Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology of secondary infections and associated clinical manifestations
- Explain the common types of secondary infections encountered in the clinical setting
- Summarize important nursing interventions to prevent secondary infection
- Apply nursing concepts and plan associated nursing care for patients with Clostridioides difficile infection
- Describe the medical therapies that apply to the care of patients with Clostridioides difficile infection
A secondary infection arises after treatment of a different, primary infection (National Library of Medicine, 2023). Secondary infections (which are also called opportunistic infections) often result in a more complicated and prolonged recovery process. Most often, the pharmacologic treatment for the initial infection causes changes in the immune system that result in another infection. Two common examples of this include a person who develops a vaginal yeast infection after taking antibiotics for a bacterial infection and a person who develops bacterial pneumonia after being treated for a viral upper respiratory infection.
Clostridioides difficile Infection
One of the most common secondary infections is named for the bacterium Clostridioides difficile, or C. diff for short (CDC, 2023b). This bacterium used to be called Clostridium difficile; however, it was reclassified in 2016 (Lawson et al., 2016). Normally located in the intestines, C. diff can cause inflammation of the colon (pseudomembranous colitis). This occurs most often after a patient takes antibiotics, which can alter the number of bacteria in the large intestine (Cleveland Clinic, 2023b). Other risk factors for the development of C. diff include:
- immunosuppression (e.g., HIV infection, cancer, organ transplant)
- older age (>65 years)
- previous C. diff infection
- recent hospitalization or residence in a long-term care facility
The hallmark clinical manifestation of C. diff infection is malodorous diarrhea (Mada et al., 2023). Additionally, patients may have fever, abdominal pain, and nausea.
Nursing Care of the Patient with C. difficile Infection
C. diff poses significant challenges in health-care settings, requiring diligent nursing care to manage symptoms, prevent transmission, and promote recovery. Nursing care for patients with C. diff encompasses a multifaceted approach, involving meticulous infection-control practices, symptom management, and targeted antibiotic therapy when warranted.
Recognizing and Analyzing Cues
Nurses play a key role in the initial detection of C. diff, especially in hospitalized patients. The nurse must be able to recognize subtle changes in the patient's condition that may be indicative of a C. diff infection. Specifically, the nurse should pay close attention to the patient’s bowel movements, assessing for changes in consistency and signs of gradual development of diarrhea. If signs of C. diff are noted, the nurse should analyze the assessed cues by determining whether the patient has risk factors, such as recent antibiotic use, that increase the chance of developing C. diff infection.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The nurse will recognize a recent history of antibiotic use as a major risk factor and hypothesize that the patient has developed a C. diff infection. Based on this information, the nurse prepares to initiate the following interventions:
- Stool sample collection: If C. diff is suspected, the nurse should send a stool sample to the laboratory for confirmation. While waiting for the results, the nurse should operate under the assumption that the patient has C. diff and use isolation precautions accordingly. If the sample comes back negative, isolation precautions can be discontinued.
- Ensure strict soap-and-water hand-hygiene regimens, not alcohol-based foams or gels, because the latter are ineffective at killing the organism. Handwashing should be completed before and after every patient encounter, not just the patient with C. diff. Nurses must thoroughly clean all surfaces objects with bleach wipes.
- Implement isolation precautions: Patients with C. diff should be placed on contact precautions. Entering the patient’s room requires gloves and a gown to prevent transmission to health-care personnel and other patients.
- Hydration and electrolyte management: Because patients with C. diff have a large amount of diarrhea, they are at increased risk of dehydration and electrolyte imbalances. The nurse should encourage oral fluids if tolerated and monitor the patient closely for signs that would indicate electrolyte imbalance.
- Symptom management: In some cases, the nurse may administer antidiarrheal or antiemetic medications, as ordered. For severe cases when the patient is immobile, a rectal tube may be ordered to contain the diarrhea and prevent skin breakdown.
