Clostridium difficile Asymptomatic Carriers The Hidden Part of the Iceberg?

Transcription

1 Clostridium difficile Asymptomatic Carriers The Hidden Part of the Iceberg?

2 Disclosures Merck Canada, BD Diagnostics, AMD Medical, Canadian Institute for Health Research Merck Canada, Pfizer

3 OBJECTIVES

4 BACKGROUND

5 Background

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8 Background 1 out of every 200 patients admitted in acute care institutions in Quebec develop CDI

9 Prevention of CDI

10 Guidelines

11 Background

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14 Stochastic modeling: food would be responsible for < 1 newly colonized patient /1,000 adms.

15 Asymptomatic Carriers

16 INCREASING INTEREST ON C. DIFFICILE COLONIZATION

17 CD-AC are not as contagious as CDI patients but almost!

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19 How numerous are CD-AC?

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24 Modeling Studies

25 Rapid detection of colonized patients can significantly affect the prevalence of CDI and its control, especially in the context of asymptomatic carriers and in-ward transmission.

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30 Typing Studies

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32 MLVA to track acquisition of CDI Environ. sample CDI, HA CD carrier Toxin test* CDI, Non-HA *CDI test + (CCNA) but symptoms do not fulfill criteria for CDI CD carrier Screening test (mainly admission)

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34 Future infection control measures?

35 Institut Universitaire de Cardiologie et Pneumologie de Québec

36 HA-CDI rates,

37 Control of CDI

38 Control of CDI of CD carriers in CDI to AC new set of

39 CD-AC measures

40 REALLY? Can t we just improve standard precautions?

41 C. difficile carrier Infection control measures

42 Similar to CDI patients with few exceptions:

43 Why gloves? Why not only soap and water?

44 Hand washing vs. C. difficile Even the best hand hygiene technique is poorly effective to remove C. difficile from hands! e.g. ABHRS against E. coli: 3.5 to 5 log reduction

45 Efficacy of gloves

46 Prophylaxis for C. difficile carriers? secondary prophylaxis

47 Detection of carriers

48 Detection of carriers

49 Detection of carriers

50 Detection of carriers

51 Detection of carriers

52 Detection of carriers

53 Detection of carriers

54 Detection of carriers

55 Detection of carriers GDH PCR

56 False +? gene by homebrew PCR 396 tested; 16 ACDC detected

57 ANALYSIS

58 Outcomes

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60 External control

61 Healthcare-Associated CDI Incidence rate in Quebec,

62 Incidence rate among university hospitals, QHLI

63 Analyses Intervention period vs. pre-intervention period Poisson regression (accounts for seasonality)

64 RESULTS

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66 Carriage rate on admission

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74 ARIMA modeling

75 Sensitivity analyses

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78 Potential Confounders

79 Potential Confounders Increased from 37% to 50% during intervention (p<0.001)

80 Antimicrobial and PPI use

81 Antimicrobial use

82 Antimicrobial use

83 Antimicrobial use

84 Antimicrobial and PPI use

85 Anti-CDI antimicrobials

86 Intensity of CDI testing

87 % of negative CDI tests

88 LONG-TERM Follow-up

89 Long-term Impact

90 Long-term Impact

91 Long-term follow-up QHLI

92 Impact of the Isolation Precaution Burden

93 Figure. Prevalence of isolation-days for C. difficile infection (CDI) or colonization April August Data presented as the number of isolation-days per 1,000 patient-days per 4-week period. Averages represent the average isolation prevalence for C. difficile for the entire periods and for the first and last 12 months of the last period. Healthcare-associated CDI incidence rates during each study period are presented on the lower panel. Abbreviations: CDI: Clostridium difficile infection; pd: patient-days

94 Figure. Prevalence of isolation-days for C. difficile infection (CDI) or colonization April August Data presented as the number of isolation-days per 1,000 patient-days per 4-week period. Averages represent the average isolation prevalence for C. difficile for the entire periods and for the first and last 12 months of the last period. Healthcare-associated CDI incidence rates during each study period are presented on the lower panel. Abbreviations: CDI: Clostridium difficile infection; pd: patient-days

95 Figure. Prevalence of isolation-days for C. difficile infection (CDI) or colonization April August Data presented as the number of isolation-days per 1,000 patient-days per 4-week period. Averages represent the average isolation prevalence for C. difficile for the entire periods and for the first and last 12 months of the last period. Healthcare-associated CDI incidence rates during each study period are presented on the lower panel. Abbreviations: CDI: Clostridium difficile infection; pd: patient-days

96 Figure. Prevalence of isolation-days for C. difficile infection (CDI) or colonization April August Data presented as the number of isolation-days per 1,000 patient-days per 4-week period. Averages represent the average isolation prevalence for C. difficile for the entire periods and for the first and last 12 months of the last period. Healthcare-associated CDI incidence rates during each study period are presented on the lower panel. Abbreviations: CDI: Clostridium difficile infection; pd: patient-days

97 Figure. Prevalence of isolation-days for C. difficile infection (CDI) or colonization April August Data presented as the number of isolation-days per 1,000 patient-days per 4-week period. Averages represent the average isolation prevalence for C. difficile for the entire periods and for the first and last 12 months of the last period. Healthcare-associated CDI incidence rates during each study period are presented on the lower panel. Abbreviations: CDI: Clostridium difficile infection; pd: patient-days

98 Proportion of Carriers with Recent Hospitalization at the QHLI

99 Cost-Benefit Estimate

100 Potential Economic Value

101 Cost-benefit analysis

102 Cost-benefit analysis

103 Unknowns and Research Agenda Very pro-infection control hospital carriers who must receive ATB?

104 Patients with diarrhea who are carriers of toxigenic C. difficile but without detectable toxin levels : are they contagious? GDH + but ToxAB -

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106 Source of new CDI cases -: 3%

107 C. difficile testing many tests, many potential uses

108 Potential use of CD carrier isolation during outbreaks? Preliminary data from 2 healthcare centers

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110 CDI outbreaks are not created equal

111 Acknowledgements

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