Published Date: 2004-08-08 23:50:00
Subject: PRO/EDR> Clostridium difficile, fatal - Canada (QC)
Archive Number: 20040808.2191

CLOSTRIDIUM DIFFICILE, FATAL - CANADA (QUEBEC)
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[1]
Date: Sat 7 Aug 2004
From: Richard Wilsnack <rwilsnac@medicine.nodak.edu>
Source: BBC.com [edited]
<http://news.bbc.co.uk/go/pr/fr/-/2/hi/health/3543926.stm>

Canada struggles with deadly bug
--------------------------------
Canadian health officials are trying to cope with a bacterial infection
found in hospitals and nursing homes. It has been blamed for the deaths of
189 patients in the past 18 months.
In a new study, infectious disease experts say cases of _Clostridium
difficile_, which causes diarrhea and colon inflammation, are increasing.
The newly published report says the incidence of the disease among the
most vulnerable patients, aged 65 and older, has increased 10-fold.
The experts investigating the Canadian outbreak say the bacterium appears
to have mutated into a highly contagious and lethal strain, but they do not
know why. It only seems to affect patients in hospitals, and it usually
strikes them after they have been given antimicrobial agents for another
condition. It has been blamed for 100 deaths, in a single Quebec hospital
alone, in the past 18 months.
The risk of contracting the disease seems to increase for patients being
treated with chemotherapy or abdominal surgery. So far, the disease has
been confined to a handful of hospitals in the province of Quebec, and, the
western city of Calgary. Quebec's health minister has urged against
panicking and questions whether all the deaths attributed to _C. difficile_
can be directly blamed on the disease. Health officials say they will set
up a system to track _C. difficile_ more efficiently, and, are urging all
staff in Canadian hospitals to increase hygiene measures such as cleaning
toilet seats and doorknobs and systematically washing hands.
[Byline: Lee Carter]
--
Richard W. Wilsnack, Ph.D.
University of North Dakota School of Medicine & Health Sciences
Grand Forks, ND
<rwilsnac@medicine.nodak.edu>
******
[2]
Date: Sun 8 Aug 2004
From: ProMED-mail <promed@promedmail.org>
Source: CBC Montreal [edited]
<http://montreal.cbc.ca/regional/servlet/View?filename=qc_superbug20040806>

Superbug spread curbed, MDs say
-------------------------------
Doctors in Sherbrooke (Quebec) are crediting simple measures with reducing
the infection rate of _C. difficile_ in their hospital.
Researchers in Sherbrooke this week [2nd week of August 2004] published a
study that showed the bacterial infection killed 100 people in that city's
hospital in the last 18 months.
Dr. Jacques Pepin is an infectious-diseases specialist at the Centre
hospitalier universitaire de Sherbrooke. His team reviewed all cases of
_C. difficile_ at the hospital between 1991 and 2003. Pepin found that the
disease killed 10 times more elderly patients in 2003 than it did in 1991.
Now, hospital officials say, since learning about the proliferation of
_C. difficile_, they have taken a number of successful steps to improve
hygiene at the hospital. Dr. Maurice Roi, who works at the hospital, says
nurses and doctors reacted immediately. They became vigilant about washing
hands, disinfecting rooms, and isolating patients who tested positive for
the bacteria. Since then, Roi says, the infection rate has been cut in half.
But, that's apparently not the case in other Quebec hospitals. Philippe
Couillard, the provincial minister of health, says there are reasons why
the rates are higher in other centers.
"We know for a fact, by observing people in hospitals, that only 30 to
40 percent of people working in hospitals wash their hands," Couillard
says. He says that that has to change in order to stop the spread of _C.
difficile_ across the province.
--
ProMED-mail
<promed@promedmail.org>
******
[3]
Date: Sun 8 Aug 2004
From: ProMED-mail <promed@promedmail.org>
Source: Canada.com [edited]
<http://www.canada.com/health/story.html?id=420dce71-3061-4bd9-bc58-5ffd
96681356>

