Clostridioides Difficile Infection - A Serious Health Concern

Introduction

Diarrhea is one of the most common forms of gastrointestinal disorders. Various microorganisms like bacteria, fungi, and viruses are responsible for such complications. One of the major causes of diarrhea is injection from Clostridium difficile. Approximately half a million Americans suffer from infection caused by this bacteria. Around 15000 of these patients died due to infection caused by this bacteria. Moreover, extensive use of antibiotics is responsible for the emergence of a new fatal variant of this microorganism.

What Is Clostridium Difficile?

Clostridium difficile is a type of gram-positive bacteria. It is a spore-forming, motile, and anaerobic bacteria. As this is an anaerobic bacteria, it may thrive and grow without the presence of oxygen. This bacteria was first described by Hall and O’Toole in 1935. This bacteria is mainly found in water, vegetables, and hospital environments. The human intestine is the most common habitat for this bacteria. This bacteria produces two types of toxins. These are enterotoxins designated as toxin A and cytotoxins designated as toxin B. Enterotoxins are around 100 times less toxic than toxin B and relatively less virulent.

What Is the Pathophysiology of Clostridium Difficile Infection?

The infection of Clostridium difficile is caused by transmission by the spore of the bacteria. In most cases, transmission happens through vegetables, soils, and handling contaminated hospital equipment. Also, the transmission takes place through the fecal-oral route. However, in some cases, an asymptomatic C. difficile colonization in adults has been observed. Around 17.5 percent of the adult population is colonized by C. difficile strain without any clinical signs and symptoms of infection. According to some research, only 5 percent of people with C. difficile bacteria in their bodies suffer from clinical complications. The factors associated with C. difficile infections are;

1. Host Factors: Healthcare workers have a much higher prevalence of intestinal concentration of C. difficile. However, the transmission rate from such persons is much higher. Such high concentrations can also be observed in infants and neonates. Concentration increases in the first four weeks of life, after which it follows a steady curve. Increased concentrations of C. difficile can be found in patients suffering from intestinal disorders like cystic fibrosis (a genetic disorder that causes excessive mucus secretion and involves the lungs and digestive system).

2. Bile Acids: The composition of bile acid plays a pivotal role in the infectivity of Clostridium difficile. The change in the composition of the bile acid is crucial for the germination of the spore of the Clostridium difficile. Primary bile acids like cholate or taurocholic acid are beneficial for the germination of spores. On the other hand, compounds like chenodeoxycholate, present in the bile acid, prevent the germination of spores.

3. Bacteriocins: These are ribosomally synthesized antimicrobial peptides. These peptides have a broad or narrow spectrum activity against bacteria. In the gastrointestinal tract, Bacillus, Lactococcus, and Enterococcus strains are responsible for synthesizing such antimicrobial compounds. Such compounds act against Clostridium difficile and prevent its growth.

4. Antibiotic and Gut Microorganisms: The gut environment and the presence of gut microorganisms are important for maintaining the balance of gut health. Also, certain gut microorganisms are associated with the prevention of the growth of Clostridium difficile. Gut bacteria belonging to phylum Bacteroidetes and Firmicutes not only maintain gut health but also prevent infection caused by Clostridium difficile. Gut dysbiosis (change in the gut microflora) is one of the major causes of the destruction of these gut-friendly microorganisms. Factors like animal protein in the diet, fatty food, and less fiber in the diet are responsible for gut dysbiosis. An increase in the population of phyla Firmicutes and Proteobacteria is associated with Clostridium difficile infection. Apart from this, a decrease in the population of Ruminococcaceae, Lachnospiraceae, and Bacteroidaceae can be seen in this case. Also, chronic alcoholism plays an important role in gut dysbiosis. Antibiotics are another responsible factor for such complications. Extensive use of antibiotics like Cephalosporins, Penicillin, and Fluoroquinolones is associated with the destruction of gut-friendly bacteria. As a result, exposure to these antibiotics is associated with Clostridium difficile infection.

What Are the Clinical Symptoms?

The clinical complications associated with Clostridium difficile may vary from mild to moderate infection to life-threatening conditions. The incubation period for this bacteria is two to three days. Patients may suffer from mild diarrhea lasting for five to ten days in mild cases. The symptoms are;

1. Passage of watery stool.

2. Presence of stool in the blood.

3. Abdominal cramps and pain due to loss of water and electrolyte.

4. Nausea and vomiting.

5. Loss of appetite.

In severe cases, complications like severe dehydration, abdominal distension (swelling of the abdomen), hypoalbuminemia with peripheral edema (loss of albumin with accumulation of fluid in the body), and circulatory shock can be observed. This is caused by complications like toxic Megacolon (severe infection of the colon leading to its dilatation), colon perforation, intestinal paralysis, kidney failure, systemic inflammatory response syndrome, and septicemia (spread of infection throughout the body) due to severe infection.

Another complication that can be caused by Clostridium difficile infection is pseudomembranous colitis. This is the inflammation of the large intestine following antibiotic therapy. Such complications are mainly seen directly after antibiotic therapy or within 14 days of antibiotic therapy. Symptoms are similar to diarrhea.

What Are the Treatment Options?

Prevention is the best treatment option in Clostridium difficile infection cases. Hand washing is the best preventive method in such cases. As the hospital is the most common site for transmission of this infection, the use of a 5 percent hypochlorite solution to clean the instruments is the most effective method to prevent it. The drugs used in such cases are;

1. In mild cases, administration of Metronidazole for 10 to 14 days can be useful.

2. In severe cases, administration of Vancomycin 125 milligrams is necessary four times a day for 10 days. Apart from this, antibiotic-like Fidaxomicin 200 milligrams twice a day for 10 days can be used.

3. Immunotherapy comprises drugs like Bezlotoxumab, MDX-066, and MDX-1388 can be used to act against bacterial toxins. These drugs help prevent recurrent infections. Also, probiotics can be added to improve gut health.

Conclusion

Clostridium difficile is a gram-positive, spore-forming, and anaerobic bacteria. Transmission of this bacteria mainly occurs through contamination. However, after antibiotic therapy, changes in the gut environment are responsible for such infection. Severe colon infections caused by this bacteria may cause death. Proper diagnosis and application of antibiotics may be helpful to cure such cases.