Clostridium DifficileInfection & Readmissions: An ounce of prevention is worth a pound of cure Brian S. Zuckerbraun, MD, FACS Henry T. Bahnson Professor of Surgery University of Pittsburgh Chief, Trauma and Acute Care Surgery University of Pittsburgh Medical Center General Surgery, VA Pittsburgh Healthcare System
Background -Clostridium difficile: anaerobic, gram positive, spore forming, bacillus -Up to 3 million cases per year in US -Estimated $4 billion/year in expenditures -Mortality estimated to be ~4-8%
Background
Pathophysiology A disease of bacterial overgrowth and toxin production.
Risk Factors -Antibiotic use (fluoroquinolones, 2 nd & 3 rd generation cephalosporins, clindamycin, & β-lactams) -Hospitalization (20-40% patients colonized) -Advanced age -Immunosuppresion -Antacids (PPI and H 2 blockers) -GI surgery, IBD, NPO, elemental diets, NG tubes
Signs/Symptoms -Diarrhea -Abdominal Cramps/Pain -Leukocytosis -Fever -End organ failure
Readmissions Among discharges from the health system (n. 51,353), 615 were diagnosed with CDI (1%). Thirty-day readmissions were more common among CDI discharges (30.1%) than non-cdi discharges (14.4%). Average LOS for CDI readmissions was 5-6 days longer than non-cdi readmissions Chopra et al. / American Journal of Infection Control 43 (2015) 314-7
Readmissions The study included 3,950 patients with CDI from 2003-2009, including 413 patients with recurrent CDI. Recurrent CDI patients were significantly more likely to have at least 1 readmission (85% vs41%; P <.001) and had more days readmitted (mean 18.6 vs7.6; P <.001) than patients without recurrent CDI. Olsen et al. American Journal of Infection Control 43 (2015) 318-22
Survival After Discharge
Top 10 ways to reduce CDI 1. A hospital-based infection control program can help to decrease the incidence of CDI.
Top 10 ways to reduce CDI 2. Antibiotic stewardship is recommended to reduce the risk of CDI. (Strong recommendation, high-quality evidence) -In one study, an antimicrobial stewardship program contributed to a 60 % decrease in CDI incidence during an epidemic. -Monitor the incidence of CDI following any change in a formulary s antibiotic drug of choice
Top 10 ways to reduce CDI 3. Contact precautions for a patient with CDI should be maintained at a minimum until the resolution of diarrhea. (Strong recommendation, high quality evidence).
Top 10 ways to reduce CDI 5. Single-use disposable equipment should be used for prevention of CDI transmission. Non-disposable medical equipment should be dedicated to the patient s room, and other equipment should be thoroughly cleaned after use in a patient with CDI. (Strong recommendation, moderate-quality evidence)
Top 10 ways to reduce CDI 6. Disinfection of environmental surfaces is recommended using an Environmental Protection Agency (EPA)-registered disinfectant with C. difficile-sporicidallabel claim or 5,000 p.p.m. chlorine containingcleaning agents in areas of potential contamination by C. difficile. (Strong recommendation, high-quality evidence)
Top 10 ways to reduce CDI 7. Low index of suspicion in patients with diarrhea to test for CDI.
Top 10 ways to reduce CDI 8. Appropriate choice of antibiotics and antimicrobial management
ACG Severity Scoring and Treatment Severity Mild: Moderate: Severe: Diarrhea Criteria Diarrhea plus any additional signs or symptoms not meeting severe or complicated criteria Any two of the following: -WBC 15000cells/mm 3 -Serum albumin <3 g/dl -Abdominal tenderness Treatment Metronidazole 500 mg PO tid Vancomycin 125mg PO qid
Metronidazolev. Vancomycin -No antimicrobial agent is clearly superior for the initial cure of C. difficile infection -Three randomized control trials have compared metronidazole to vancomycin *One trial demonstrated vancosuperior in severe disease (Zar et al, Clinical Infectious Disease, 2007) (evidence considered insufficient)
-Non-inferior to vancomycin for cure rate -Lower recurrence rate compared to vanco -expensive -Use in setting of recurrences
Top 10 ways to reduce CDI 9. Recognize and treat recurrences appropriately Recommended for recurrent disease 1 st Recurrence: Vancomycin 2 nd Recurrence: Vancomycin7 week taper 3 rd Recurrence: Fecal MicrobiotaTherapy
Although there is moderate evidence that probiotics decrease the incidence of antibiotic associated diarrhea, there is insufficient evidence that probiotics prevent CDI.
Top 10 ways to reduce CDI 10. Educate patients! -High recurrence rates -Prevent dehydration