- TORONTO -- A bacterial agent
commonly found in health-care settings has been blamed for the deaths of
100 patients in the last 18 months in a single Quebec hospital, says an
infectious disease expert at the facility, who is calling for government
action to forestall more outbreaks across the country.
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- Dr. Jacques Pepin says cases of Clostridium difficile
at University Hospital in Sherbrooke have been steadily increasing. And
the incidence among those most vulnerable to the disease - patients aged
65 and older - jumped 10-fold between 1991 and the end of 2003.
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- The infection has been blamed for killing 54 patients
in 2003 and another 46 in the first six months of this year at the 683-bed
hospital, said Dr. Pepin, lead author of a study in the Canadian Medical
Association Journal.
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- Using patient records, the University of Sherbrooke researchers
compiled cases of C. difficile and deaths from the infection over the last
14 years. They found the proportion of patients who died within 30 days
of diagnosis soared to almost 14 per cent in 2001 from less than 5 per
cent in 1991.
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- "A lot of these patients were quite elderly people
and for some of them, they obviously died for other reasons," Dr.
Pepin said Wednesday from Sherbrooke, explaining that many were being treated
for other serious illnesses. "But ... in my opinion, the vast majority
of these patients died directly of this infection."
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- Outbreaks of C. difficile have killed almost 90 patients
at several hospitals in both Montreal and Calgary. And more recently, a
patient died of the disease in a hospital in Newmarket, just north of Toronto.
In June, Quebec's chief medical officer ordered hospitals to record all
cases of the infection so the province can determine if the disease is
actually on the rise.
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- C. difficile is a garden-variety bacterium in hospitals
and usually poses no threat to healthy people. But it can become dangerous
for hospital patients treated with antibiotics for other illnesses, such
as pneumonia, because the drugs kill off so-called good bacteria in the
intestinal tract, allowing C. difficile to flourish.
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- It then begins secreting a toxin, said Dr. Pepin. "And
it is this toxin which starts producing the symptoms."
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- The most obvious symptom is diarrhea, which can be so
severe that some patients lose too much fluid in their bodies and go into
shock caused by plummeting blood pressure and then die, he said.
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- Dr. Pepin theorizes that the C. difficile mini-epidemics
may be related to a greater number of older patients occupying hospital
beds because of an aging population and the possibility that more virulent
strains of the bacterium have developed, which produce more toxins.
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- "It used to be considered just something annoying.
You'd get four or five loose stools a day ... and it wouldn't be that bad,"
said Dr. Pepin. "But what we've been seeing for the last couple of
years is much more severe diarrhea. So if you have 15 or 20 bowel movements
a day," the chance of it spreading from patient to patient is much
greater.
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- As well, cuts in health-care dollars have meant many
Canadian hospitals have not been renovated, making it more difficult to
ensure sanitary conditions, he said, noting that in some Quebec hospitals,
there can be 40 patients on a ward sharing one or two bathrooms.
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- "The result is that in some of these old buildings,
the sanitary conditions are intolerable. I mean, it's indecent."
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- Dr. Pepin, noting that treating a single patient with
C. difficile costs about $10,000, said funding is needed from the province
to improve hospital infrastructure so the infection can be better controlled.
But he also believes Ottawa must take a role as it did in helping to combat
the SARS outbreaks last year that killed 44 Canadians - far fewer than
have died from C. difficile.
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- "I think what would be needed at the federal level
would be some research to look at better treatments and better infection-control
measures," he said. "There is certainly a possibility that it
might spread outside of Quebec. The potential for transmission is there."
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- While it is not mandatory to report cases of C. difficile
to government agencies, Health Canada is helping to fund a study to determine
how pervasive the disease has become in Canada.
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- Dr. Andrew Simor, head of microbiology at Sunnybrook
and Women's College Health Sciences Centre, said the Toronto hospital is
among about 20 or 25 across the country that will be taking part in the
study beginning this fall.
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- A surveillance of C. difficile in 20 Canadian hospitals
was done in 1997, said Dr. Simor, an infectious disease specialist. "But
in view of the recent reports from Quebec and Montreal, as well as from
other parts of the world, of increasing Clostridium difficile infection
rates and also what appears to be an increasing severity of the disease,
we thought it would be very important to repeat our previous study to see
if there has been a change and what parts of the country are involved."
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- Besides the possibility of a more virulent strain, overuse
of antibiotics in general and the two used specifically to treat C. difficile
- metronidazole and vancomycin - may have contributed to strains that are
also becoming drug-resistant, doctors say.
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- Until researchers can produce more effective treatments
or a vaccine against the C. difficile toxin, the best strategy for controlling
the disease in hospitals is strict infection-control measures - washing
hands, using gloves and gowns, and maintaining sanitation - coupled with
appropriate use of antibiotics, Dr. Simor said.
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- "I think all hospitals across the country need to
be prepared for larger outbreaks caused by this organism and more severe
disease," he said. "One thing we've learned about the spread
of infectious disease is that none of us live in a protected, isolated
environment.
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- "So a problem that appears in another country in
the world or in a certain part of Canada, it's likely to be on our own
doorstep sooner or later."
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