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Hospital Infection Spreads, Toughens: C. Diff Cases in Region Grow

Posted on: Friday, 20 January 2006, 12:00 CST

By Josh Goldstein, The Philadelphia Inquirer

Jan. 20--Just hours before the intense nausea hit, Robin Wache was bragging to her friends about how good she felt after surgery to treat an intestinal infection.

Then the mother of three got the worst case of diarrhea ever. It lasted for weeks and was so severe she could hardly leave her Ambler home.

Wache, 45, was stricken by Clostridium difficile, a sometimes deadly bacterium that has recently become more virulent and widespread, putting health officials on edge.

"The disease that is being seen is much more severe, and there is a new epidemic strain circulating nationally and internationally," said Neil Fishman, a University of Pennsylvania infectious-disease specialist.

The infection initially had been found mostly in hospitals and nursing homes.

An Inquirer computer analysis shows the number of hospital patients diagnosed with the infection is rising.

In Philadelphia and its Pennsylvania suburbs, the rate of patients diagnosed with C. diff, as the disease is known, shot up 42 percent from 1997 to 2003.

In New Jersey, the rate more than doubled between 1997 and 2004 to 9.5 cases per 1,000 hospital patients. In 2004, hospitals in New Jersey diagnosed 10,852 patients with the illness, up from 4,818 in 1997.

Nationwide, there were 178,000 C. diff patients in 2003, about a 60 percent increase since 1997, according to the National Hospital Discharge Survey.

C. diff is a leading cause of antibiotic-associated diarrhea and, until recently, was primarily seen as a problem confined to hospitals and nursing homes.

Now researchers have identified a strain that appears to have developed resistance to some antibiotics. Further, it may no longer be confined to hospitals.

"We need to figure out whether the community cases are increasing," said L. Clifford McDonald of the Centers for Disease Control and Prevention in Atlanta.

Traditionally, the disease is linked to recent use of antibiotics. The drugs kill off a patient's existing bacteria, giving the C. difficile an opening to colonize.

Last month, the federal agency issued a report that examined possible "community-acquired" cases in Pennsylvania, New Jersey, New Hampshire and Ohio.

The agency found 33 cases in "otherwise healthy patients with minimal or no exposure to a health-care setting." In eight of those, the patients reported no antibiotic use for at least three months before they became ill.

A 10-year-old girl with no recent visit to a health-care facility or antibiotic use became severely ill with "diarrhea, projectile vomiting, fever and abdominal pain," the CDC reported. The girl recovered.

Doctors are seeing more of the disease in people previously thought to be at low risk.

"We have seen young people, after one dose of an antibiotic, develop a severe problem," said Martin Topiel, director of infection control at Virtua Health, a hospital system in South Jersey.

Topiel and other infectious-disease experts say inappropriate use of antibiotics contributes to the spread of this type of disease.

"This is just another example of the evolution of emerging infections that we are going to be facing over the years," he said. "This is a major health-care issue that has really gone under the radar."

Most studies show that elderly and infirm patients in hospitals and nursing homes are at greatest risk, said Dale N. Gerding of the Hines VA hospital in Illinois.

While most patients survive, complications caused from the infection can kill the most vulnerable, he said, but there are exceptions.

"What happens is you have somebody already sick in the hospital for something else and you pile on severe diarrhea," said Gerding, who has studied the bacterium for 20 years.

In June, the Pennsylvania Patient Safety Authority warned hospitals of a growing number of C. diff illnesses that contributed to at least 15 deaths.

Since then, "we have received reports of at least five more deaths associated with C. difficile," said Alan B. K. Rabinowitz, administrator of the agency.

"We have also received reports indicating serious outcomes associated with C. diff infections," he said. For example, five patients had their colons removed, a last-ditch, lifesaving measure.

The disease recurs for one in five patients, Fishman said. Even more alarming, nearly half of those who get the disease a second time contract it a third time, he said.

The average patient spends an extra 3.6 days in the hospital at a cost of more than $3,650, the Patient Safety Authority reported.

The growth of the problem can be seen in sales of Vancocin -- the key antibiotic used to treat C. diff. In 2005, sales of the antibiotic rose 34 percent, according to ViroPharma Inc., the small Exton-based firm that makes the medicine.

Those figures also indicate that the nation's Northeast is a hot spot for the disease, said Colin Bloom, ViroPharma's chief scientific officer.

John J. Kelly, chief medical officer of Abington Memorial Hospital, is so worried that he gathered his department managers last week to lay out a strategy to contain it.

As with most infectious diseases, hand-washing is an important protective measure. C. diff spores are best killed by soap and water, not alcohol-based hand rubs. The disease is spread through spores shed by infected people and ingested by others.

Kelly and other experts say infected patients are usually isolated and health-care workers wear gloves and gowns. Powerful cleansers are used to kill the spores.

Perhaps most important, Kelly said, is taking more care when prescribing antibiotics.

"It is not a good thing if a patient develops a life-threatening illness because we gave them a drug they did not need," Kelly said.

Robin Wache recognizes that the antibiotics used to treat the ruptured abscess in her intestine were necessary and might have saved her life. But she worries that many people are getting the drugs inappropriately, causing the C. difficile bacterium to become stronger.

The debilitating C. diff infection she contracted changed her life and her family's.

Her diarrhea lasted about 10 weeks. For much of that time, Wache stopped taking walks in her neighborhood for fear of being too far from a bathroom.

"I was pretty much housebound," Wache said.

Her husband quit a well-paying job in Milwaukee so he could be close to home.

Wache reserved one bathroom in the house for herself to reduce the family's exposure to the bacteria. She insisted the entire family wash their hands continually. She used bleach to wash her clothes and powerful cleaners throughout the house to kill C. diff spores.

Even after Wache recovered, fear of the illness weighed on her. When her grandmother was hospitalized, Wache was reluctant to visit for fear of being reinfected.

A Severe, Even Deadly, Illness

Clostridium difficile is a bacterium that can cause severe, even deadly, infections in people. It is usually associated with antibiotic use and, until recently, has been largely confined to hospitals and other health-care settings.

Symptoms: Diarrhea, fever, abdominal pain and nausea.

How you get it:C. diff follows a fecal-oral transmission route, making hand washing an important protection. Antibiotics often kill benign bacteria in the intestines, leaving a person susceptible to C. diff colonization.

Treatment: Antibiotics, metronisazole and vancomycin, although there is concern that the former has become less effective against the disease.

ONLINE EXTRA

To learn more about an illness on the rise, go tohttp://go.philly. com/cdiff

Contact staff writer Josh Goldstein at 215-854-4733 or jgoldstein@phillynews.com.

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Source: The Philadelphia Inquirer

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