Understanding C. diff. atomalliance.org/cdifftraining

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1 Understanding C. diff atomalliance.org/cdifftraining

2 This booklet is a printed guide of the online educational resource atomalliance.org/cdifftraining

3 Target Audience Understanding C. diff This educational activity is designed for practicing physicians, residents, and fellows in internal medicine and family practice, physician assistants, nurses, infection prevention nurses and nurse practitioners. Objectives After participating in this activity, participants should be able to describe and discuss: 1. The epidemiology and risk factors for the development of Clostridium diffcile infections 2. Evidence-based approaches to diagnosing Clostridium diffcile infections 3. Evidence-based approaches to treating patients with Clostridium diffcile infections 4. Evidence-based approaches to preventing infection from Clostridium diffcile Faculty Course Co-Director: Manoj Jain, MD, MPH, Quality Program Medical Director; atom Alliance Qsource Course Co-Director: Tom Talbot, MD, MPH, Associate Professor of Medicine, Vanderbilt University School of Medicine Planner: Lesley Hays, RHIA, CPHQ, Community Manager; atom Alliance Qsource Planner: Gladys Hunt, QI Advisor; atom Alliance Qsource 1.

4 Understanding C. diff Short TM Introduction Clostridium diffcile kills. Clostridium diffcile, or C. diff, is an infection affecting the colon. From 1999 to 2004 alone, mortality rates from C. diff increased more than four-fold. Welcome to Understanding C. diff. This course will help you understand how to diagnose, manage, prevent and control C. diff infections. 2.

5 3.

6 Lecture Hall - Epidemiology History C. diff is a spore-forming bacteria which causes severe diarrhea. Severe C. diff infections can lead to death. In the 1970s, it was discovered that broad spectrum antibiotics could increase the likelihood of a C. diff infection. The most commonly-associated antibiotic was clindamycin. Between 1980 and 2000 the primary cause of C. diff infections shifted to parenteral third generation cephalosporins. Since 2003, fluoroquinolones became the major induction agent for C. diff. New infections became more frequent and severe. Increasingly, C. diff was resistant to ordinary treatments and patients were more prone to relapse. 4.

7 Impact C. diff infections are often acquired in hospitals, with symptoms appearing either in the hospital or shortly after a hospital stay. Unlike other hospital-acquired infections, or HAIs, C. diff cases are on the rise. C. diff s impact can be felt throughout the healthcare system. According to the CDC, there are about 478,000 cases of C. diff infections annually, at a cost of $3.8 billion, and resulting in more than 28,000 deaths. All of these cases share the healthcare system as a common thread, pointing to the need for healthcare workers to understand the fundamentals of C. diff infection, prevention and control. 5.

8 Risk Factors Anyone can acquire C. diff, but not everyone is at equal risk of C. diff infection. Several risk factors have been identified, including advanced age, hospitalization, critical illness, tube feeding, suppression of the immune system, broad spectrum antibiotic treatments, and exposure to the C. diff bacteria. Many of these factors are not under the control of the patient or hospital staff. For instance, an immunosuppressed patient is at greater risk, and neither healthcare staff nor the patient can change the patient s immunosuppressed status. On the other hand, some risk factors are controllable. The two most common modifiable risk factors are the use of broad spectrum antibiotics and exposure to the C. diff bacteria itself. 6.

9 Questions Answers on Page 24 7.

10 Microbiology Lab - Testing Pathogenesis C. diff is acquired by ingesting spores which are extremely resilient, and able to survive in a variety of harsh conditions. Spores travel through the digestive system to the small intestine where they germinate into a vegetative state. In the large intestine, prior treatment with broad-spectrum antibiotics frequently alters the gut flora. This allows C. diff to proliferate and produce two toxins which cause diarrhea, and in more serious cases, pseudomembranous colitis. Once an individual has acquired C. diff, improper hand washing techniques can leave C. diff spores on the hands. These spores can then be transmitted to others by physical contact, or left behind in the environment for others to encounter. 8.

