CDI The Impact. Disclosures. Acknowledgments. Objectives and Agenda. What s in the Name? 11/14/2012. Lets Talk Numbers

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1 Disclosures No conflict of interest to declare Acknowledgments Objectives and Agenda Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) Guidelines CDC Dr. Archbald, University of Virginia Colleagues and Family Understand the impact of C. difficile infection and its evolving epidemiology Summarize latest testing and treatment modalities for C. difficile infection Learn the specific characteristics of C. difficile and hence, need for specific prevention practices and policies What s in the Name? CDI/CDAD/CDC They are all the same! We will call it CDI - Clostridium Difficile Infection. CDI The Impact Lets Talk Numbers 1

2 Diarrhea in the Elderly CDI Incidence highest in the Elderly 85% of Diarrheal Deaths in the US are in the Elderly (> 60yo) 10 Fold in the > 65yo 2 Fold in General Population Morley, JAMDA 2009 CDC- McDonald, EID 2006 CDI Mortality Increasing CDI Mortality highest in the Very Elderly US mortality rate per million population 4 Fold increase in CDI Mortality 10-14% Mortality Rate >80yo CDC- Redelings, EID 2007 Archbald, JAMDA 2012 Healthcare Burden Increased Acute-Care Burden Most common cause of Infectious Diarrhea in healthcare settings In 2008: $4.8 billion in CDI related excess costs in U.S acute care facilities alone. Dubberke, CID

3 Increased LTCF Burden LTCF CDI is ubiquitous! CDI Increases the odds of discharge to LTCF to 62% as compared to Home. (32% w CDI vs 23% w-out CDI) Half of Healthcare-onset CDI occur in LTCF CDI Colonization (Asymptomatic Carrier) Healthy community adults: 3% Hospitalized adults: 20% LTCF adults: 35-50% Dubberke, CID 2012; Dumyati, IDSA 2009 Riggs, CID 2007; Kyne, NEJM 2000; McFarland, NEJM 1989 LTCF What are the Challenges? CDI Evolving Epidemiology Population: Frail Elderly Care Transitions Facility design Staffing Resources Visitation access 1978: Earliest cases of CDI Associated with R to Clindamycin 2003: Hypervirulent (NAP1/BI/O27) strain Associated with R to Floroquinolones More aggressive infection Increased risk for transmission and recurrence 2005: O78 strain Community acquired Younger healthy population Clostridium Difficile CDI The Life of a Bug Spore forming, Anaerobic, Gram positive bacillus Lives in environment for weeks-months; Nonreplicative state Bleach 10% or more kills spores; Alcohol doesn t 3

4 Clostridium Difficile CDI - Clinical Syndrome Transmission to host Feco-oral Asymptomatic carrier state TO Toxic megacolon Active replicative state Toxin-mediated Inflammation of colonic wall Virulence of pathogen Host immune response Host Risk Factors ATB Alteration of normal gut flora Enteral feeding CDI - Clinical Course Advanced age GI surgery Critical illness Acid suppression Chemotherapy Immunosuppressed state CDI - Let s Talk Diagnosis Clinical picture most imp! A case of CDI is defined by: the presence of symptoms (usually diarrhea) AND a stool test positive for C. difficile toxins or toxigenic C. difficile, OR colonoscopic or histopathologic findings revealing pseudomembranous colitis. Watery diarrhea, lower abdominal cramps, fevers, elevated white count Toxic picture with Ileus If clinical pretest probability high - Order further testing Initiate infection control practices May initiate treatment if severe and complicated illness SHEA-IDSA Cohen, ICHE

5 Further testing But, remember Test Specificity Sensitivity Time/ cost/ access SHEA-IDSA Comments Testing to be performed ONLY on watery, loose or unformed stool, unless ileus suspected Stool culture + cytotoxin assay (Goldstandard) EIA for Toxin A & B HIGHEST HIGH Slow/ High/ Difficult HIGH LOW Rapid/Low / Easy Essential for Epidemiological studies and standard for other tests Rapid but less sensitive suboptimal for diagnosis Repeat testing during the same episode of diarrhea increases false positives - discouraged Repeat testing as test of cure not recommended PCR HIGH HIGH Rapid/ Average/ Moderate Rapid, Sensitive and Specific may replace others Testing positive, Now what? SHEA-IDSA Guidelines STOP and NARROW spectrum ATB Infection control practices (if not already in place) Start ATB Rx for CDI per guidelines Supportive measures: Fluids Electrolytes Which ATB? Initial Episode Which ATB? 1 st Recurrence SHEA-IDSA Cohen, ICHE

