What s the diff with C. diff.? Accelerating Prevention Using a Bundle Approach

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1 What s the diff with C. diff.? Accelerating Prevention Using a Bundle Approach GHA Learning & Action Network - 01/13/16 Russ Olmsted Dir., Infection Prevention & Control (IPC) System Office, Livonia olmstedr@trinity-health.org 2014 Trinity Health. All Rights Reserved. 1

2 Objectives & Disclosures 1.Describe the epidemiology of C. difficile infection (CDI) in the U.S. 2. Understand the pathogenesis of CDI. 3. List at least one strategy to prevent CDI 4. Describe elements of a bundle of prevention strategies to prevent CDI.. R. Olmsted is a member of a Speakers Bureau sponsored by Ethicon, Inc. & consultant to Premier Inc. s Safety Institute 2014 Trinity 2014 Health. Trinity All Health Rights - Livonia, Reserved. MI 2

3 Antibiotic Associated Pseudomembranous Colitis Due to Toxin-Producing Bacteria Bartlett and co-workers 1 demonstrated cytotoxicity in tissue culture and enterocolitis in hamsters from stool isolates from patients with pseudomembranous colitis Isolate was C. difficile Bacillus difficilis (now confirmed as C. difficile) was cultured from healthy neonates (with difficulty, hence the name) in Bartlett JG, et al. NEJM. 1978;298: Hall JC and O Toole E. Am J Dis Child. 1935;49: Trinity Health. All Rights Reserved. 3

Morbidity & Mortality Associated with C.

5 Discharge rate for Clostridium difficile infection from US short-stay hospitals by age Fernanda C. Lessa et al. Clin Infect Dis. 2012;55:S65-S70

Building the Case for Prevention in the Community; experience in GA with CDI Reddy S.

8 Experience with CDI in Long Term Care Setting 122 VA LTCFs, U.S. Pooled rate = 1.98/10k Res. Days CDI Bundle: i)ppe + Cont Prec ii)hand Hyg. iii)env. cleaning & Disinfection iv) ASP Long-term care facility onset Lab ID rate = 50% decline. Clinically confirmed facility onset rate also declined but not statistically significant. Reason? Culls test results of those who are asymptomatic. Reeves JS, et al. Infect Control Hosp Epidemiol 2015 (Dec);first view article 2014 Trinity Health. All Rights Reserved. 8

9 SPECIAL CHALLENGES IN INFECTION CONTROL; CMS state operations manual, rev. 122, 9/26/14 Multidrug-resistant organisms (MDROs) Ambulatory Care Communicable disease outbreaks Bioterrorism Antimicrobial stewardship new in Trinity 2014 Health. Trinity All Health Rights - Livonia, Reserved. MI 9

11 New Frontier for ASP? implementation of outpatient interventions to reduce inappropriate antibiotic use could substantially decrease CA-CDI rates Oral penicillins and β-lactams with increased activity (amoxicillin/clavulanic acid), 2 antibiotic classes with greatest potential for declines in CA-CDI rates... Dantes R, et al. Open Forum Infectious Diseases Trinity Health. All Rights Reserved. 11

12 Risk Factors for Infection Hospitalization or long-term care facility Antibiotics (some more than others) Other medication exposure: chemotherapy, immunosuppressants, proton pump inhibitors Increasing age (>65, >>80) Co-morbidities Surgery Community-associated cases Peri-partum Close contact of CDI (C. difficile infection) case Food? 2014 Trinity Health. All Rights Reserved. 12

13 Outcomes of CDI Increases length of stay by days. Attributable costs of inpatient CDI in 2008 dollars = $3,006 $15,397 per episode. Patients with CDI were almost 2x as likely to be discharged to a long-term care facility Attributable mortality = 5% 10% Colonization of healthy non-hospitalized adults is uncommon (ie, rate <5%), however among hospitalized patients and especially nursing home residents range= 25-55% Dubberke ER, et al. Infect Control Hosp Epidemiol 2014;35: Trinity Health. All Rights Reserved. 13

transmission through contaminated environment and hands of healthcare personnel

15 Clostridium difficile Anaerobic, spore-forming Gram positive bacillus Diseases: pseudomembranous colitis, toxic megacolon, sepsis, and death Fecal-oral transmission through contaminated environment and hands of healthcare personnel Antimicrobial exposure is major risk factor for disease Healthy colon Pseudomembranous colitis

