Journey to Decreasing Clostridium Difficile and the Unexpected Twist Jackie Morton, Infection Prevention Cortney Swiggart, Medication Safety Officer 4/13/2018
Objectives Discuss the organism and clinical symptoms of Clostridium difficile (C. diff) Discuss measures for prevention Discuss treatment options utilized for treatment of C. diff
Clostridium difficile (C. diff) What is it? C. difficile is a spore-forming, grampositive anaerobic bacillus. It is a common cause of antibiotic associated diarrhea in hospitalized patients. It can cause colitis and other serious conditions such as pseudomembranous colitis, toxic megacolon, bowel perforation, sepsis, and death. It is spread through feces Image: Centers for Disease Control and Prevention/ADAM.
Clostridium difficile (C. diff) Signs and Symptoms Watery diarrhea - usually frequent and often uncontrollable Fever Abdominal tenderness Loss of appetite Pain or cramping in abdomen
Outcomes Associated with Clostridium Difficile Increased LOS 3-6 days Increased cost $3,000-15,400 Twice as likely to be discharged to long term care Attributable mortality 5%-10% Estimated 14,000-20,000 US deaths per year
Journey to Decrease C. Difficile Antibiotic Stewardship Appropriate Testing Environment al Decreasing C. Difficile Risk Assessment Policiy/Educat ion
1.4 CDIFF SIR 1.2 1.19 1 0.922 0.837 Median 0.8 0.6 0.4 0.454 Decile 0.2 0 2015 2016 2017 2018Q1
Patients Harmed C. Difficile 300 284 CDIFF Pts Harmed 250 200 209 186 150 100 92 50 0 2015 2016 2017 Projection based 2018Q1
Antimicrobial Stewardship The optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance Mayo Clin Proc. Nov 2011; 86(11):1113-1123
Benefits of Antimicrobial Stewardship Improve quality of care Optimize treatment Reduce adverse events Enhance patient safety Fewer treatment failures Decrease rates of resistant organisms and C.diff infections Cost Savings Hospital Patient
CDC Core Elements Leadership commitment Accountability Drug Expertise Action Tracking Reporting Education
Antimicrobial Stewardship ID physician Information technology Pharmacist Laboratory Antimicrobial Stewardship Infection Prevention Epidemiology Microbiology
Initiatives associated with reduced C.diff Formulary changes, restrictions, preauthorizations Prospective audit and feedback Protocols or algorithms for specific infections Use of technology Education
Initiatives at MLH Pharmacokinetic drug monitoring Renal dose adjustment Automatic 7 day stop on all Antibiotics (Adults) Automatic IV-to-PO interchange Antibiotic Restriction Restricted to ID physicians Restricted to certain indications Electronic forms must be completed
Antibiotic Restriction Form
Clinical Surveillance System Tracks antibiotic utilization Redundant betalactam therapy Redundant anaerobic therapy Stores intervention data Provides stewardship alerts Bug-Drug mismatch Poly-antimicrobial De-escalation IV to PO conversion
Clinical Surveillance System Challenges Additional system to log into One time orders and On-Call orders affect accuracy Difficult to validate antibiotic utilization data Benefits Ties interventions to a dollar amount Reports can be exported In 2017 25,000 interventions reported with cost savings of 3 million dollars
Clinical Indication Suspected/Known Indication List: Prophylaxis Bacteremia Bone/Joint infection CNS infection Gastrointestinal infection Febrile neutropenia Intra-abdominal infection Upper respiratory tract infection Lower respiratory tract infection Sepsis (unclear source) Skin/Soft tissue infection Urinary tract infection Other (Free text box)
Antibiotic Indication Required Challenges Concern from prescribers List is not all inclusive Use of other Benefits Allows dose evaluation by pharmacy based on indication Easier to identify appropriate length of therapy
Antibiotic Time Out Pop-up alert to physicians Who does it fire to? When does it fire? What if there are multiple antibiotics? Pilot performed Smart Zone alert Viewable by all physicians Doesn t require action Pharmacist driven Task fires to pharmacist Pharmacist discusses on rounds Form is completed
Limited case-control study Collect data on C.diff patients and compare with a control group Review Odds Ratio and overall use to determine association with c. diff Identify antibiotics most associated with C.diff infections in your organization Currently undergoing this process Target your stewardship interventions around those antibiotics
