6/14/2012. Welcome! PRESENTATION OUTLINE CLOSTRIDIUM DIFFICILE PREVENTION. Teaming Up to Prevent Infections! 1) Impact. 2) Testing Recommendations

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1 CLOSTRIDIUM DIFFICILE PREVENTION Beth Goodall, RN, BSN Board Certified in Infection Prevention and Control DCH Health System Epidemiology Director Welcome! Teaming Up to Prevent Infections! CLOSTRIDIUM DIFFICILE PRESENTATION OUTLINE 1) Impact 2) Testing Recommendations 3) Prevention 1

2 BACKGROUND: PATHOGENESIS OF CDI 1. Ingestion of spores transmitted from other patients via the hands of healthcare personnel and environment 3. Altered lower intestine flora (due to antimicrobial use) allows 4. Toxin A & B Production proliferation of leads to colon damage C. difficile in colon +/- pseudomembrane 2. Germination into growing (vegetative) form Sunenshine et al. Cleve Clin J Med. 2006;73: BACKGROUND: EPIDEMIOLOGY RISK FACTORS Antimicrobial exposure Acquisition of C. difficile Advanced age Underlying illness Immunosuppression Tube feeds Gastric acid suppression Main modifiable risk factors Nursing Home 2

3 C. difficile germs move with patients from one health care facility to another, infecting other patients. o The most dangerous source of spread to others is the patients with diarrhea. o Unnecessary antibiotic use in patients at one facility may increase the spread of C. diff. in another facility when patients transfer. o When patient transfers, it is not always communicated that the patient has or recently had C. diff. infection, so they may not be taking the right actions to prevent spread. RISK OF CLOSTRIDIUM DIFFICILE While C difficile is the most commonly recognized cause of antibiotic-associated diarrhea, it accounts for only 15%-25% of all such diarrheal episodes. Likelihood is increased if the patient has received antibiotics in the previous 8-12 weeks, is over 65 years of age, and has 3 or more diarrheal stools in a 24-hour period. BACKGROUND: IMPACT Campbell et al. Infect Control Hosp Epidemiol. 2009:30: ;14: Dubberke et al. Clin Infect Dis. 2008;46: Brief # Hospital-acquired, hospitalonset: 165,000 cases, $1.3 billion in excess costs, and 9,000 deaths annually Hospital-acquired, postdischarge (up to 4 weeks): 50, cases, $0.3 billion in excess costs, and 3,000 deaths annually Nursing home-onset: 263,000 cases, $2.2 billion in excess costs, and 16,500 deaths annually Dubberke et al. Emerg Infect Dis. Elixhauser et al. HCUP Statistical 3

4 DEATHS CAUSED BY C. DIFFICILE INFECTIONS 400% rise from 2000 to 2007 Up to 14,000 deaths annually $1.3 billion in extra cost Source: CDC National Center for Health Statistics 2012 TESTING FOR CLOSTRIDIUM DIFFICILE INFECTION It is important to ensure that only patients with active diarrhea are being tested; otherwise, the tests are more likely to detect asymptomatic colonization. Moreover, patients who have recovered from CDI will often remain colonized for a prolonged period, and therefore repeat testing of patients to prove cure should be discouraged. DIAGNOSTIC TESTING METHODS Most laboratories have relied on Toxin A/B enzyme immunoassays - EIA Low sensitivities (70-80%) lead to low negative predictive value Poor test ordering practices (i.e. testing formed stool or repeat testing in negative patients) ts) may lead to many false positives Cost $5 Consider more sensitive diagnostic testing, PCRbased molecular assay Highly sensitive, > 90% 10% of PCR+ are probably colonized rather than infected Cost $25 - $50 4

5 COLONIZATION VS. INFECTION Clostridium difficile colonization Patient exhibits NO clinical symptoms Patient tests positive for Clostridium difficile More common than infection Clostridium difficile infection Patient exhibits clinical symptoms Patient test positive for Clostridium difficile CLOSTRIDIUM DIFFICILE INFECTIONS CAN BE PREVENTED. DOCTORS AND NURSES Prescribe antibiotics carefully. Once culture results are available, make sure abx are correct and necessary. Order testing only if >3 unformed stools in 24h. Be aware of infection rates in your facility. Isolate patients with C. diff immediately. Clean room surfaces with bleach. When a patient transfers, notify the new facility. Wear gloves and gowns. Wash hands with soap and water. 5

6 SUPPLEMENTAL PREVENTION STRATEGIES: RATIONALE FOR SOAP AND WATER: LACK OF EFFICACY OF ALCOHOL-BASED HANDRUB AGAINST C. DIFFICILE Oughton et al. Infect Control Hosp Epidemiol 2009;30: FACILITY ADMINISTRATORS Support better testing, tracking, and reporting of infection prevention efforts. Make sure cleaning staff follows CDC guidelines, using spore-killing disinfectant in C. diff patient rooms. Notify other health care facilities about infectious diseases when patients transfer, especially between hospitals and nursing homes. Participate in regional prevention efforts. PATIENTS Take antibiotics only as prescribed by your doctor. Antibiotics can be lifesaving medicines. Tell your doctor if you gave been on antibiotics and get diarrhea within a few months. Wash your hands after using the bathroom. Try to use a separate bathroom if you have diarrhea, or be sure the bathroom is cleaned well. 6

7 SUMMARY OF PREVENTION MEASURES Core Measures Contact Precautions for duration of illness Hand hygiene in compliance with CDC/WHO Cleaning and disinfection of equipment and environment Laboratory-based alert system CDI surveillance Education Supplemental Measures Prolonged duration of Contact Precautions* Presumptive isolation Evaluate and optimize testing Soap and water for HH upon exiting CDI room Universal glove use on units with high CDI rates* Bleach for environmental disinfection Antimicrobial stewardship program * Not included in CDC/HICPAC 2007 Guideline for Isolation Precautions CLOSTRIDIUM DIFFICILE -THE BOTTOM LINE Given that both the incidence and severity of CDI are at historic highs, it is important that clinicians become more aware of how to recognize, diagnose, treat, and prevent CDI. CDI can be prevented by washing hands with soap and water between patients, wearing gloves and gowns when entering rooms of patients with diarrhea, and using antibiotics judiciously. Go Forth... 7