This document summarizes a presentation on contamination of hospital food with Clostridium difficile in Central Italy. The presentation discusses C. difficile as a major cause of hospital-acquired infection, associated risk factors like antibiotic use, and management strategies recommended by regulatory bodies. It reviews literature on C. difficile contamination of food from studies in the UK, Italy, and India. The presentation identifies critical control points in food handling to prevent contamination, including receiving, storage, preparation, cooking and holding foods. It concludes that prevention strategies are needed to control the increasing incidence of C. difficile infection.

1. Organism- Clostridium difficile
Reference paper topic- Contamination of hospital food with Clostridium
difficile in Central Italy
PRESENTED BY:
TAHURA MARIYAM
MSc. MICROBIOLOGY (Sem -II)
P.ID: 19MSCMB009
PRESENTED TO: Prof. Rubina Lawrence (HOD, JIBB, SHUATS)
Dr. Ebenezer(Assistant professor JIBB, SHUATS)
DEPARTMENT OF INDUSTRIAL MICROBIOLOGY
JACOB INSTITUTE OF BIOTECHNOLOGY AND BIO-ENGINEERING
SAM HIGGINBOTTOM UNIVERSITY OF AGRICULTURE,TECHNOLOGY, AND SCIENCES, PRAYAGRAJ

2. Content
• Clostridium difficile
• Major cause of hospital infection
• Various associated risk factors
• Management strategies recommended by regulatory bodies
• Critical Control points (CCCPs) and decision tree

3. Clostridium difficile
• Clostridium difficile- first described in 1935 when it was isolated
from stool samples of new-born babies.
• It was not until the mid 1970’s that it became recognized as a
cause of antibiotic-associated diarrhea and colitis.
• Anaerobic, spore-forming, Gram positive bacillus
• C. difficile is the major cause of pseudo- membranous colitis
and antibiotic associated diarrhea.
• Fecal-oral transmission through contaminated environment and
hands of healthcare personnel
Fig. Endospores shown in white
inclusions in rod shaped bacteria

4. Major cause of hospital infection
• Antibiotic-associated (C. difficile) colitis is an infection of the colon caused by
C. difficile that occurs primarily among individuals who have been using
antibiotics. It is the most common infection acquired by patients while they are
in the hospital. More than three million C. difficile infectious occur in hospitals in
the US each year.

5. Review literature (based on some foreign research)
Authors and place
of research
Year Findings related to C. diifficile
Barbara M. Lund et al ;
Norwich, United Kingdom
2015 Spores of toxigenic Clostridium difficile and spores of food-poisoning strains of Clostridium perfringens show a similar
prevalence in meats. Spores of both species are heat resistant and can survive cooking of foods. Research is needed to
establish whether infection with C. difficile can be caused by transmission on food.
Sara Primavilla et al ;
Central Italy
2018 This study investigates the contamination of foods with Clostridium difficile. Data support the potential risk of food as a
source of toxigenic C. difficile for hospitalized patients, but further investigations are needed.

6. Review literature (based on Indian research)
Authors and place of
research
Year Findings related to C. diifficile
A. Gogate, et al ;
Mumbai, India
2005 Overall positivity was 18 % in this study group compared to the controls. Maximum positive cases were in 5-8 yr. age group.
Amongst positive cases, 68.9 % responded to discontinuation of antibiotics and 31.1% to metronidazole therapy.
Rama Chaudhry et al ;
New Delhi, India
2008 A total of 7.1% specimens were positive for C. difficile toxin (from 2001 to 2005). They observed an increase in the number
of stool specimens tested for C. difficile infection because of toxin they produce but a decrease in C. difficile positives.
Chetana Vaishnavi ;
Chandigarh, India
2010 Hospitalized patients receiving antibiotics for their ailments are at great risk of acquiring CDAD. Infection control procedures
that should be followed to prevent spread of the disease include environmental hygiene, washing hands and Environmental
cleaning should be done with phenolic disinfectant.
Meghraj Ingle et al ;
Mumbai, India
2011 On multivariate analysis, exposure to immunosuppressive agents was the only risk factor associated with CDAD.
Metronidazole was effective in a majority of patients except in few but on them vancomycin was effective.
Shashidhar Vishwanath et al
; Karnataka, India
2013 All patients with C. difficile infection received prior treatment with third-generation cephalosporins or β-lactam / β-lactamase
inhibitor antibiotics. C. perfringens enterotoxin was found in 8% patients. Severe colitis was seen in 25% patients who had
co-infection with C. difficile and C. perfringens.

7. Various associated risk factors
• Antibiotic associated (C. difficile) colitis is an infection of colon caused by C. difficile that occurs
primarily among individuals who have been using antibiotics. It is the most common infection
acquired by patients while they are in hospital.
• C. difficile associated disease occurs when the normal intestinal flora is altered, allowing C. difficile
to flourish in the intestinal tract and produce a toxin that causes a watery diarrhoea.
• Antibiotic use
• proton- pump inhibitors (antacids)
• Cross contamination from environment
• Food sources
• Asthma medications
• Age
• Produce toxin A and B which make the food toxigenic and also cause gastrointestinal diseases.
• The highest identified risk was actually with use of antidepressants. By logistic regression, the number of days
of PPI use was a significant predictor of C. difficile infection.

