How do we best manage Clostridioides difficle infections in the elderly?

KEYWORDS:

• Geriatric medicine
• Clostridioides difficile
• antimicrobial stewardship
• infection control
• hand hygiene
• recurrent infection

1. Introduction

Clostridioides difficile (C. difficile) is a Gram-positive anaerobic spore-forming bacillus that causes toxin-mediated infection and inflammation in the colon. C. difficile most commonly causes infection when antibiotics disrupt the physiologic intestinal microbiome. While factually correct, how do these facts translate into clinical medicine and taking care of our geriatric patients? While the microbiologic characteristics may seem a bit esoteric, there are key characteristics that are important to understand in the prevention and treatment of C. difficile infection (CDI), as well as to help guide appropriate infection control policies. The management of CDI is more than treatment. Appropriate management of CDI includes prevention, infection control and antimicrobial stewardship, appropriate diagnostic testing based on clinical presentation, as well as appropriate treatment regimen.

Of the five bacteria cited as “Urgent Threats from Antibiotic Resistance, the Centers for Disease Control and Prevention (CDC) listed C. difficile as the third most urgent threat to address.¹ The complexity and urgent need to address CDI is not due to the resistance patterns the bacterium has developed. CDI ‘is not a resistant infection but is related to antibiotic use and antibiotic resistance’ due to the “same factors that drive antibiotic resistance [1].

CDI is unique when compared to other infections that are common in older adults. CDI has tremendous impact on patients, their communities, and the health care system. In 2017, the health care cost attributable to CDI was approximately one billion United States Dollars (USD). The attributable financial cost per single patient with hospital-onset CDI was $12,675 in 2017 [1]. There are over 200,000 cases of CDI in the US each year, with an estimated 12,800 deaths in hospitals [1]. Over half of all patients diagnosed with CDI reside in long-term care facilities [1]. The CDC report highlights that even this staggering financial impact ‘does not include any downstream healthcare costs that may occur after the index hospitalization, nor does it include any economic impacts to the patient from lost work time, diminished productivity, pain and suffering, or any long-term morbidities resulting from the infection’ which can be tremendous [1]. CDI is more common and becomes a more severe infection more often in patients that are 65 years old and older [1]. Older patients are also at increased risk to develop the cycle of recurrent CDI (rCDI). The risk of subsequent recurrence can be as high as 25–50% for each recurrence [2]. Patient responses to the validated ‘Cdiff32’ survey showed decreased quality in physical, social and mental domains for all patients with CDI and impact that is more pronounced for patients with rCDI [2].

There specific microbiologic characteristics that are important to understanding how to prevent, treat, and prevent spread of CDI. Treatment of CDI is complicated, so we must first focus on prevention of CDI through infection control policies and antimicrobial stewardship. Addressing the spore-forming nature of C. difficile is a critical guide for infection control policies.

The spore form of C. difficile can be dormant on surfaces for weeks to months, not killed by antiseptics or alcohol-based cleaning agents [3–5]. Because of these spores, proper hand washing with soap and water is required to physically remove spores from our hands. Additionally, cleaning exposed area with bleach-based solutions are needed to create pores in the spores for the cleaning agents to get to bacterial machinery to kill the bacteria. These increased cleaning protocols for infection control are especially important in congregate living situations, such as subacute skilled and long-term care facilities, to prevent spread to other potentially medically vulnerable residents.

Antimicrobial stewardship is the cornerstone of decreasing unnecessary and inappropriate use of antibiotics and, in turn, alterations of a patient’s intestinal microbiome. It is ‘essential that health care providers understand appropriate antimicrobial pharmacotherapy in the elderly patient [6].’ When looking specifically at the population of older adults who reside in long-term care facilities, 50–80% of these residents receive at least 1 course of antibiotics annually, and that 50% of antibiotic use of considered inappropriate [7–9].

Antimicrobial stewardship is in practice and in policy is critical in decreasing a patient’s risk of CDI and the risk of CDI spread within vulnerable populations. Utilization of clinical guidelines can help clinicians to assess a patient’s symptoms and develop likelihood of a true infection that requires antibiotic treatment. Every prescribed antibiotic regimen should contain the ‘antibiotic time out’ with the specific dose, duration and indication, to decrease risk of inappropriate and unnecessary use [10].

Appropriately diagnosing CDI starts with clinical symptoms. CDI is an infection in the colon and causes diarrhea. With very rare exception, a patient with CDI has diarrhea- three or more loose or watery stools in a day- that is new and not explained by other factors, like medications, specifically laxatives [11]. Assessing for early recognition of a patient with new diarrhea is best done through the empowerment of the patient, their care circle, and the inter-professional care team [12]. Clinical assessment of the patient can be done by in-person physical exam or by audio-video telemedicine visit. Once clinical criteria is met, assessing the stool for C. difficile is part of the diagnosis. There are many types of tests for C. difficile and diagnostic laboratories may have specific testing protocols. It is important that each clinician ordering C. difficile testing knows the testing algorithm for the corresponding laboratory [11].

CDI treatment guidelines have evolved quickly over the past few decades- often, when updated guidelines are published; there have already been novel agents or approaches to treatment shown to be beneficial in newer clinical trials [13,14]. As of this writing, the most recent 2021 CDI treatment guidelines have been published by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) [13].

2. Expert opinion

In addition to significant mortality, CDI can have devastating impact on quality of life and morbidity for elderly people who become infected. The treatment of CDI, and especially recurrent CDI, is complicated and not always effective. While experts have on-going research and clinical studies to optimize treatment of CDI, each clinician can directly affect their elderly patient’s risk of CDI by ensuring appropriate antibiotic use and early identification of clinical changes. The current magnitude of CDI in the US is not inevitable or unavoidable. As has been shown with the current COVID-19 pandemic, appropriate infection control policies can break the cycle of spreading CDI and improve outcomes for our elderly patients.

Author contributions

The author has substantially contributed to the conception and design of the article and interpreting the relevant literature, and wrote and revised the article for intellectual content.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or material discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or mending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

In part, this work has been presented at the Post-Acute and Long-term Care Society Annual Convention 2021.

Additional information

Funding

This paper was not funded.