Treatment and Prevention of Clostridium difficile Infection in the Long-Term Care Setting
The treatment and prevention of Clostridium difficile infection (CDI) in the long-term care (LTC) setting presents unique challenges. In this review, we offer an overview of CDI treatment along with a brief discussion of infection control strategies in the LTC setting. The approach to recurrent CDI is also addressed.
Key words: Clostridium difficile, aging, metronidazole, vancomycin, long-term care.
Introduction
In the past decade, Clostridium difficile infection (CDI) has increased in frequency and severity and, as a result, has become more difficult to manage and treat. The changing epidemiology of CDI has been closely linked to the emergence of the epidemic B1/NAP1 strain of C. difficile, which produces increased levels of toxins A and B, the major virulence determinants of C. difficile.1,2 The changing epidemiology of CDI is also likely related to the increasing age and comorbidities among hospitalized patients.
Factors associated with increased risk of developing CDI include the following: age greater than 65, prior hospitalization, longer duration of previous hospitalization, use of broad spectrum antibiotics, longer duration of antibiotic use, use of multiple antibiotics, use of acid suppressive therapy, receipt of cancer chemotherapy, renal insufficiency, hemodialysis, and presence of a nasogastric tube. In general, older adults have been disproportionately affected; advanced age is a risk factor for acquiring CDI, and attributable mortality appears to increase with age.3,4 Older adults also experience a higher rate of CDI relapse, as well as more treatment failures on standard therapy.5,6
Clostridium difficile infection has been recognized as the most common cause of nonepidemic diarrheal illness in long-term care (LTC) facilities, where CDI outbreaks can be very difficult to control.7 Little published data are specific to older adults, and residence in an LTC facility further complicates treatment and prevention strategies. Finally, the issues of drug-related side effects, drug-drug interactions, and medication cost are especially significant in this patient population.
In this review, we offer an overview of specific agents used to treat CDI and also briefly discuss the approach to CDI relapse as well as infection control in the LTC setting.
Treatment
General Issues
Treatment for CDI is recommended only for symptomatic patients; asymptomatic carriers of C. difficile do not require treatment with antimicrobials.7 The mean time for clinical improvement after initiating treatment for CDI is 2–4 days, and, in general, a lack of clinical response after 6 days of treatment is considered a treatment failure.8 However, a change in treatment may be indicated much sooner than 6 days depending on the patient’s overall clinical condition. In general, a “treatment success” denotes resolution of diarrhea and other symptoms (e.g., abdominal pain, fever), if present.
Whenever possible, the offending antibiotic agent should be stopped as an adjunctive treatment measure.9 Antiperistaltic agents such as loperamide should be avoided in patients with CDI as there is a possible association between the use of these drugs and the development of megacolon.9
Table 1 presents a summary of the medications used in the treatment of CDI, along with respective dosages and comments.
Metronidazole
Metronidazole remains the first-line agent for the treatment of uncomplicated CDI. Although there is a role for intravenous metronidazole therapy in the setting of severe CDI, these scenarios almost always