by Noel Brandon Kelsch, RDHAP
Someone asked a question in one of my courses that made me think. Do I need to be concerned about Clostridium difficile in the dental setting since it is transmitted from feces? The answer about this spore-forming, gram-positive, anaerobic bacillus that produces two exotoxins may surprise you. There are areas of this bacteria infection that relate directly to dentistry.
In the report on the Centers for Disease Control website, data has been shared that is staggering:
- 94% of all C. difficile in the country is related to health care in some way, and that includes dental care.
- A majority of those at risk from this possibly deadly diarrheal infection have taken antibiotics and have received medical care in any setting.
- C. difficile is linked to about 14,000 American deaths annually.1
It is not the spread of this bacterial disease in the dental setting that is the issue. C. difficile is typically not transmitted in the dental setting.
Other articles by Kelsch:
Transmission occurs through contact with feces, which is not a typical exposure risk in dental health-care settings. The health-care locations where transmission does occur are hospitals and long-term care facilities. The lack of exposure to feces and infection control protocols in dentistry prevent the transmission. Dental health-care professionals who are working in hospitals and long-term care facilities must address the additional risks involved when serving patients with C. difficile (see related sidebar).
So what can dental professionals do?
The first line of defense in prevention would be recognition of the disease in patients. The symptoms of this disease include:
- Watery diarrhea
- Loss of appetite
- Abdominal pain/tenderness
Making patients aware of the concern for this disease during health history evaluation puts dentistry at the forefront of prevention. Patients with these symptoms should be immediately referred for evaluation and care.
The second area that dental health-care professionals need to address is the use of antibiotics. The issue is that the risk of patients getting C. difficile is increased seven- to tenfold while they're taking antibiotics, and over the month following discontinuation. Even after two months, the risk continues at a two- to threefold rate.2 The CDC states, "Use antibiotics judiciously." It is imperative to stay up-to-date on the current standards for use of antibiotics. The use of prophylactic antibiotics continues to change. For example, the American Heart Association's 2007 guidelines stated, "Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis."3 Careful consideration needs to be used in all decisions about the use of antibiotics.
Recent findings have brought forward a greater understanding of this disease. The focus of transmission of this disease in the past has been the hospital setting through the release of spores from an infected patient's diarrhea. A recent study showed that "Unexpectedly few cases appear to be acquired from direct ward-based contact with other symptomatic cases," David Eyre, MB, ChB, a clinical researcher at the University of Oxford, England stated. "These have previously been thought to be the main source of infections, and the focus of prevention efforts."4
The three-year study was conducted to see if the bacteria are genetically similar or distinct and included 1,223 cases; 13% of patients had isolates that were genetically related and also had close hospital contact with another patient, which had been thought to be the primary route of C. diff transmission. "Distinct subtypes of infection continued to be identified throughout the study," the authors wrote. This diversity, Dr. Eyre said, indicates a "reservoir of disease not previously appreciated."
The sources of transmission and reservoir are not completely understood at this point. There are many areas that have been identified as possible sources. For example research has suggested that water, pets and food may harbor C. diff but tracing infections back to those sources would be very difficult to do.5
During the three years of the study, the rate of C. diff infections in Oxfordshire fell, not only in hospitals, but also in community-acquired cases. In the hospitals in this areas infection control has included daily sterilization with bleach in the rooms of patients with confirmed or suspected C. diff, preemptive isolation of suspected cases and continued monitoring and feedback for noncompliance.
Infection prevention focused on using sporicides like sodium hypochlorite to disinfect hospital wards. What has come to light in a new study from Dr. Eyre and et. Al shows that clinicians may want to "adopt a wider lens when looking for sources of C. diff" The study clarifies that there may be additional sources of acquiring this disease.4
The interesting thing about this study is that they do not believe that improvements in infection control contributed to the observed decline in C. diff infections during the study. They directly contribute the fall to the restricting of the use of antibiotics.
During that period the administration of quinolones and cephalosporin fell drastically.
Antimicrobial stewardship remains a vital part of keeping C. diff transmission low. Since it is now known that are there could be a variety of potential sources and not just hospitals, we need to make an effort to reduce the number of susceptible patients decreasing unnecessary use of antibiotics. Two of the main areas that were focused on are unnecessary premedication for dental treatment and viral respiratory infections.
The questions about the risks involved with C. difficile are important for all dental health-care professionals. We must all look at our roles and address the areas of this bacterial infection that relate directly to dentistry.
Mobile dentistry, hospital dentistry, long-term care facilities
Many dental health-care providers are now seeing patients outside of the dental office. According to the CDC, C. difficile is shed and transmitted in feces. Any surface, device, or material that becomes contaminated with feces may serve as a reservoir for the spores. Spores are transferred to patients mainly via the hands of health-care personnel who have touched a contaminated surface or item. If you are a dental health-care provider seeing patients in these facilities, it is vital to be aware of the CDC recommendations in this area. These patients are typically placed in private rooms or in rooms with other patients experiencing C. difficile.
The CDC recommends the following:
- Read and discuss all patient health histories before entering any room.
- Use gloves when entering patients' rooms and during patient care.
- Perform hand hygiene after removing gloves.
- Because alcohol does not kill C. difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs. However, early experimental data suggest that, even using soap and water, the removal of C. difficile spores is more challenging than the removal or inactivation of other common pathogens.
- Preventing contamination of the hands via glove use remains the cornerstone for preventing C. difficile transmission via the hands of health-care workers. Any theoretical benefit from instituting soap and water must be balanced against the potential for decreased compliance resulting from a more complex hand hygiene protocol.
- If your institution experiences an outbreak, consider using only soap and water for hand hygiene when caring for patients with C. difficile infection.
- Use gowns when entering patients' rooms and during patient care.
- Dedicate or perform cleaning of any shared medical equipment.
- Continue these precautions until diarrhea ceases.
- Because C. difficile-infected patients continue to shed organisms for a number of days following cessation of diarrhea, some institutions routinely continue isolation for either several days beyond symptom resolution or until discharge, depending on the type of setting and average length of stay.
- Implement an environmental cleaning and disinfection strategy.
- Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently.
- Consider using an EPA-registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions. Generic sources of hypochlorite (e.g., household chlorine bleach) may also be appropriately diluted and used. (Note -- Standard EPA-registered hospital disinfectants are not effective against C. difficile spores.) Hypochlorite-based disinfectants may be most effective in preventing C. difficile transmission in units with high endemic rates of C. difficile infection. Routine cleaning should be performed prior to disinfection. EPA-registered disinfectants with a sporicidal claim have been used with success for environmental surface disinfection in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of C. difficile.
- Note: --EPA-registered disinfectants are recommended for use in patient-care areas. When choosing a disinfectant, check product labels for inactivation claims, indications for use, and instructions.
- Follow the manufacturer's instructions for disinfection of all devices.
- Recommended infection control practices in long-term care and home health settings are similar to those practices taken in traditional health-care settings.
NOEL BRANDON KELSCH, RDHAP, is a syndicated columnist, writer, speaker, and cartoonist. She serves on the editorial review committee for the Organization for Safety, Asepsis and Prevention newsletter and has received many national awards. Kelsch owns her dental hygiene practice that focuses on access to care for all and helps facilitate the Simi Valley Free Dental Clinic. She has devoted much of her 35 years in dentistry to educating people about the devastating effects of methamphetamines and drug use. She is a past president of the California Dental Hygienists’ Association.
3. Circulation. 2007;116:1736-1754
4. Eyre DW et al. N Engl J Med 2013;369:1195-1205
5. Hensgens MP et al. Clin Microbiol Infect 2012;18:635-645
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