HEALTHCARE- ASSOCIATED INFECTIONS: A FOCUS ON Clostridium difficile

Transcription

1 OBJECTIVES HEALTHCARE- ASSOCIATED INFECTIONS: A FOCUS ON Clostridium difficile Identify and describe the pathophysiology of C. diff. Identify and describe current therapies in treatment of C. diff Identify and describe nursing interventions that will help prevent HAIs. Vanessa A Makarewicz, RN-BC, MN Infection Control Operations Manager Harborview Medical Center Seattle, WA vamakar@uw.edu DEFINITIONS Healthcare Associated Infections (HAIs): Encompass almost all clinically evident infections that do not originate from a patient's original admitting diagnosis. Also can be called Nosocomial Infections. Are infections that patients acquire during the course of receiving treatment for other conditions within a healthcare setting. Once a Pt leaves the hospital and develops and infection, it could be considered nosocomial based on certain factors. SCOPE OF THE SITUATION: UNITED STATES Cost exceeds $ BILLION DOLLARS ANNUALLY! We can prevent $ BILLION DOLLARS! 5-10% of patients are affected annually ( million), depending on type of institution. 1. UTIs (32%: Estimated Death = 13,088) 2. Surgical Site Infections (22%: 8,205) 3. Pneumonia (15%: 35,967) 4. Blood Stream Infections (14%: 30,655) h"p:// Sco", R. D. (2009). The Direct Medical Costs of Heathcare- Associated InfecOons in U.S. Hospitals and the Benefits of PrevenOon. Online: 1/20/2012 at h8p:// Kelvens, R.M., Edwards, J.R., Richards, C.L., Horan, T.C., Gaynes, R.P., Pollock, D.A., et al. (2007). EsOmaOng health care- Associated infecoons and deaths in U.S. hospitals, Public Health Reports, 122, Clostridium difficile INFECTION (CID): INCIDENCE Hospital- onset: 165,000 cases, $1.3 billion in excess costs, and 9,000 deaths annually TRANSMISSION OF HAI Starts with you! Nursing home- onset: 263,000 cases, $2.2 billion in excess costs, and 16,500 deaths annually Community- onset, healthcare- facility associated: 50,000 cases, $0.3 billion in excess costs, and 3,000 deaths annually Campbell et al. Infect Control Hosp Epid. 2009:30: Dubberke et al. Emerg Infect Dis. 2008;14: Dubberke et al. Clin Infect Dis. 2008;46: Elixhauser et al. HCUP StaXsXcal Brief # Lessa et al. CID. 2012: 55: S65- S70. Google Images University of Washington - uwcne.org 1

2 Chain of Infection Convergence Model Genetic and Biological Factors Physical Environmental Factors Microbe Human Social, Political and Economic Factors Ecological Factors Ignatavicius, D.D. & Workman, M.L. (2002). Medical Surgical Nursing: 4 th Edition. Elseveir. Philadelphia. Convergence Model (Microbial Threats to Health IOM/NAS, 2003) CASE STUDY CLOSTRIDIUM DIFFICILE 49 y/o AA female: HIV infected 6/7: admitting dx of CAP with watery diarrhea Treated with azithromycin and ceftriaxzone Discharged on 6/12 with amoxicillin 6/22: presented to clinic with HF symptoms was admitted to the hospital. 6/25: she was started on moxifloxacin, also she developed abd discomfort RUQ, Clostridium difficile sample sent 6/26: CT scan showed new pan colitis 6/27: C. diff Toxin A and B were positive 6/28: WBCs increased from 26 to 44: Rapid Response 6/29: Sent to OR for total colectomy Gram positive (gm+) spore-forming obligate anaerobe bacillus. Produces protein toxins Toxin A: ENTEROtoxin that causes fluid secretion, mucosal damage, and intestinal inflammation. Toxin B: CYTOtoxin Synergistic vs A-B+ PATHOGENESIS Frisen, L. and Woolridge, N. Downloaded: November 18, 2013 from: Frisen, L. and Woolridge, N. Downloaded: November 18, 2013 from: University of Washington - uwcne.org 2

3 ASYMPTOMATIC CARRIAGE >50% of healthy neonates are asymptomatic carriers <5% of healthy adults are carriers, unless treated with abx 20-40% of hospitalized pts are stool carriers. Treatment is not recommended. Frisen, L. and Woolridge, N. Downloaded: November 18, 2013 from: C. DIFF PRESENTATION 1. Mild to Moderate diarrhea ± lower abdominal cramping Delayed symptoms post abx Toxins present in stool 2. Severe colitis w/o Pseudomembrane formation Severe diarrhea Fever, nausea, malaise, dehydration Colonic bleeding Thickened or edematous colonic mucosa on CT 3. Pseudomembrane Colitis (PCM) Diarrhea, abd pain, worse systemic sx PCM plaques 4. Fulminant Colitis Life-threatening Loss of colonic muscle tone Megacolon Perforation Surgical intervention TRANSMISSION RISK FACTORS FECAL-ORAL Patient FOMITES: any surface Hands Clothing Equipment Advanced Age Prolonged Hospitalization Antibiotic Exposure Cephalosporins Clindamycin Fluoroquinolones PPI usage Antimotility Agents Immunosuppression University of Washington - uwcne.org 3

