Lawrence J. Brandt, MD; Erik Dubberke, MD; Daniel E. Freedberg, MD, MS; Dale N. Gerding, MD; Yoav Golan, MD, MS; and Peter L. Salgo, MD, highlight additional considerations in the treatment and management of Clostridium difficile infection.
Peter L. Salgo, MD: Let me bring up one of the most surprising and shocking problems that I’ve seen over the past few years: hand washing. People aren’t washing their hands. Our visitors need to wash their hands. Physicians need to wash their hands. And another problem I’ve seen is with the use of the alcohol-based cleaners—those Purell-like compounds—instead of hand washing. They don’t kill the spores at all. How do you bring handwashing back?
Dale N. Gerding, MD: That is a challenge that I think all of us have in infection control because the use of alcohol in hand hygiene has really replaced hand washing in many cases. We always recommend that if you have visible soiling that you wash your hands. And I think in our hospital at least, when we have an isolated patient with Clostridium difficile, we automatically require people to wash their hands after leaving that room. That is not a universally recommended practice, however. It is a practice that is reserved for high rates of Clostridium difficile. We do it all the time in our hospital, and I think it’s appropriate. We don’t know for sure what the best hand hygiene is after leaving a room of a patient with Clostridium difficile if you’ve been wearing gloves because you probably don’t contaminate your hands all that much.
Erik Dubberke, MD: I think the first step is actually, even if you take off your personal protective equipment (PPE) properly, to wear the gloves and the gowns. That’s our first step. If you never contaminate your hands in the first place, it doesn’t matter if you use alcohol or not. And you also need to remember that Clostridium difficile is all over these rooms. So, if you’re going to walk in that room, you need to wear those gloves. In one study, they showed that a healthcare worker’s hands were just as likely to be contaminated with Clostridium difficile whether or not they ever touched the patient after leaving the room.
Peter L. Salgo, MD: The keyboards, the surfaces.
Erik Dubberke, MD: Yes. Clostridium difficile is all over that room. Put on the gowns and gloves and then remove them properly, because we’ve been doing some studies lately, as well, that show there’s a lot of self-contamination. And by removing PPE, the gloves and gowns, we find that 25% to 35% of the time, healthcare workers are contaminating themselves.
Yoav Golan, MD, MS: It’s also important to remember to consider how do you wash your hands and who should wash their hands. It’s not just healthcare providers, but it’s also the patient and the family of the patient. Those are used as the vehicles, even if they don’t get sick. Clostridium difficile does not jump from one patient to the other and patients usually don’t interact within hospitals. But it goes through the hands of whoever. And, when you wash your hands it’s important to remember that you really have to do it for a period of 30 seconds and should physically wash your hands, because it’s not the detergent or the water, it’s the physical activity.
Peter L. Salgo, MD: With that, we’re going to move on. This has been a terrific discussion. Before we end this discussion, what I’d like to get are some final thoughts from each of our panelists. Dr. Brandt, why don’t you start us off?
Lawrence J. Brandt, MD: First, thank you for inviting me. I enjoyed this, and I learned a lot. But the points that I would make are to reemphasize the importance of antibiotic stewardship, to emphasize how important it is to be aware of Clostridium difficile and how common it is and to think of it whenever you have any patient who has diarrhea. Especially as gastroenterologists, your patients with ulcerative colitis who come in for what appears to be a flare of disease should be tested for Clostridium difficile. And when we manage our patients with Clostridium difficile as a gastroenterologist, talk to your infectious disease colleagues.
Peter L. Salgo, MD: Dr. Dubberke?
Erik Dubberke, MD: I definitely agree with the comment on antimicrobial stewardship. Definitely, as Yoav mentioned, 30% to 50% of people on antibiotics don’t even need that antibiotic. That’s pretty low-hanging fruit for being able to reduce Clostridium difficile infection. And another thing I think to stress is to remember that when that patient does develop Clostridium difficile infection, you should educate them about it. Let them know there’s a good chance it might come back and if the diarrhea starts to come back, they should give a call. And something we haven’t touched on yet, but is part of my education (especially for those patients with recurrent Clostridium difficile), is that I actually recommend that they use a bleach-based cleaner—not only in their bathroom but also in their kitchen—because these patients with Clostridium difficile, when they go home, contaminate their home with that strain of Clostridium difficile they left the hospital with.
Peter L. Salgo, MD: Dr. Freedberg?
Daniel E. Freedberg, MD, MS: Clostridium difficile is the archetypal disease of the gastrointestinal microbiome. It’s caused by a single organism, and it’s cured by replacing a damaged microbiome with a normal one. Right now we treat Clostridium difficile with antibiotics. But in the future, I think the near future, we’ll be treating Clostridium difficile with some kind of targeted therapy—although we’re not quite there yet. Community physicians should know how to diagnose and treat Clostridium difficile, and then they should be a part of antibiotic stewardship for Clostridium difficile. Clostridium difficile is a reason not to prescribe antibiotics to patients. So, in that sense, perhaps it’s the silver lining in the cloud, and you can explain this to patients. And some, at least, will understand why you’re not prescribing antibiotics in situations where they’re not necessary.
Peter L. Salgo, MD: Dr. Gerding?
Dale N. Gerding, MD: I think the state of fecal microbiome transplant (FMT) is still in its infancy. It is not an approved therapy, and I would suggest that if you’re interested in doing FMT, that you enter your patients into randomized controlled trials. We’re starting to learn a great deal about comparative treatments versus FMT, and I think there’s a huge amount to learn. The other thing that we talked about is all the things you shouldn’t do in antimicrobial stewardship. And to avoid leaving you with no recommendation about what you should do for patients who need an antibiotic in the ambulatory setting, there’s pretty good evidence that tetracycline, doxycycline, and minocycline are probably protective against Clostridium difficile in this ambulatory setting—so I would suggest using more of those drugs. They’re inexpensive and they’re very effective. And another alternative that also is low risk is to use trimethoprim/sulfamethoxazole in those settings. So, that would be my suggestion if you’re practicing good antimicrobial stewardship.
Peter L. Salgo, MD: And with the last word, Dr. Golan?
Yoav Golan, MD, MS: I don’t have too much to add. Just for our community care providers, I think what really is important is to remember that Clostridium difficile is not a rare disease anymore. If you have a patient who was recently exposed to antibiotics or is on antibiotics, and develops diarrhea and really becomes sick and has bad diarrhea, think about Clostridium difficile. Test for clostridium difficile in those patients. If the patient feels fine, even if they have new diarrhea, you don’t necessarily have to test them for that.
Peter L. Salgo, MD: I want to thank all of you for being here. This has been a tremendous discussion, actually. It’s a terrible disease. My sense is it’s getting worse and there are some new therapies on the horizon. So, it’s encouraging, but at the same time, you have to be careful. That’s my takeaway from what I heard from all of you. I want to thank you for watching. I’m Dr. Peter Salgo, and I’ll see you next time.