6 Which ATB? 2 nd Recurrence But, remember Do NOT use MTZ beyond 1 st recurrence potential neurotoxicity Ongoing ATB Duration of CDI Rx -> ATB + 1 week If ileus suspected vancomycin retention enema Colectomy for severely ill patients Avoid these! Recurrent CDI - 3 rd or more Antiperistaltic agents Bile-acid binding resins Cholestyramine/ Colestipol Probiotics May have to think Outside the Box! Fidaxomicin (Dificid) Rifaximin (Xifaxan) Fecal Transplant healthy donor, retention enema - very effective! Zar, CID 2007; Johnson, CID 2007; Aas, CID 2003 Treatment can be Challenging and Ineffective CDI Prevention Prevent Horizontal Transmission Decrease Risk if Exposure High Healthcare providers Antibiotic stewardship Environmental Probiotics/ Yogurt PREVENTION is the Key! CDI Patient Avoid gastric acid suppressants 6

7 ATB Stewardship Probiotics or Yogurt? Increase use linked to colonization and/ or infection Broad spectrum/ multiple agents/ longer duration Risk high even 1-3 months after ATB use Although any ATB Avoid Clindamycin*, Cephalosporins*, Floroquinolones *SHEA-IDSA Cohen, ICHE 2010 Probiotics: Benefit seen, but lack of standardization, and possibility of bacteremia/ fungemia Live active culture yogurt: Benefit seen TO EARLY TO CALL! Perhaps Prevention > Treatment Yogurt > Probiotics Acid Suppression CDI Prevention Increase association of CDI with Achlorhydria Prevent Horizontal Transmission Decrease Risk in others if Exposure High Feb, 2012 FDA Safety Advisory: Healthcare providers Antibiotic stewardship A diagnosis of CDI should be considered for PPI users with diarrhea that does not improve. Use the lowest dose and shortest duration of PPI therapy. Environmental CDI Patient Probiotics/ Yogurt Avoid gastric acid suppressants If someone at high risk of CDI May suggest stop/hold PPI therapy Prevent Horizontal Transmission Infection Control Practices Start with SUSPICION of CDI and End with SOLID STOOLS! 7

8 Hand Hygiene Hand Hygiene Hand-washing vs Alcohol based products Soap and water vs > 60% alcohol solutions Guideline: Preferential use of handwashing AFTER taking care of CDI patients ONLY in outbreak settings (BIII) Theory vs Evidence CDI spores vs MRSA,VRE, H1N1 etc Availability vs Compliance Best practice: Handwashing BEFORE and AFTER taking care of CDI patients in ALL settings (outbreak or non-outbreak) SHEA-IDSA Cohen, ICHE 2010 Dubberke, SHEA Fall 2011 update Hand Washing Alcohol Based Products Wet Hands with warm water and apply soap Rub hands to make a lather, scrub all surfaces of hand Rub hands for 20 seconds ABCs or Happy Birthday song x 2 Rinse hands under running water Dry hands using clean paper towel or air dry Use paper towel to turn off faucet and open door knob Apply product to palm of one hand Rub hands together Rub over all surfaces Rub hands until dry DONOT use on visibly soiled or wet hands Prevent Horizontal Transmission Contact Precautions Gloves: single most important intervention with most evidence for preventing spread of CDI Gowns: potential of soiling of healthcare personnel s uniforms with CDI spores 8

9 Facilities - Isolation Prevent Horizontal Transmission Private Rooms Personal bedside commode if single rooms not available Cohorting OK to cohort two CDI Patients until persistent diarrhea Clean sinks NOT the one CDI Patient uses Important considerations as Healthcare Facilities prepare to curb nosocomial infections in future! Environmental Cleaning Use of Disposables CD spores survive in the environment for months or years! CDI spread linked with contaminated commodes, BP cuffs, oral/rectal thermometers Ideal sporicidal concentration of Chlorine solution ( ppm) i.e 10% or more Bleach for 10 mins Routine environmental screening for CD spores not recommended Single-use thermometers CDI Patient-specific BP cuff, stethoscope CDI Surveillance Policy Matters HCF Associated (HCFA) Hospital/ LTCF Onset (HO) Community Onset (CO) Community Associated (CA-CDI) Need to start monitoring HO-HCFA at the least! Specific Needs: Gloves & Gowns, Clean-sinks, Disposable thermometers, stethoscopes, BP cuffs, 10% Bleach and Staff Education and Awareness Connections with Labs Surveillance Leadership commitment 9

10 Objectives and Agenda In Summary Understand the impact of C. difficile infection and its evolving epidemiology Summarize latest testing and treatment modalities for C. difficile infection Learn the specific characteristics of C. difficile and hence, need for specific prevention practices and policies CDI is a serious and significant healthcare burden Prevention is much easier than treatment Needs specific practices and policies Hand-washing for 20 secs 10% Bleach for 10 mins Avoid/ Limit ATB and Healthcare exposure Thank You 10