16 Pathogenesis of C. difficile Infection (CDI) Ingestion Germination Proliferation Toxin Production Sunenshine RH, McDonald LC. Cleve Clin J Med. 2006;73: ; with permission.

17 Fig 1. Developmental life cycle of Clostridium difficile during infection. Shen A (2015) A Gut Odyssey: The Impact of the Microbiota on Clostridium difficile Spore Formation and Germination. PLoS Pathog 11(10): e doi: /journal.ppat Trinity Health. All Rights Reserved. 17

18 Prerequisites for CDI Cefa getem all Antimicrobial therapy Disturbed colonic microflora Acquisition of toxigenic C. difficile Advanced age Underlying illness Enterotoxin A & cytotoxin B production CDI CDI due to recent (re)acquisition of C. difficile Incubation period unknown <7 days to several weeks? Antimicrobial exposure may or may not precede acquisition The two appear to be in proximity

19 Increased Toxin B Production In Vitro In vitro production of toxins A and B by C. difficile isolates. Median concentration and IQRs are shown. C. difficile strains included 25 toxinotype 0 and 15 NAP1/027 strains (toxinotype III) from various locations. IQR=interquartile range. Adapted from Warny M, et al. Lancet. 2005;366: ; with permission.

Laboratory Diagnosis of CDI APIC Implementation Guide: Guide to

21 CDC s Vital Signs Report 03/06/2012 Patient: George

22 Transmission Dynamics Model CDI Donskey C. CID 2010:50 (1 June)

Prevent the spread Prevention Strategies Antibiotic

Environmental cleaning/disinfection Educate: HCWs,

between patients via the hands of HCW s Put on gloves

23 Prevent the spread Prevention Strategies Antibiotic stewardship (prudent use) Use of contact precautions Environmental cleaning/disinfection Educate: HCWs, patients, family and visitors Prevent cross transmission between patients via the hands of HCW s Put on gloves just before or soon after entering patient s room Emphasize Use of hand hygiene

24 Targeted antibiotic consumption and nosocomial C. difficile disease Tertiary care hospital; Quebec, Valiquette, et al. Clin Infect Dis 2007;45:S112.

25 Impact of Antimicrobial Stewardship Program (ASP) on HAI Outcomes; quarterly Rate of isolates per 10,000 patient days Baseline 8 Quarters mean Post Intervention mean 17 Quarters Difference in Isolates Comparison of Means p-value C. difficile* VRE * MRSA* MSSA* ESBL Pseudomonas Acinetobacter Candida* The changes in isolate values are reflected as either a reduction (negative sign) or increase number. Using Student T-test comparison of the means before and after intervention at p<0.05 *Statistically significant rate reduction per quarter of pathogen isolates per patient days. Madison G, Kleina L, Turco T, Hunter J, Hallur R.; ASP Team, Mercy Philadelphia Hospital, 10/20/15

26 ASP Program Impact: Purchases of Targeted Drugs by Quarter Overall reduction of 74% in targeted drugs purchased. Individual antibiotic percent reduction is as follows: carbapenems (59%), linezolid (85%), piperacillin/tazobactam (77%), vancomycin (54%).

28 When Can Isolation Be Discontinued? Duration of illness; After resolution of symptoms, patients with CDI can continue to shed C. difficile in stool and contaminate the environment. Use for duration of hospital stay = special approach Donskey C. CID 2010:50 (1 June) & SHEA CDI Compendium, 2014

Wear gloves before entry to the room and remove prior to exiting the room. It is difficult to wash off spores. If hands or gloves are visibly soiled or there is an outbreak.

