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Brote por clostridium difficile en un hospital general del sector salud en México

Brote por clostridium difficile en un hospital general del sector salud en México

Autor principal: Marco Antonio Paredes Montaño

Vol. XVIII; nº 19; 996

Outbreak by clostridium difficile in a general hospital of the health sector hospital in Mexico

Fecha de recepción: 04/09/2023

Fecha de aceptación: 02/10/2023

Incluido en Revista Electrónica de PortalesMedicos.com Volumen XVIII. Número 19 Primera quincena de Octubre de 2023 – Página inicial: Vol. XVIII; nº 19; 996

Autores: Marco Antonio Paredes Montaño1, Carlos Navarrete Vázquez2

Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Toluca México.1-2

Declaración de buenas prácticas

Los autores de este manuscrito declaran que:

Todos ellos han participado en su elaboración y no tienen conflictos de intereses

La investigación se ha realizado siguiendo las Pautas éticas internacionales para la investigación relacionada con la salud con seres humanos elaboradas por el Consejo de Organizaciones Internacionales de las Ciencias Médicas (CIOMS) en colaboración con la Organización Mundial de la Salud (OMS).

El manuscrito es original y no contiene plagio.

El manuscrito no ha sido publicado en ningún medio y no está en proceso de revisión en otra revista.

Han obtenido los permisos necesarios para las imágenes y gráficos utilizados.

Han preservado las identidades de los pacientes.

RESUMEN

Introducción: El Clostridium difficile es un anaerobio grampositivo oportunista cuya patogenicidad está asociada con la producción de dos exotoxinas: la toxina A (enterotoxina) y la toxina B (citotoxina). El organismo a menudo está presente en las manos del personal del hospital que atiende a dichos pacientes. Los factores de riesgo son: hospitalización, edad avanzada, inmunodepresión, exposición a antibióticos y el uso de inhibidores de la bomba de protones.

Presentación de Caso Clínico: El 3 de marzo del 2021 se detectó el primer caso en el área de COVID19, el paciente presentó fiebre, dolor abdominal, acompañado de distensión, diarrea y leucositosis, el paciente contaba con factores de riesgo. En total se presentaron 18 casos del 3 de marzo al 9 de abril del 2021, 8 casos confirmados por laboratorio, los 10 restantes positivos por asociación epidemiológica, fallecieron 9 pacientes y 9 fueron dados de alta. La asociación entre los casos era el personal de salud, debido a que usaban guantes en el área covid, lo que favoreció a la transmisión cruzada.

Discusión y conclusión: La falta de aplicación de los procedimientos por el personal de salud para prevenir infecciones cruzadas continúa siendo un problema para los hospitales, a pesar de recibir capacitaciones de diversos tópicos, existe personal que hace caso omiso a las indicaciones, las cuales exponen a los pacientes a complicaciones que ponen en peligro la vida y también incrementan la permanencia de los pacientes y los costos de atención. El tratamiento para el Clostridium difficile puede ser con metronidazol o vancomicina o fidaxomicina, la rifampicina o la adición por vía oral de la levadura Saccharomyces boulardii al tratamiento con vancomicina o metronidazol previene la diarrea subsiguiente en pacientes con enfermedad recurrente. La limpieza y desinfección de las áreas, mobiliario, equipo, etc. es esencial para el control de brotes hospitalarios.

Palabras clave: Clostridium Difficile, hospitales, Infección cruzada, bacterias, riesgo.

SUMMARY

Introduction: Clostridium difficile is an opportunistic gram-positive anaerobe whose pathogenicity is associated with the production of two exotoxins: toxin A (enterotoxin) and toxin B (cytotoxin). The organism is often present on the hands of hospital personnel caring for such patients. Risk factors are: hospitalization, advanced age, immunosuppression, exposure to antibiotics, and the use of proton pump inhibitors.

Clinical Case: On March 3, 2021, the first case of COVID19 was detected in the area, the patient presented fever, abdominal pain, accompanied by distension, diarrhea and leukocytosis, the patient had risk factors. In total, there were 18 cases from March 3 to April 9, 2021, 8 laboratory-confirmed cases, the remaining 10 positive due to epidemiological association, 9 patients died and 9 were discharged. The association between the cases was health personnel, because they used gloves in the covid area, which favored cross-transmission.

Discussion and conclusion: The lack of application of procedures by health personnel to prevent cross infections continues to be a problem for hospitals, despite receiving training on various topics, there are personnel who ignore the indications, which expose patients to complications that are life-threatening and also increase patient length of stay and costs of care. Treatment for Clostridium difficile can be with metronidazole or vancomycin or fidaxomicin, rifampin or the oral addition of the yeast Saccharomyces boulardii to vancomycin or metronidazole treatment prevents subsequent diarrhea in patients with recurrent disease. Cleaning and disinfection of areas, furniture, equipment, etc. it is essential for the control of hospital outbreaks.

