Sheryl Ubelacker, CNEWS

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.

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.

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 Pepin, lead author of a study in the Canadian Medical Association Journal.

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 five per cent in 1991.

"A lot of these patients were quite elderly people and for some of them, they obviously died for other reasons," 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."

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.

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.

It then begins secreting a toxin, said Pepin. "And it is this toxin which starts producing the symptoms."

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.

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.

"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 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.

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.

"The result is that in some of these old buildings, the sanitary conditions are intolerable. I mean, it's indecent."

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.

"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."

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.

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.

A surveillance of C. difficile in 20 Canadian hospitals was done in 1997, said 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."

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.

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, Simor said.

"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.

"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."