29 Urban Legend? C diff and Hand Hygiene Soap Or Alcohol Hand Rub? What is the most important action to prevent contamination of hands with spores? Is soap and water required for hand hygiene in a C diff room? Does alcohol hand rub increase the rate of Clostridium difficile in the hospital? Wear gloves before entry to the room and remove prior to exiting the room. It is difficult to wash off spores. If hands or gloves are visibly soiled or there is an outbreak. Several studies find that alcohol hand rub does not increase the rate. What happens if there is an outbreak or a high incidence of C diff on a unit? Infection Prevention & control will notify the unit if changes in hand hygiene method are needed. SHEA CDI & Hand Hygiene Compendium, 2014

Renewed Respect for Role of the Environment: Prior Room Occupant = Risk of Acquisition Growing evidence on increased risk of acquisition of specific pathogens, C.

30 Renewed Respect for Role of the Environment: Prior Room Occupant = Risk of Acquisition Growing evidence on increased risk of acquisition of specific pathogens, C. difficile, MRSA, and VRE, when admitted to room where prior occupant had one of these or if in multi-occupancy room Huang SS (2006) 1 Drees M (2008) 2 Zhou Q (2008) 3 Moore C (2008) 4 Hamel M (2010) 5 Shaughnessy et al. ICHE 2011;32: Huang SS, et al. Arch Intern Med. 2006;166(18): Drees M, et al. Clin Infect Dis. 2008;46(5): Zhou Q, et al. Infect Control Hosp Epidemiol. 2008;29(5): Moore C, et al. Infect Control Hosp Epidemiol. 2008;29(7): Hamel M, et al. Am J Infect Control. 2010;38(3): Trinity Health. All Rights Reserved. 30

The Environment Of Care When possible, use

equipment before use on another patient Focus

, bed rails, over bed table, bedside commode,

31 The Environment Of Care When possible, use dedicated patient-care equipment (e.g., blood pressure cuffs) or If reusable equipment is unavoidable, clean and disinfect equipment before use on another patient Focus on frequently touched surfaces (e.g., bed rails, over bed table, bedside commode, bathrooms surfaces) and equipment in the immediate vicinity of the patient

32 What Do Healthcare Personnel Touch with High FREQUENCY? ICU Setting (N=28) Huslage K, Rutala WA, Sickbert-Bennett E, Weber DJ. ICHE 2010;31:

TERMINAL ROOM CLEANING: DEMONSTRATION OF IMPROVED CLEANING Evaluated cleaning before and after an intervention to improve cleaning 36 US acute care hospitals Assessed cleaning using a fluorescent dye

33 TERMINAL ROOM CLEANING: DEMONSTRATION OF IMPROVED CLEANING Evaluated cleaning before and after an intervention to improve cleaning 36 US acute care hospitals Assessed cleaning using a fluorescent dye Interventions Increased education of environmental service workers Feedback to environmental service workers Regularly change dotted items to prevent targeting objects Carling PC, et al. ICHE 2008;29:

34 Automated, No-Touch Disinfection Vaporized Hydrogen Peroxide Ultraviolet Germicidal Irradiation (UVGI)

35 Comparison of H2O2 vs UVGI NTD NTD = No touch disinfection Emerging evidence; J Hosp Infect 2013;83:1-13 select devices 2014 Trinity Health - Livonia, MI 35

36 Recommended Framework for Assessing Need and Value of No Touch Disinfection (NTD) 1. Review data on frequency of healthcare associated infections (HAIs) does this identify opportunities to improve cleaning/disinfection of the environment? 2. Engage key stakeholders; Environmental Services and Infection Prevention & Control (IPC) leaders to review and assess need + value 3. Apply peer-reviewed, scientific evidence to identify need 4. Is there sufficient infrastructure to operate NTD devices and will this be sustained? 5. What is level of adherence by colleagues and clinicians with other core prevention strategies, e.g. hand hygiene, isolation precautions, antibiotic stewardship, etc.? 2014 Trinity 2014 Health. Trinity All Health Rights - Livonia, Reserved. MI 36