11 Colonization C. diff infection may result in either asymptomatic colonization or symptomatic infection. In asymptomatic colonization, C.diff spores are present but the patient does not display outward symptoms, such as diarrhea. In symptomatic infection, C. diff spores are flourishing and releasing toxins. 9.

12 Mild and Moderate C. diff Patients with mild or moderate C. diff infections will display ten to fifteen watery bowel movements per day. They will also experience cramping and low-grade fever. The patient may display an elevated white blood count, in lab findings. This elevated WBC can precede diarrhea and often goes unnoticed. 10.

13 Severe C. diff Patients with severe C. diff infections will display symptoms similar to mild infection, but much more pronounced. These patients colons will display yellow or off-white plaques. Patients with severe C. diff may experience fulminant colitis, with either paralytic intestinal obstruction or toxic megacolon, or both. These patients may require a surgical consult. 11.

14 ICU Room - Treatment There are three relatively common tests for C. diff infection, which vary in effectiveness: enzyme immunoassay, EIA glutamine dehydrogenase, and polymerase chain reaction. The enzyme immunoassay, or EIA test, is the most common. Because it has a relatively low sensitivity to C. diff-produced toxins, clinicians often repeat a test with a negative result, or treat patients who display C. diff symptoms. The EIA- glutamine dehydrogenase, or EIA-GDH test, is becoming increasingly common. It combines two tests to raise the sensitivity and specificity for C. diff. If the antigen results of an EIA-GDH test are positive and the toxin results are negative, the patient is likely colonized. If the toxin result is positive, the patient is infected. Polymerase chain reaction testing is also increasingly common. It is both rapid and sensitive. However, it does not differentiate between colonized and infected patients. Because of this it s important to test only patients with three unformed stools, or stools which do not take the shape of their container, and to enforce laboratory policies to reject formed stools for testing. 12.

15 Questions Answers on Page

16 ICU Toom - Treatment Treatment Options In mild or moderate C. diff cases, where the white blood count is less than fifteen thousand per micro-liter, you should treat with metronidazole, 500 milligrams 3 times daily, PO. In severe cases, where the white blood count is over fifteen thousand per microliter, C. diff should be treated with vancomycin, 125 milligrams 4 times daily PO. In either case, treatment should continue for days. Severe and complicated C. diff involves complications such as hypotension, or shock, ileus, and/or megacolon. In such cases, treat with metronidazole 500 mg IV every 8 hours or vancomycin PO, 500 milligram doses, 4 times daily. There may be a need for a surgical consult for a possible colectomy. Relapses occur in about 25 percent of cases. In case of a relapse, treat the first relapse as you treated the initial episode. Subsequent relapses, however, should be treated with a tapering dose of vancomycin PO. Studies have found no benefits in treating C. diff with probiotics or vancomycin IV. Benefits have been shown using fecal therapy, rifaximin, and fidaxomicin. 14.

17 Questions Answers on Page

18 Infection Prevention Offce - Infection Prevention Antibiotic Restrictions Use the mnemonic AEIOU to help control and prevent C. diff infections. A stands for antibiotic restrictions. Limiting usage and reducing dosages of antibiotics lead to fewer C. diff infections. For example, in one study, reducing the use of clindamycin coincided with a reduction in C. diff cases from 11 to 3 per month. Other ways to decrease C. diff infections include avoiding the use of third generation cephalosporins and reducing treatment length. If there is no sign of C. diff, stop treatment after 2-3 days. Treatment methods can also affect C. diff rates. Switching from IV to PO treatment has been shown to decrease CDIs. Also, switching from cefixime to piperacillin/tazobactam can reduce CDIs. 16.

