The effect of the infection Clostridium difficile on the rehabilitation

© 2014 Edina Tanovic et al.; licensee University of Sarajevo Faculty of Health Studies. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. UNIVERSITY OF SARAJEVO FACULTY OF HEALTH STUDIES ABSTRACT


INTRODUCTION
Clostridium diffi cile is the cause of the post antibiotic colitis.Th is anaerobe, sporogenous, gram-positive bacteria is most often recognized as the cause of the nosocomial diarrhea (1)(2)(3)(4).
Diarrhea caused by the Clostridium diffi cile can either occur individually or in smaller epidemics and can be transmitted from person to another person (5,6).It occurs up to 8% of the hospitalized patients and can be responsible for 20-30% cases of diarrhea.Risk factors are advanced age, serious illnesses, lengthy period of hospitalization, residence at nursing homes or chronic patients (7)(8)(9).Lately, it has been proven also that risk factors include application of blockage of proton pump and application of non-steroid anti-rheumatic (10).Dominant pre-disposed factor of the host is the antibiotic induced gastro intestinal disorder.Th e course of the disease varies from asymptomatic to necrosis colitis (11)(12)(13).Rarely there are limited impacts of the tissue as well as sepsis of the acute abdomen.With previous application of the cephalosporin there can be occurrences of not fully formed stool (not liquid) and leukocytes in the stool (14,15).Asymptomatic patients with Clostridium diffi cile in their stool are more common than symptomatic patients, in ratio 3:1.After diarrhea caused by Clostridium diffi cile, reactive arthritis is described (16)(17)(18).Risk factors are: advanced age, serious illnesses, lengthy period of hospitalization, residence at nursing homes or chronic patients.Typical clinical symptoms are diarrhea, increased body temperature (fever), pain in the stomach area and leucocytosis (19,20).Th e cases of ileus are increasingly described, as well as cases of perforation of colon, toxic megacolon with development of the shock, to very com-plicated colitis that can lead to death (21,22).Th e aim of this work is to show the impact of the infection Clostridium diffi cile on the result of rehabilitation of the patients that have been treated in the rehabilitation facility.

METHODS
Total of 448 patients were hospitalized at the Clinic for physical medicine and rehabilitation of the Clinical Center University of Sarajevo, in the period of May 2011 to May 2012.As the source of the information, we have used the existing medical documentation.We have done ELISA -RIDASCREEN Clostridium diffi cile to determine the existence of the toxin in the stool.We analyzed the following: gender, age, results of the rehabilitation with Barthel index, length of the hospitalization, as well as values of the albumin in the blood.

Statistical analysis
Kolmogorov-Smirnov test, Mann-Whitney U test and One Sample Wilcoxon Signed Rank test were used for data analysis.P<0.05 was considered statistically signifi cant.

RESULTS
Infection with C. diffi cile occured 7 (2%) out of total 448 patients.Of those, 4 (53%) were female and  3 (47%) were men.Th e mean age for females was 67.5 years and for males 52.0 years (Figure 1).Th e Barthel index values were signifi cantly diff erent at admission and discharge (Figure 2).Also, the length of hospitalization was sigifi cantly diff erent for patiens with and patients without C.diffi cile infection (Figure 3).

DISCUSSION
In our study we analyzed 448 patients.With 11 patients, there was a suspicion of the infection C.diffi cile and at 7 patients, the infection was confi rmed.All the patients were accepted for the rehabilitation as transfers from the Clinic for Neurology.Th e frequency of the infection with Clostridium diffi cile in our study was 2%.Th e research of the Orsini et al. published in 2010 on included 747 patients with 22 having infection, with frequency of 2.9%.Female patients were slightly more represented in the study (57%) which does not correspond with other research which demonstrates that male genders are more represented.
When we analyze age of the patients, we see diff erent results.In literature we found diff erent values depending on the institution where the research was conducted.Th e average patients were represented at the advanced age but the illness can sporadically oc-cur at younger patients as well.Th e majority of cases of infection developed with 30 days of admission (27).Th e results of the rehabilitation were estimated using Barthel index.All of the suspected patients were isolated and the process of the rehabilitation at the proven cases was conducted in special conditions.I our work we noticed signifi cant statistical diff erence in the values of Barthel index at the admission (M=4.0) and discharge (M=8.0),p=0.047.However, results of the rehabilitation with patients with C.diffi cile are less eff ective compared to patients without infection.Similar results were obtained by Orisini et al.Th e hospitalization for patients without infection with C.diffi cile is shorter (M=28.8)compared to patients with infection (M=43.0).Similar results were verifi ed by Orsini et al. which note the length of the hospitalization at 55.3 days.Th e values of the albumin in the blood for patients with infection C.diffi cile are signifi cantly lower than the referent values; there is a high signifi cance p=0.016.Several research studies show the same or similar results with diff erently pronounced values of the signifi cance.We have not verifi ed horizontal transmission of the infection.Measurements for the control of the infection are important for reducing the transmission of the C.diffi cile from health workers to patients, as well as between the patients.Reduced used of the clindamycin in the hospitals, has reduced the incident of the illness.Relapse can occur in 15-20% of the patients.Higher occurrence of the illness caused by Clostridium diffi cile can be interpreted with the selection of the new type NAP1/027 which excretes much higher levels of the toxins A and B compared to until now prevailing types of the Clostridium diffi cile.It is assumed that the gene mutation occurred which regulates the secretion of the toxins.It is still unclear how much eff ect on the selection of this type of Clostridium diffi cile had the prescribing as well as use of anti-microbic medicine.Importance of the CD following is also indicated by Olson et al. who examined the mortality connected with the infection of the C.diffi cile.Th eir results on 908 cases of CDAD show that 6 patients (0.06%) died from the active pseudomembranosis colitis (PMC) as the primary disease.Results of the study done by Morris et al. show that the mortality of the patients with colonotomy, toxical megacolon and perforatated colon was high (up to 50%).In the United Kingdom hospitals it is noted the increase of death cases that had infection C.diffi cile during their primary disease.Th e information also indicates two to three times higher death rate during year 2004 compared to year 1999 (20).Prevention remains a priority, high standards of hygiene and careful attention to the judicious prescription of antibiotics and crucial regard (28).Patients admitted to acute rehabilitation may have an elevated rate of intestinal colonization with C. diffi cile without clinical symptoms.Inadvertent transfer of the organism within the rehabilitation setting may occur because asymptomatic colonization is not recognized (29).Eff ective management requires a coordinated eff ort among all members of the healthcare team to facilitate early identifi cation of patients at risk for CD, early recognition of disease onset and confi rmatory testing, prompt initiation of the most appropriate management approach and ongoing monitoring throughout the continuum care (19,23,30). .

CONCLUSION
Patients that had infection with Clostridium difficile had longer period of the rehabilitation and the results were less favorable.

FIGURE 1 .FIGURE 2 .
FIGURE 1. Age distribution in patients with C.diffi cile infection

FIGURE 3 .
FIGURE 3. Length of hospitalization for patients with Clostridium diffi cile infection compared to patients without infection with mean length of hospitalization of 28.8 days (Z=2.282;P=0.015).