C Diff; Toxin Negative Or Toxin Positive

C diff, now called Clostridioides or Clostridioides difficile, is often found in nursing homes or in post-surgical patients after multiple doses of antibiotics¹. Antibiotics disrupt the normal gut flora, and in a weakened immune system, it is allowed to flourish.  Immunocompromised patients fall prey to this condition, that can actually lead to death from a toxic megacolon. When C diff colonizes in the colon, a layer of dead tissue, fibrin, and white blood cells cover the bowel wall which is called pseudomembranous colitis².

The spores of C diff are very resilient and can live on surfaces for a long period of time, allowing for their spread through toilet seats, door knobs, linen, medical equipment, and anything with potential feces on it. Not only are they stout, but they are difficult to destroy with cleaning. However, not all strains of C diff form toxins that make people sick.

Toxins

Some patients can contract C diff but have no symptoms. These patients have a non-toxin-producing strain that is thought to protect them from infection¹. On the other hand, if a patient has a toxin-producing strain, then they are in danger of developing the disease. 

There are two types of toxins contained in C diff - toxin A and toxin B². 75% of patients with C diff will form one or the other². Toxins are the source of the noxious part of the disease that cause gram+ anaerobic C diff bacteria. Toxin A is identified as Tcda and is one of the most common bacterial toxins. B is identified as Tcdb². 

Cellular level

The toxins contained in C diff damage living cells which causes structural and functional changes to the cells³. The cells can become more permeable with less ability to adhere³. All of this leads to the death of the cell through shrinking of the cell, and nuclear fragmentation, which leads to decay and death - apoptosis³. With the death of the cell and all of its protective and functional properties, bad bacteria have the chance to flourish in the patient's GI tract.

Tests to Detect Toxins

With the increase in C diff cases and an increase in the pernicious strains, new tests are needed in order to detect them. In the past, there have been two tests developed: the toxigenic culture, and cell toxicity neutralization³. The problem right now with these tests is that they take days to perform and garner results. When a patient is in the hospital with other issues and develops C diff with toxins, they need help right away to deter further decline in health. Delaying care for a test is not optimal for these patients. 

Recently, a new test for the detection of C diff is being developed using enzyme immunosuppression³. However, it isn't sensitive enough, so it needs more research³. There is another test, the nucleic acid amplification test, that allows genotyping and is quicker and more sensitive³. There are also PCR (polymerase chain reaction) tests that can detect organisms that produce toxins but not their presence³. 

Treatment

Vancomycin and fidaxomicin are the two antibiotics being used to treat C diff². Fecal transplants have been around for many years and are effective in their treatment, as well as the FMT capsules (fecal material in capsules)². 

An important aspect of decreasing the spread of infection is using preventative measures such as handwashing, limited use of antacids and PPIs, and not using antibiotics for viruses. 

Conclusion

As time marches forward and new types of disease become known, there comes the issue of detection and treatment, as we have seen with Covid. With the barriers present in the detection of toxins in C diff patients, there is a delay in care and unneeded treatment. Asymptomatic patients with C diff are being treated for the infection when it's not needed. All of these things add up and affect the patient and burdens the healthcare system with an increased cost which we all know comes back around to the patient.

What Can Nurses Do?

As nurses, we can use the protective measures already in place such as using appropriate PPE and washing our hands to protect ourselves and our other patients. Educating our patients and their family is very important in the prevention of the spread of C diff. 

Have you seen the toxin results on your C diff patient?

References

1  C. difficile (C.diff): An urgent threat

2  What is Clostridium Difficile Toxin Test?

3  The Toxin Trouble with C. difficile