8. Management strategies recommended by
regulatory bodies• The U.S. Food and Drug Administration (FDA) is informing the public that
the use of stomach acid drugs known as proton pump inhibitors (PPIs) may
be associated with an increased risk of Clostridium difficile–associated
diarrhoea (CDAD). Patients should immediately contact their healthcare
professional and seek care if they take PPIs and develop diarrhoea that
does not improve.
• Treatment for CDAD includes the replacement of fluids and electrolytes
and the use of special antibiotics.
• The FDA is working with manufacturers to include information about the
increased risk of CDAD with use of PPIs in the drug labels.
• Healthcare personnel must use gloves and gowns on entry to a room of a
patient with CDI and while caring for patients with CDI.
• FDA is also reviewing the risk of CDAD in users of histamine H2 receptor
blockers. H2 receptor blockers are used to treat conditions such as
gastroesophageal reflux disease (GERD), stomach and small intestine
ulcers, and heartburn.
• Continue take precautions for at least 48 hours after diarrhoea has
resolved.
Hand
hygiene
Environmental
hygiene
Screening of
cohorting
patients
Surveillanc
e
Antibiotic
stewardshi
p
Followin
g
guideline
s

9. Critical Control points (CCPs)
• Receiving
Hazard- mishandling
Preventive measures- maintain hygienic conditions
• Storage
Hazard- storage at or above 4oC
Preventive measures- monitor the internal product temperature
• Thawing
Hazard- improper time management
Preventive measures- take more than four hours to thaw it properly, so dangerous
microorganisms are not allowed to grow
• Preparing
Hazard- food ingredients and chopping tools is not properly cleaned.
Preventive measures- knife for chopping should be clean, properly wash everything before use
and its advisable to boil it 1st.

10. CCPs contd….
• Cooking
Hazard- improper cooking
Preventive measures- cook or heating food at temperature above 72 - 75 OC
• Holding
Hazard- holding for long time
Preventive measures- checking the food in every 2 hours, this allows enough time to
take corrective action on food to avoid C. difficile
• Serving
Hazard- unhygienic conditions
Preventive measures- the serving utensils should be properly clean with soap water

11. Receiving
Storage
(chilling)
Thawing
Preparing
Cooking
Holding
Serving
CCPtreeforHospitalfood

12. Does a control measure exist for the hazard
Yes
Is the step specifically designed to eliminate, prevent or reduce the likely occurrence of a hazard to an acceptable level?
No
Could contamination with identified hazard occur in excess of acceptable level?
Yes
Will a subsequent step eliminate, prevent or reduce the likely occurrence to acceptable level?
No
CRITICAL CONTROL POINT
DECISIONTREE

13. Conclusion
• Over the past decade, the incidence and severity of both hospital and community-acquired CDI has increased
significantly.
• There is an emerging population who may contract CDI without the traditional risk factors and several novel risk
factors have been identified.
• PCR based testing is highly sensitive and repeat testing is usually not advised after an initial negative test, or to
confirm clearance after treatment in a patient who has responded symptomatically.
• In a patient with recurrent diarrhea, repeat testing should be performed to distinguish recurrent infection from
other causes, such as post infectious irritable bowel syndrome.
• Treatment strategies are based on severity and severe infection must be treated with oral vancomycin. Recurrent
infection continues to be a major challenge and newer treatment options such as FMT may become the mainstay
for recurrent CDI.

14. Reference
• Al-Tureihi FIJ, Hassoun A, Wolf-Klein G, et al. Albumin, length of stay, and proton pump inhibitors: key factors in
Clostridium difficile-associated disease in nursing home patients. J Am Med Dir Assoc. 2005; 6:105-108.
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prevention and control of Clostridium difficile: a global review of guidelines, strategies, and recommendations. NCBI; Vol 6
• Chaudhry Rama, Joshy Lovely, Kumar Lalit & Dhawan Benu. 2008- Changing pattern of Clostridium difficile associated
diarrhoea in a tertiary care hospital: A 5-year retrospective study. Departments of Microbiology, *Medical Oncology,
Institute-Rotary Cancer Hospital All India Institute of Medical Sciences, New Delhi, India; pp 377-382
• Gerding Dale N., Johnson Stuart. Management of Clostridium difficile infection: thinking inside and outside the box-
Clinical Infectious Diseases, Volume 51, issue 11, 1 December 2010, Pages 1306- 1313
• Gogate A, Nanivadekar R, M. Mathur, K. Saraswathi, Jog A & Kulkarni*- 2005. Diagnostic role of stool culture & toxin
detection in antibiotic associated diarrhoea due to Clostridium difficile in children. Departments of Microbiology &
*Pediatrics, L.T.M. Medical College, Mumbai, India; pp 518-524
• Ingle Meghraj, Deshmukh Abhijit, Desai Devendra, Abraham Philip, Joshi Anand, Camilla Rodrigues, Mankeshwar Ranjit.
2011- Prevalence and clinical course of Clostridium difficile infection in a tertiary-care hospital: a retrospective analysis;
30(2):89–93

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