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Thursday, 1 September 2011

The difficult case of C. difficile.

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An earlier blog (July 8 2011) touched on the spread of C. Difficile through Quebec and Ontario.  In both jurisdictions once the issue received widespread media attention, reporting and progress of the outbreak has become very quiet.   Two factors may have caused this, one is the application of better infection control practices and antimicrobial stewardship may have reduced the actual incidence, second is that politically it is enough of a hot potatoe that keeping it off the front pages has been a priority for public relations folks since early July in Ontario when the last reports were public.

The bottom line is the number of outbreaks of C. difficile would appear to be increasing, which means the number of people infected is likely increasing – finding that data seems impossible. Please send links.
The Canadian Nosocomial Infection Surveillance Program  (CNISP) Clostridium difficile in Canada     has some data up to 2007 and then an abyss. PHAC has a recently updated fact sheet where they even acknowledge/claim that they lead CNISP  PHAC information on C. Difficile .  Leadership also provides control over information release, and their last posted information is from 2005. 
C. difficile requires two conditions to be present for infection to manifest itself.  First is transmission of the organism which readily moves from person to person but does not cause illness.   The second is usually the use of a strong antibiotic.  “Strong” being a simple description for an antibiotic that kills not only bacteria that are causes a specific illness, but also kill a high proportion of healthy and normal bacteria.   It is the death of the healthy bacteria that provides the necessary environment for C. difficile to flourish and cause its toxic effects.
C. difficile is the most problematic of the superbugs currently in that affected persons suffer illness, usually result in more days in hospital where most cases are occurring, and occasional results in death.  
There are three ways to avoid the infection; 1. stay very healthy   2.  Avoid hospitals  3. Avoid antibiotics.    Sounds simple, but for many persons, particularly suffering illness associated with aging, hospitalization is health protection and antibiotics an be a necessity.   The final way to avoid infection is to prevent the transmission of the organism within the hospital setting – and we know how to do this through handwashing and other immaculate hygiene and infection control practices.  Even the best of health care professionals rarely wash their hands more than 50% of the time that they should.   Infection control practices have improved in the wake of SARS and H1N1 outbreaks, but remain far short of what we might hope is being practiced if we were hospitalized patients.  
Be a knowledgeable consumer, and if you go to hospital, check that staff have washed their hands entering and leaving the room.   Ask if they have had their influenza immunization.  Be sure that “equipment” for your comfort is dedicated for your use only and not shared.   Just don’t assume that it is being taken care of on your behalf. 
Amidst the threat of C. difficile is buried a controversy on fecal transplantation as a treatment.  If one of the problems is the loss of normal healthy bacteria, there might seem to be rationale in taking those bacteria from others and reestablishing the normal balance.   Not to take sides in the debate, the purpose is to acknowledge that there is proposed solution. In what might seem a pattern, such radical thinking is not being subjected to the process of scientific evaluation, but is receiving considerable policy debate because of the negative perceptions of the practice and in some instances the radical stance taken by some practitioners without persuing rigorous evaluation.  
For the moment, I’ll try to stay healthy, avoid hospitals and reserve antibiotics for those very rare really really bad infections. 

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