19 Environment E is for environment. Reducing environmental contamination can reduce C. diff infections. Twenty-five percent of symptomatic C. diff carrier patient rooms yield C. diff spores. Up to fifty percent of infected patient rooms yield spores. You can help prevent and control C. diff outbreaks by paying special attention to areas in the environment used by multiple patients, such as commodes, blood pressure cuffs, or thermometers. Another strategy is to use bleach (or sodium hypochlorite) and chlorine solutions to effectively eliminate spores from the environment. Sodium hypochlorite can be caustic to hospital equipment, so use it with caution. Ammonia products will not kill C. diff spores. Switching from quaternary ammonium to a hypochlorite solution has been shown to lead to a significant reduction in C. diff infections. You can also use an EPA-registered sporicidal agent with more than five thousand parts per million of sodium hypochlorite. Remember that you might find spores on any surface. Only initiate routine surveillance when an outbreak has occurred. 17.

20 Isolation I is for isolation. One of the most effective means of controlling C. diff infections is to prevent initial contact with spores. Start by wearing gloves and gowns when working with C. diff patients. One study has identified a drop from 7.7 to 1.5 C. diff infections per one thousand patients discharged after contact isolation rules were implemented. Although uniforms have not been identified as a spore transmission mechanism, C. diff spores have been detected on uniforms. Gowns can help prevent them from attaching to your uniform. Note that masks have not been shown to have an effect on C. diff rates. Transmission is from hand to mouth, not through the air. Another strategy for control of C. diff is to implement good hand hygiene with hand washing. C. diff, unlike other vegetative bacteria, is resistant to control with alcohol-based antiseptics. However, studies have shown no increase in C. diff when alcohol-based hand cleaners are in use. Hand hygiene using soap and water or chlorhexidine is most effective in reducing spores and managing outbreaks. 18.

21 Outbreak Avoidance O is for outbreak avoidance. The best way to avoid an outbreak is to maintain hospital surveillance of C. diff infections. As soon as you see an increase in the number of cases, implement the proper protocols to contain and eliminate the outbreak. Finally, U is for You and your team. With leadership from the appropriate experts, including infection preventionists, pharmacists, quality improvement specialists, infectious disease consultants and intensivists, you ll have all the help you need to control an outbreak. 19.

22 Questions Answers on Page

23 Summary and Conclusion I was getting ready for a church function, and I really was the one that hosted it. But it hit me, and I came down with diarrhea 21.

24 Ms. Courtney Peacock was one of my patients. She had been admitted to the hospital repeatedly for congestive heart failure and infections. She had her share of the antibiotics, and then suddenly, she developed C. diff diarrhea. As a doctor I am frustrated. Each month, each year, we re seeing an increasing number of cases of C. diff. I ve even seen a patient die from C. diff diarrhea. One of the things that I ve learned is that we cannot just control the rate of C. diff, but we can even bring the rate down. There are four things that we can do to bring that rate down; first, by strict antibiotic restrictions, programs like antibiotic stewardship, second, by patient isolation, third, by better environmental cleaning, and lastly and most importantly, by simple hand washing. We can eliminate C. diffcile. Just look, over the past decade, we have reduced MRSA infections. Together, let s eliminate C diffcile. It can be done, and it must be done. 22.

25 You have completed Understanding C. diff. You should now be able to identify what C. diff is and how it spreads, explain options for treating it, and describe methods used to manage and control C. diff. It is deadly, but it is also avoidable. Avoiding C. diff starts with you! 23.

26 Answers for Page

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30 Notes 28.

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32 For more information about how you can ignite powerful and sustainable change in healthcare quality, please visit atomalliance.org Contact Alabama AQAF Lee Pearce, MSW, MSHA, FACHE Indiana Qsource Mary Ellen Jackson, RN, BSN Kentucky Qsource Janet Pollock, BA, MA Mississippi IQH Vickie Taylor, RN, MSN, CIC Tennessee Qsource Lesley Hays, RHIA, CPHQ This material was prepared by atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama, under a contract with the Centers for Medicare & Medicaid Services (CMS), a federal agency of the U.S. Department of Health and Human Services. Content does not necessarily reflect CMS policy. 14.ASC

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