Clostridioides difficile Infection: What s the BIG Stink? GLORIA MATHIS, RN, BSN, CIC 29 TH ANNUAL MEDICAL SURGICAL CONFERENCE APRIL 4, 2019 SAN FRANCISCO, CA
I am sre my patient has C. diff. I cold smell it as soon as I walked on the nit. MED-SURG UNIT NURSE, ANY TOWN USA Have yo heard this one before? Does yor Nose Know C. diff when it smells it?
Objectives Describe the hman and financial impact of Clostridioides difficile (C. diff) Understand the pathogenesis, epidemiology, detection, and treatment of C. diff infections Identify key strategies to prevent the transmission of C. diff
So What s the Big STINK with C. diff? Most common microbial case of HAI s in America 2011, cased approximately 500,000 infections 65% of those infections considered healthcare associated. 29,000 patients died within 30 days of diagnosis 1 ot of 11 patients aged 65 and older diagnosed with C. diff infection died within 30 days $3000 - $9000 excess attribtable costs per infection $4.8 billion each year in excess health care costs for acte care facilities alone McDonald LC et al. Clin Infect Dis 2018; 66: e1-e48
C. diff: Who Gets It? Risk for C. diff Increases with: Antibiotic Exposre Extended Length of Stay in Healthcare Settings Serios Underlying Illness Immnocompromising Conditions Advanced Age Gastrointestinal Srgery/Maniplation https://www.cdc.gov/hai/organisms/cdiff/cdiff_faqs_hcp.html
C. diff Pathophysiology Lives in environment in spore form Spread fecal-oral Spores can srvive gastric environment, colonize intestines Gt flora altered C. diff germinates into vegetative form Release of toxins alters intestinal lining diarrhea, colitis https://www.cdc.gov/hai/organisms/cdiff/cdiff_faqs_hcp.html
C. diff Otcomes: Why Do We Care? C. diff Infection clinical otcomes: Diarrhea Psedomembranos Colitis Flminant Colitis Toxic Megacolon Perforation Septic Shock Death ICU Admission Colectomy (0.3-1.3% patients) Death (4.5 7.5% endemic, 6.9-16.7% epidemic). McDonald LC et al. Clin Infect Dis 2018; 66: e1-e48
C. diff Transmission Fecal-Oral Transmission cycle Emoji Style Fecal-Oral Transmission of C. diff
C. diff Transmission Role of Skin Boblsky GS et al. Clin Infect Dis 2008; 46: 447-450.
C. diff Transmission Role of Environment Sethi et al showed Environmental contamination highest before treatment, then 37% at resoltion diarrhea 14% at end of treatment 50% at 1 to 4 weeks after treatment Samore et al fond hand contamination was: 0% when environmental contamination was 0% to 25%, 8% when environmental contamination was 26% to 50%, and 36% when environmental contamination was greater than 50% Sethi AK et al. ICHE 2010; 31: 21-27 Samore MH et al. Am J Med 1996; 100: 32-40
C. diff Transmission Role of Skin & Environment Sethi AK et al. ICHE 2010; 31: 21-27
C. diff Testing When: Unexplained and new onset 3 nformed stools in 24 hors Unexplained i.e. consider laxatives, tbe feedings, other medications If negative, do not repeat within 7 days No test of cre Not recommended in children 1 y.o. How: Stool toxin test as part of mlti-step algorithm GDH pls toxin, GDH pls toxin followed by NAAT, NAAT pls toxin Sniff test Not approved, bt does it work? McDonald LC et al. Clin Infect Dis 2018; 66: e1-e48
Qestion of the Day.. Can Nrses Detect C. diff by the smell alone? What the stdies say: 2002 2007: hospital RN s were 55-84% sensitive and 77-83% specific in detecting C. diff by odor. 2004 Presence of niqe volatile organic componds in stools of C. diff patients 2013 Rao et al performed sniff test in the laboratory Mins other clinical ces, RN s were only able to correctly identify C. diff stool samples 45% of the time What abot Dogs? 83% sensitive, 98% specific Rao K. et al. Clin Infect Dis 2013; 54(4); 615-616 Bomers MK et al. BMJ 2012; 345: e7396
C. diff Treatment Pharmaceticals Discontine nnecessary antibiotics Vancomycin or Fidaxomicin for initial episode Srgery for severely ill Fecal Microbiota transplantation for patients with mltiple recrrences, failed antibiotic treatments McDonald LC et al. Clin Infect Dis 2018; 66: e1-e48
C. diff Prevention Isolation Private Room, Dedicated Toilet, Dedicated eqipment Contact Precation - gown and gloves Hand Hygiene! with soap and water Enhanced Environmental Cleaning sporicidal agent Antimicrobial Stewardship Edcation of Patients and Families McDonald LC et al. Clin Infect Dis 2018; 66: e1-e48 https://www.cdph.ca.gov/programs/chcq/hai/cdph%20docment %20Library/CDIQicksheetMarch2017.pdf
C. diff: Prevention is in yor Hands