Quebec health minister urges proper hygiene to fight bacteria
-----------------------------------------------
On Thu 5 Aug 2004, Quebec's health minister urged better hygiene, and more
information, to combat a bacteria commonly found in health-care settings
that apparently killed 100 patients in the last 18 months in a single
Quebec hospital. But, Philippe Couillard questioned whether the deaths at
the University of Sherbrooke's medical center could be directly blamed on
_Clostridium difficile_.
"We have to be careful and put things in perspective," Couillard said. "The
study shows that the rate of infection has increased in Sherbrooke, as
elsewhere in Canada. But, the figure of 100 has to be taken with a grain of
salt. 100 died while having the bacteria in them. It doesn't mean that
their deaths were due to the bacteria."
Couillard said a more efficient and detailed program of surveillance is
needed across the country to track the causes. "This problem can be
controlled," he said, noting that Quebec has tracked cases since June 2004.
Couillard said public health officials had urged provincial health-care
institutions to practice better hygiene, and, to ensure that facilities are
kept clean and that staff take precautions, such as systematically washing
their hands. Couillard also said that doctors should be cautious about
prescribing antibiotics, which can spark the illness in certain combinations.
"Basic preventive measures, like hand washing, as easy as it may seem, are
not followed as rigidly as they should be," he said. "Broad spectrum
antibiotics sometimes may be used a little bit too liberally." He added the
bacteria itself may also have mutated.
Last spring [2004], a study reported that _C. difficile_ had killed up to
89 people in Montreal and Calgary hospitals since 2001.
In Sherbrooke, Dr. Maurice Roy said the university hospital has been
working to control the infection for some time, and, that there has been a
decrease in the number of cases since February 2004. "The measures put in
place have enabled us to continue the decline" in the number of cases, said
Roy, the hospital's director of professional services. The measures
included the distribution of more information about the problem, the
presence of more nurses, and the use of stronger disinfectants for cleaning.
Dr. Jacques Pepin, an infectious disease expert at the University of
Sherbrooke medical center, and one of the authors of the report that
highlighted the situation at his hospital, said the problem is not confined
to Sherbrooke. "It's not specific to our institution," he said.
"In the last 3 months, there has been a 50 percent reduction in the number
of cases. The number of cases remains high, but there is hope on the horizon."
Research indicates that the incidence among those most vulnerable to the
disease -- patients aged 65 and older -- jumped 10-fold between 1991 and
the end of 2003.
--
ProMED-mail
<promed@promedmail.org>
[The paper referred to is Valiquette L, Low DE, Pepin J, et al.
_Clostridium difficile_ infection in hospitals: a brewing storm. CMAJ
2004;171:27-9. Several other papers in this issue of the Canadian Medical
Association Journal also dealt with this organism.
Pseudomembranous enterocolitis, the illness caused by toxins produced by
_C. difficile_, causes diarrhea, fever, and an elevated white blood cell
count. On inspection of the colonic mucosa by endoscopy, pseudo-membranes
are seen, which are focal collections of debris caused by the effect of the
toxin on the colonic lining.
The entity has been known for the last half of the 20th century. In the
early 1970s, an association was made with administration of the then
recently licensed antimicrobial agent clindamycin. Many other antimicrobial
agents, especially ampicillin, have been associated with the illness, which
results from _C. difficile's_ (which may be hospital-acquired) colonization
of the colon, coupled with, a change in the indigenous microflora by
antimicrobials. Enteric administration of either vancomycin or
metronidazole is usually effective, but, relapse may occur.
Although the denominator is not mentioned in the postings, having this many
deaths from _C. difficile_ is of concern, but it is not clear that this
mortality is attributable to this pathogen. More information is needed to
know whether the pseudomembranous enterocolitis, sometimes referred to as
PMEC, was the cause of death. Complications of PMEC include toxic
megacolon, in which the colon becomes massively dilated, and peritonitis,
from perforation of the colonic wall.
As a general rule, the strict use of hand washing, to minimize transmission
of the organism from patient to health care worker to patient, and rational
use of antimicrobial agents is usually effective in controlling PMEC.
Whether the Canadian strains have mutated to become more virulent is
unclear at this time. - Mod.LL]
..................mpp/ll/msp/mpp

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