile are people with manifest forms of infections and asymptomatic carriers of the causative agent, who emits them in the environment. Infection in most cases occurs in a hospital, where medical personnel and patients are likely sources of infection. In this regard, as it was already mentioned, C. difficile infection is considered to be predominantly nosocomial.
According to Cunha (1998), "C. difficile is acquired from the environment or from the stool of other colonized or infected people by the fecal-oral route. Intestinal colonization rates in healthy neonates and young infants can be as high as 50% but usually are less than 5% in children older than 2 years of age and in adults. Hospitals, nursing homes, and child care facilities are major reservoirs for C difficile. Risk factors for disease are those that increase exposure to organisms and those that diminish the barrier effect of the normal intestinal flora, allowing C difficile to proliferate and elaborate toxin(s) in vivo." Household transmission of C. difficile with a variety of factors creates a serious risk of nosocomial infections, especially in patients treated with massive antibiotics. The cohorts at risk of developing severe nosocomial Clostridium difficile-infections are also young children with weakened organism, as well as patients who stay in the hospital for rather long time.
Risk factors
In addition to previously stated information Fekety (2003) added that "risk factors for developing disease include antimicrobial therapy, repeated enemas, prolonged nasogastric tube insertion, and gastrointestinal tract surgery and having renal insufficiency." Johnson and Gerding (2004) also concluded that "Penicillins, clindamycin, and cephalosporins are the antimicrobial drugs most commonly associated with C difficile colitis, but colitis has been associated with almost every antimicrobial agent. A previously uncommon strain of C. difficile with variations in toxin genes has become more resistant to fluoroquinolones and has emerged as a cause of outbreaks of C. difficile-associated diarrhea."
Symptoms of C. difficile
Intestinal C. difficile occurs more frequently on the type of pseudo-membranous colitis, or as acute enteritis and enterocolitis.
Saying about pseudomembranous colitis it is necessary to mention that the disease begins at the 4 - 10 day after starting antibiotic therapy. This stage is characterized by acute beginning. The body temperature rises up to 39,5° C and above, there are flatulence, anorexia, weight loss. Different main symptoms of intoxication appear and rapidly grow. Patients have severe spasmodic abdominal pain, repeated vomiting. Spasm and pain of small and large intestines are examined on palpation. Stool is copious, liquid, watery, greenish, with a putrid smell, admixture of mucus and often consists of the blood, shreds of fibrinogenous components. Aktories and Wilkins (2000) said that "severe diarrhea also can lead to dehydration and disturbances in the electrolytes (minerals) in the body. Rarely, severe colitis can lead to life-threatening complications such as megacolon (markedly dilated colon), peritonitis (inflammation of the lining of the abdominal), and perforation of the colon."
Treatment of C. difficile
Treatment of intestinal infection caused by C. difficile primarily includes the suspension of the antibiotic therapy - if this is justified from a medical point of view - and filling a huge loss of fluid and electrolytes. In most cases, these measures are enough to relieve symptoms. Anastaltic drugs are prohibited in these cases, because they contribute inhibition of bacterial toxins in the gastrointestinal tract. In severe disease may require antibiotics of narrow effect, such as vancomycin and metronidazole, because they are effective against C. difficile. However, to avoid the emergence of resistance to certain antibiotics, these drugs should be used only in cases when the patient's clinical condition makes the use of antibiotics therapy absolutely necessary.
Conclusion
Summarizing the above stated information it is possible to conclude that C. difficile has great impact on human population at present time. Such situation has a place, because nosocomial infection usually overrides the existing disease, always burden existed state, and often becomes the last page in the history of the disease. Thus, it is necessary to remember about prevention measures. The main prevention measure includes strict compliance with the rules of personal hygiene, as well as the strict implementation of all requirements for compliance with sanitary-epidemiological regime in hospitals. Moreover, increase of sanitary culture among population and the increasing professionalism of health workers will help to overcome C. difficile and help patients to become healthier.