Major Overall Challenges Time Data Resources
C. Difficile and the Environment
C. Difficile and the Environment
C. Difficile Risks Assessment 80% 70% 67% 62% 60% 50% 46% 49% 53% 40% 41% 30% 25% 27% 27% 29% 30% 20% 10% 0%
Clostridium Difficile Patients and Assesment 70% 60% 50% 40% 49% 61% 30% 20% 10% 0% 22% HO b/c delayed test 26% Tested for Cure On Laxatives No Symptoms Symptoms diarrhea (3 or more loose stools in 24 hours) and/or WBC > 12,000 Fever, Abdominal pain or tenderness
Testing Per Guidelines ORDERS APPROPRIATE TESTING INAPPROPRIATE TESTING INFECTION PREVENTION Physician directed ONLY Watery/loose stools Patient has no Diarrhea (do not send test) Contact Isolation gloves/gown every time Lab Refuses formed stool samples 3 watery/loose stools in 24 hours not otherwise explained Formed stool or sample does not conform to cup Glove use and ABHR for healthcare workers Stool sample should conform to cup Test for cure Use of soap and water for patients and family hand hygiene Routine screening Use Disinfectant w/c-diff spore claim
Report of Pending C. Difficile Orders Available Patient name Unit location of order Ordering Physician Laxatives History of C. Difficile Last documented stool description Report available through MOLLI and/or Cerner >P00 Explorer Menu>C. Difficile Laxative Report>select facility and dates>execute
Automatic Cancellation Any C. Diff order on hospital day one auto-cancelled at midnight on hospital day 3 Any C. Diff order on hospital day 2 or after should be cancelled in 48 hours
Inappropriate Testing Laxatives in past 72H One loose stool or absence of diarrhea (unless ileus suspected) Absence of diarrhea Formed stool Testing without MD order Test of cure and retesting* Positive C. Diff result in the past 28 days (will shed spore for weeks) Rectal washout Less than 2 years old *NOTE: Most patients who are clinically cured with treatment will continue to have toxigenic C. difficile in their stool for multiple weeks test of cure should not be conducted if a patient is being transferred to another healthcare facility.
C. Difficile Order Alert Keeping in mind there is a high incidence of asymptomatic carriage of C. Difficile, order Clostridium difficile assay only if the patient: has received antibiotics within the preceding month, has diarrhea (3 or >loose stools in 24 hours or watery diarrhea) and check one or more: WBC > 12,000 (unless neutropenic) Fever Abdominal pain or tenderness Not Appropriate Testing: Laxatives in past 72H One loose stool or absence of diarrhea (unless ileus suspected) Absence of diarrhea and/or formed stool Testing without MD order Test of cure Absence of diarrhea and/or formed stool Positive C. Diff result in the past 28 days Rectal washout Less than 2 years old
C. Difficile Alert with HX of Laxatives Your patient has received laxatives and, as expected, has loose stools. Keeping in mind there is a high incidence of asymptomatic carriage of C. Difficile, order Clostridium difficile assay only if the patient: has received antibiotics within the preceding month, and has diarrhea (3 or >loose stools in 24 hours or watery diarrhea) and check one or more: WBC > 12,000 (unless neutropenic) Fever Abdominal pain or tenderness Not Appropriate Testing: Laxatives in past 72H One loose stool or absence of diarrhea (unless ileus suspected) Absence of diarrhea and/or formed stool Testing without MD order Test of cure Positive C. Diff result in the past 28 days Rectal washout Less than 2 years old
Primary Indications for FMT Prevent further clinical deterioration due to severity of the patient s CDI. Recurrent or relapsing CDI defined as at least three episodes of mild to moderate CDI: and Failure of a 6- to 8-week taper with Vancomycin with or without an alternative antibiotic. 4/13/2018
Fecal Microbiota Transplant (FMT) FMT shown to cure over 90% of the most refractory C. difficile cases that had previously failed standard antibiotic therapy Special consent needed investigational therapy potential risks Openbiome provides screened, filtered, and frozen material ready for clinical use. Donors include young researchers and scientists within the MIT, Harvard, and Tufts communities and professionals from the Tufts University area. 4/13/2018
Thank you! Cortney Swiggart cortney.swiggart@mlh.org Jackie Morton, jackie.morton@mlh.org