37 No Touch Disinfection? Key questions APIC. Guide to Preventing CDI, 2013

38 Highlights from ID Week, 2015 UVGI was deployed for 21.1% (542/2569) of all patient discharges on the 3 study units Rates of CDI declined 25% on the study units and increased 16% on non-study units during the intervention vs. baseline period Trinity Health. All Rights Reserved. 38

Highlights from ID Week, 2015 28 months in 9 study hospitals from 4/2012 to 7/2014 quaternary ammonium (reference group A) compared to 3 enhanced cleaning strategies: quaternary ammonium + UV-C (B),

39 Highlights from ID Week, months in 9 study hospitals from 4/2012 to 7/2014 quaternary ammonium (reference group A) compared to 3 enhanced cleaning strategies: quaternary ammonium + UV-C (B), bleach (C), and bleach + UV-C (D). bleach was used for daily and terminal disinfection of all known C. difficile rooms, regardless of study arm. Target pathogens = MRSA, VRE, C. difficile, or MDR Acinetobacter 2014 Trinity Health. All Rights Reserved. 39

40 Highlights from ID Week, 2015 BETR Study, continued all target MDROs was 37% lower in Group B (p=0.03) and 32% lower in Group D (p=0.01) No significant impact on incidence of CDI with UVGI over dilute bleach alone Trinity Health. All Rights Reserved. 40

41 Bundle Approach SHEA CDI Compendium,2014 Limit testing to those with symptoms of CDI do not perform repeat test for cure Prompt identification of suspect case - consider lab-base alert for + Avoid use of electronic thermometers for those with CDI dedicated equipment if possible Contact Precautions; ideally in private rooms Don gown and gloves upon entry to the patient s room Hand hygiene based on CDC or WHO guidelines Ensure cleaning and disinfection of equipment and the environment Sodium hypochlorite (household bleach) diluted 1 : 10 with water or an EPA registered sporicidal product in an outbreak or high rates Surveillance, education providers and patients Special approaches: risk assessment then Data are currently too limited to draw any conclusions as to whether or when these devices should be a component of a CDI prevention program. In addition, excellent results can be achieved with manual cleaning with a sporicidal disinfectant 2014 Trinity 2014 Health. Trinity All Health Rights - Livonia, Reserved. MI 41

CDI Prevention Strategies; Use and Perception of Strength of Supporting Evidence, U.S. Hospitals Saint S, et al.

43 Reality Check; Back to Basics & Human Factors Full compliance with Contact Precautions (CP) for CDI was low at 2 different hospitals Adherence with CP for CDI is a complex, timeconsuming process Need human factors engineering approach to improve Yanke E, et al. Am J Infect Control 2015;43: Trinity Health. All Rights Reserved. 43

Bundle Approach to Prevention & Control of CDI GHA LEAPT/GAPP

47 Fecal microbiota transplants (FMT) FMT has demonstrated extraordinary clinical resolution, C. difficile infection cure rates of over 90%, and low recurrence [Borody T, et al. Expert Rev Gastroenterol Hepatol Sep 28:1-13] One option; Open Biome Trinity 2014 Health. Trinity All Health Rights - Livonia, Reserved. MI 47

48 Risk Based Planning Risk Assessment Infection risk assessment IC Evaluation IC Implementation IC Risks IC Goals Goal Reduce or eliminate infection Implementation Based on guidelines and organizationspecific risk Evaluation Rates reduced? Best practices followed? Implementation complete? D. Rumovitz St. Mary Medical Ctr, Langhorne, PA; Spring 2014 ART Conference

C Difficile - The Ultimate Challenge: Controlling the Spread

C Difficile - The Ultimate Challenge: Controlling the Spread Linda R. Greene, RN, MPS, CIC Manager of Infection Prevention Highland Hospital Rochester, NY University of Rochester Medical Center linda_greene@urmc.rochester.edu