- Educate patient and family: The nurse should educate the patient and family about measures to prevent the spread of C. diff. If the patient is prescribed antibiotics for C. diff, the nurse should educate the patient about the importance of finishing the course of medication to prevent antibiotic resistance.
Evaluation of Nursing Care for the Patient with C. difficile Infection
Evaluation of nursing care for the patient with C. diff involves assessing the patient's response to treatment, monitoring for resolution of symptoms, and preventing recurrence of infection. Examples include having the patient complete return demonstration of proper hand hygiene. Another way the nurse can evaluate the patient’s and/or family’s understanding and opportunity for more education is to have them explain why cleaning the home with bleach wipes is necessary.
Evaluating Outcomes
First, the nurse will assess the patient’s response to treatment. If the patient has been prescribed a new antibiotic, the nurse should monitor for signs and symptoms that would indicate tolerance of the medication. If the patient reports GI distress or rash, the nurse should recognize those as potential signs of medication intolerance and alert the provider immediately. The nurse should monitor the patient’s bowel movements closely, assessing for changes that would indicate the diarrhea is improving. After beginning treatment, the bowel movements should continue to become less liquid and more formed over the course of a few weeks. Lastly, the nurse should evaluate for potential risk factors for recurrence of infection. Specifically, the nurse should inquire about the patient’s adherence to their antibiotic prescription to ensure the entire course was taken, which decreases their risk for developing a recurring infection.
Medical Therapies and Related Care for the Patient with C. difficile Infection
First and foremost, medical treatment for C. diff includes stopping the antibiotic that likely caused the infection. In many cases, the patient will develop C. diff a few days or weeks after finishing the antibiotics, so this is not possible. However, in cases where the patient is still taking an antibiotic that could have caused the infection, the antibiotic should be stopped immediately. The patient will then be prescribed different antibiotics for the C. diff itself: typically, metronidazole, vancomycin, or fidaxomicin. Mild cases can be treated with oral antibiotics, whereas more severe cases often require IV administration. For patients with recurring C. diff infections, colectomy or fecal transplant may be required. A colectomy is the removal of a portion of the colon, and a fecal transplant involves transferring medically processed stool from a healthy donor into the affected colon to restore healthy bacteria.
General Nursing Interventions for Preventing Secondary Infection
The priority intervention for preventing the development of secondary infections in general is the use of proper hand hygiene. Most secondary infections are transmitted through person-to-person contact, so washing the hands properly greatly reduces the risk of transmission. Additionally, nurses and other health-care personnel should always use gloves when caring for patients with secondary infections. This will help prevent hand contamination and subsequent transmission to other health-care workers or patients.
Although many secondary infections are related to pharmacologic interventions, some may develop secondary to placement of invasive tubes or lines. Critically ill patients often require intubation for mechanical ventilation, insertion of indwelling urinary catheters, or insertion of central lines. All these interventions involve placement of tubes in the body, increasing the risk for infection. For example, using mechanical ventilation greatly increases the risk of ventilator-associated pneumonia, and the use of urinary catheters and central lines increase the risk for catheter-associated urinary tract infection and central line–associated blood infection, respectively. Many hospitals have started implementing committees that solely focus on the early discontinuation of these invasive tubes and lines. Extubating patients and removing indwelling lines as soon as possible greatly reduces the risk for developing secondary infections. This is significant because hospital-acquired secondary infections can negatively affect patient outcomes, increase length of hospitalization, and result in increased costs for the health-care institution.
Immunizations are another excellent strategy for prevention of secondary infections. For example, getting annual influenza and COVID-19 vaccines helps prevent initial infections that may require hospitalization, thus reducing the chance of developing a secondary infection. There are also several vaccines that prevent bacterial infections (e.g., meningococcal and pneumococcal infections). These reduce the chance of the patient requiring treatment with antibiotics, which, in turn, decreases the risk of developing secondary infections associated with antibiotic use, such as C. diff.
Link to Learning
Learn more about how to prevent secondary infections at this CDC webpage. The information focuses on opportunistic infections in the context of HIV, but many of the strategies are applicable to other kinds of secondary infection.