4 COMMUNITY ASSOCIATED C. difficile CLOSTRIDIUM DIFFICILE Defined as no hospitalizations or LTCF >3 months Minnesota cases, 41% community-acquired Younger (median age 50), healthier, female (76%), less abx exposure (78%), acid suppressants (22%), cancer dx (17%), less severe (20%) Multi-State study patients 36% did not receive abx, 18% no outpatient exposure, 31% PPI Hospital Acquired vs. Hospital Associated Infection. Why is it such a big deal? s B1/NAP1/027 strain s TcdC gene Pardi, et. al (2012). Am J Gastroenterol. 107(1): Chitnis, et al. (2013). JAMA. 173(14):1359, DIAGNOSIS/TESTING Cell Cytotoxicity Assay Effects Toxin B on human cell growth. 48 hours turnaround Antigen testing (EIA) C.diff antigen = negative = negative for C.diff C.diff antigen=positive= more testing Test for Toxin A and Toxin B Toxin A negative does not mean pt is negative Must wait for Toxin B to be negative to R/O PCR Immediate Results! (close to immediate) Just testing for pathogenic C. diff Voth, D. E. & Ballard, J.D. (2005). Clostridium difficile Toxins: Mechanism of Action and Role in Disease Clin. Microbiol. 18:2: MANAGEMENT OF CID REDUCTION OF C. DIFFICILE THROUGH ANTIMICROBIAL STEWARDSHIP Limiting antimicrobial exposure Infection CONTROL Use Soap and Water Contact Precautions ENV cleaning EARLY IDENTIFICATION Treatment Reduction in antimicrobial use: All: 23% Targeted 54% SHEA and IDSA Guidelines: Infect Control Hosp Epidemiol 2010;31: Clin Infect Dis 2007;45:S University of Washington - uwcne.org 4

5 ENV CLEANING THE ROOM IS THE PATIENT! Environmental Contamination % Infect Control Hosp Epidemiol 2010;31:21-7 Patients with CDAD 60 Asymptomatic Carriers ENVIRONMENT ANY CALL BUTTON BED RAIL TABLE TELEPHONE 30 Non carriers How do you know your room is clean? Bed Linen Patient Gown Overbed Table BP Cuff Side Rails Bath Door Handle IV Pump Button Room Door Handle Percent of Surfaces Positive for MRSA Infect Control Hosp Epidemiol 1997;18: Percent positive Contact Contamination UV-C DECONTAMINATION TREATMENTS Medications Metronidazole, PO Vancomycin, PO/PR Fidaxomicin Fecal Transplant Total Abdominal Colectomy Infect Control Hosp Epidemiol 2011;32: FECAL MICORBIOTA TRANSPANTATION Recurrent CDI attributed to: Reinfection with C. difficile Inability to mount adequate immune response Persistent alteration in normal gut flora by Abx/Rx Persistent C. difficile spores in colon Recurrent Indications: 3 or more episodes of mild to moderate CDI Failed treatment 6-8 weeks 2 or more severe episodes of CDI requiring hospitalization Not responding to Abx 92% cure rate PROCEDURE: (NO STANDARD PROTOCOL) Fresh vs frozen donated stool g. Use within 6 hours Specimen emulsified with normal saline Strained through filter or gauze Desired volume varies with route. (25-50 ml with NG route; ml with colonoscope or enema) Fecal pills? Unger, N. (2013). Fecal Transplantation Lecture: October 10th Unger, N. (2013). Fecal Transplantation Lecture: October 10th University of Washington - uwcne.org 5

6 FMT RESULTS GET ME OUT!! C. DIFF Author CDI Administration Results Kelly et al, 2012 Relapsing CDI Colonoscope 24/26 Cured Hamilton et al, 2012 Recurrent CDI Colonoscope 37/43 (86%) eradication rate Mattila et al, 2012 Refractory CDI Colonoscope 66/70 (94%) eradication rate Brandt et al, 2012 Recurrent CDI Colonoscope Primary cure rate 91%; Secondary Cure rate 98%; Resolution of diarrhea in 74% of Patients by day 3 Off isolation: The patient no longer has GI symptoms (diarrhea), and has received 7 days of therapy, OR The patient continues to have GI symptoms (diarrhea) after completing a course of therapy, and one post-therapy stool sample is negative for toxin A & B. Complete clean of ENV/Room Unger, N. (2013). Fecal Transplantation Lecture: October 10th PROBIOTICS PEARLS FOR C. DIFF Systemic review of RCT: Only 352 treatment studies showed some benefit from S. boulardii Some benefit of yogurt containing Lactobacillus supp. And streptococcus 30 thermophilus Concern over safety of probiotics in severely ill or 25 immunocompromised patients. Few reports of S. boulardii fungemia. 20 Placebo Insufficient evidence to support routine use of probiotics Active Agent to 15 prevent or treat C. difficile infections. 10 Percent of Patients with Diarrhea 5 0 S. boulardii Lactobacillus Yogurt Unger, N. (2013). Fecal Transplantation Lecture: October 10 th Gastroenterology 1989;96:981-8, BMJ 2007;335:80-4 Dig Dis Sci 2003;48: Ruling out, put on isolation until proven otherwise Wash Hands/ENV/ISOLATION PROTOCOL Speak up! PSYCHOSOCIAL ASPECT OF ISOLATION Bored, lonely, confined, frustrated, stigmatized, enclosed Your role to improve Pt satisfaction You re going to be busy Infection Control takes time But it is for the safety of yourself and your patients. Be educated and educate, wash your hands, and advocate for your patients Ward, D. (2000). Infection control: reducing the psychological effects of isolation. British Journal of Nursing, 9, University of Washington - uwcne.org 6

7 ACKNOWLEDGEMENTS Thank you to Nancy Unger, ARNP and Tim Dellit, MD for supplemental slides. University of Washington - uwcne.org 7