Keywords: Clostridium Difficile, hospitals, cross infection, bacteria, risk.

Introduction

Clostridium difficile made its first appearance in the literature when Hall and O’Toole (1935) described Bacillus dificilis as part of the bacterial flora of meconium and feces of infants.1-2

Clostridium difficile is an opportunistic gram-positive anaerobe whose pathogenicity is associated with the production of two exotoxins: toxin A (enterotoxin) and toxin B (cytotoxin).3

Infection of the colon with the gram-positive bacterium Clostridium difficile is life-threatening, especially in the elderly and in patients who have gut microbiota dysbiosis after exposure to antimicrobial drugs. C. difficile is the leading cause of healthcare-associated infectious diarrhea, its life cycle is influenced by antimicrobial agents, the host immune system, and the host microbiota and its associated metabolites.4

Contagion and transmission in hospitalized patients of C. difficile is well documented5, 6, 7 8, the organism is often present on the hands of hospital personnel caring for such patients.9

The fundamental risk factors: hospitalization, institutionalization in residences, advanced age, immunosuppression, history of gastrointestinal surgery, exposure to antibiotics and the use of proton pump inhibitors (PPIs) have also been described as a possible risk factor.10-11-12-13-14

In the United States, C. difficile diarrhea was associated with an increase in estimated total hospital costs of $3,669 and an increase in length of hospital stay of 3.6 days. The crude mortality rate of patients with C. difficile diarrhea was higher than that of patients without C. difficile diarrhea.15

Clinical case

On March 3, 2021, a case of gastroenteritis was detected in the isolated area for COVID19 patients, the epidemiology service was consulted, due to fever, abdominal pain, accompanied by distension, diarrhea and leukocytosis, with a diagnosis of probable gastroenteritis. by Clostridium difficile, since the patient had risk factors due to the prolonged use of antibiotics and omeprazole, these factors favor the loss of the normal microbiota of the gastrointestinal tract, coupled with the fact that omeprazole favors conditions at the level of the gastric mucosa by neutralizing the acidic pH of the stomach, which in turn serves as a protective mechanism against the presence of intestinal pathogens.

Laboratory studies were requested for the detection of toxins A and B for C. difficile by multiplex PCR, the report was positive for the detection of toxins A/B of clostridioides (Clostridium difficile), starting treatment with vancomycin. Based on NOM-017-SSA-2012, an outbreak was considered since subsection 3.1.4, where an Outbreak is defined as “the occurrence of two or more cases epidemiologically associated with each other. The existence of a single case under special surveillance in an area where the disease did not exist is also considered an outbreak.

On March 9, a second case was detected for which a laboratory study could not be carried out due to lack of supplies, considering it positive due to epidemiological association based on NOM-017-SSA-2012. On March 12, 3 more cases were presented , of these three cases for the same reason as the previous one, only one of them underwent the specific study, the result being positive for the detection of clostridoid A/B toxins, the two remaining cases were positive due to epidemiological association. In the period of March 15, two more cases were presented, one underwent laboratory studies, being positive for the detection of clostridoid toxins A/B, the second case of the day was positive due to epidemiological association.

At this time, it was found that the association between these cases was health personnel, because they used gloves in the covid area and did not wash their hands, which favored cross-transmission generated by health personnel. It is important to reiterate that this outbreak was detected in the covid area, where medical and paramedical personnel use maximum barrier protection equipment characterized by: tivek type suit, googles, KN ​​95, two pairs of gloves and boots

From March 17 to April 9, 11 more cases were presented, of which 7 cases underwent laboratory studies, being positive and the remaining 4 cases were found to be positive due to epidemiological association (Table 1 and 2). All patients were I treat them with vancomycin, their evolution for the condition being satisfactory, however some died from the complications of COVID19.

Discussion

Cleaning and disinfection is the cornerstone for the control of hospital outbreaks, some forms of life, such as spores, can survive for more than 6 months, so monitoring and active search for probable cases of C. Difficile diarrhea continue. however, as of March 21, 2023, no positive cases have been found by laboratory or by epidemiological association.

In most patients, C. difficile colitis resolves after treatment with metronidazole or vancomycin; however, a significant minority develop progressive systemic symptoms despite appropriate and timely medical therapy.16-17-18-19-20-21

However, fidaxomicin is significantly more effective than vancomycin in achieving clinical cure in the presence of concomitant antibiotic (AC) therapy and in preventing recurrence regardless of the use of AC.22

Combination therapy with vancomycin plus rifampicin or the oral addition of the yeast Saccharomyces boulardii to vancomycin or metronidazole therapy has been shown to prevent subsequent diarrhea in patients with recurrent disease.23

Conclusions

The lack of application or omission of procedures by health personnel to prevent cross infections continues to be a problem for hospital units, despite receiving training on various topics, there are health personnel who ignore the recommendations and indications, which expose patients to life-threatening complications and also increase patient length of stay and costs of care.

Anexo

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