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Clostridium difficile Management in Healthcare
Facilities
Gail Bennett, RN, MSN, CIC
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Clostridium difficile Clostridium difficile Infection (CDI)Infection (CDI) - - ObjectivesObjectives
Describe the changing epidemiology of Clostridium difficile.
State two differences between acute care and long term care in managing patients/residents with C. difficile infection.
List three important strategies for preventing transmission of C. difficile within healthcare facilities.
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Primary References for Presentation
APIC Guide to the Elimination of Clostridium difficile Infections in Healthcare Settings
CDC, Clostridium difficile Infections Toolkit
Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)
Note: these documents were developed prior to approval of EPA registered disinfectants with kill claims against spores. Therefore they still recommend use of a bleach product for disinfection.
http://www.apic.org/Content/NavigationMenu/PracticeGuidance/APICEliminationGuides/C.diff_Elimination_guide_logo.pdf
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Clostridium difficile Clostridium difficile Infection Infection (CDI) (CDI) Antibiotic induced diarrhea May cause approximately 30% of all cases
of healthcare associated diarrhea Most common cause of acute infectious
diarrhea in nursing homes Disease may be a nuisance or cause life
threatening pseudomembranous colitis Increasing numbers of cases
Cases tripled in US hospitals from 2000 until 2005
Increasing disease severity and mortality
Background: Impact
• Hospital-acquired, hospital-onset: 165,000 cases, $1.3 billion in excess costs, and 9,000 deaths annually
• Hospital-acquired, post-discharge (up to 4 weeks): 50,000 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
Campbell et al. Infect Control Hosp Epidemiol. 2009:30:523-33. Dubberke et al. Emerg Infect Dis. 2008;14:1031-8.
Dubberke et al. Clin Infect Dis. 2008;46:497-504. Elixhauser et al. HCUP Statistical Brief #50. 2008.
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Clostridium difficile Clostridium difficile Colonization vs InfectionColonization vs Infection Colonization: presence of microorganisms
without tissue invasion or damage, therefore no signs or symptoms
Colonization rate of C. difficile About 10-25% of hospitalized patients About 4-20% of long term care residents Antibiotic therapy may disrupt normal colonic flora in
colonized patients and C. difficile proliferates, producing toxins and symptomatic disease
Infection: presence of microorganisms with tissue invasion and damage, therefore signs or symptoms
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Background: EpidemiologyRisk Factors
Antimicrobial exposure Acquisition of C. difficile Advanced age Underlying illness Immunosuppression Tube feeds ? Gastric acid suppression
Main modifiable risk factors
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Antibiotics most often associated with Clostridium difficile
Ampicillin Amoxicillin Cephalosporins Clindamycin Fluoroquinolones
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New Toxic Strain
A new BINAP strain (B1/NAP1/027) is circulating in the U.S., Europe, and Canada that is more toxic
Produces large quantities of Toxins A and B
More severe disease, higher mortality
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Testing for Clostridium difficile
Toxin testing Quick – same day
Stool culture Takes 48-96 hours
Testing for C. difficile should be done on unformed (liquid) stool only unless ileus is suspected
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Testing for CDI by the Lab - Summary
Culture and toxin neutralization not practical in
most laboratories (but gold standard) EIA for toxins A and/or B is easy to do, but not very
sensitive (giving false negatives) GDH tells you C. difficile is present, but doesn’t tell
you if it is toxin-producing GDH+ plus EIA+ = toxigenic C. difficile, but still
have sensitivity problem related to EIA PCR more sensitive and as specific, and it identifies
A&B toxin gene
Slide courtesy of: Alfred DeMaria, Public Health Department, Massachusetts
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Treatments: Non-specific
Discontinue antibiotics if possible Fluid and electrolyte replacement Do not use antimotility agents
(e.g. opiates)
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Specific Treatment for Clostridium difficile
Metronidazole (Flagyl) 250 mg QID or 500 mg TID for 10-14 days
Vancomycin 125 mg QID for 7-10 days - used if resident does not respond to or cannot take Flagyl; may be used first if severe disease No reports of Metronidazole or Vancomycin
resistance following treatment New drug: Dificid (Fidaxomicin) – 200 mg bid
for 10 days Experimental fecal transplant (enemas)
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Recurrent Clostridium difficile infection
Rates of recurrence 20% after 1st episode 45% after 1st recurrence 65% after two or more recurrences
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C. difficile in Acute vs. Non-acute Settings
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Tiered Approach to Managing C. difficile
Includes a basic and an enhanced approach A tiered approach is presented by
Association for Professionals in Infection Control and Epidemiology (APIC)
Elimination Guide for C. difficile “Routine and heightened” approaches
Society for Healthcare Epidemiology of America (SHEA) and Infectious Diseases Society of America( IDSA)
Clinical Practice Guideline No tiered approach but categorizes recommendations by
“strength of the recommendation” Centers for Disease Control (CDC)
Recommendations to Prevent Spread of C. difficile Toolkit “Core and supplemental” approaches
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Tiered Approach to Clostridium difficile Infection (CDI) Transmission Prevention
Basic/Core/Routine Approach: C. difficile transmission prevention activities during routine infection prevention and control responses
Enhanced/Supplemental/Heightened Approach: C. difficile transmission prevention activities during heightened infection prevention and control responses
Evidence of ongoing transmission of C. difficile an increase in CDI rates and/or evidence of change in the pathogenesis of CDI (increased
morbidity/mortality among CDI patients) despite routine preventive measures
Note: many facilities choose to use the enhanced/supplemental approach all of the time.
Why Would Enhanced Strategies be Needed?
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What we are currently doing is failing!!
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Infection Prevention Strategies
Hand hygieneHand hygiene Contact precautionsContact precautions Identification of casesIdentification of cases Environmental disinfection Appropriate use of antibiotics
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For basic measures, may use alcohol handrubs with C. difficile – OR use soap and water
Perform hand hygiene
before contact with the patient/resident
after removing gloves after contact with the
environment
Hand Hygiene for Clostridium difficile
Hand Hygiene – Soap vs. Alcohol gel
Alcohol not effective in eradicating C. difficile spores
However, one hospital study found that from 2000-2003, despite increasing use of alcohol hand rub, there was no concomitant increase in CDI rates
Discouraging alcohol gel use may undermine overall hand hygiene program with untoward consequences for HAIs in general
Boyce et al. Infect Control Hosp Epidemiol 2006;27:479-83.
CDC adds: Because alcohol does not kill Clostridium
difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs.
However, early experimental data suggest that, even using soap and water, the removal of C. difficile spores is more challenging than the removal or inactivation of other common pathogens.
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For enhanced measures, do not use alcohol handrubs with the CDI patient/resident – use soap and water
Washing away the spores may be the optimal way to perform hand hygiene when transmission of C. difficile is occurring
Many facilities choose to use the enhanced strategy all of the time
Hand Hygiene for Clostridium difficile (continued)
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CDC Guideline for Hand Hygiene in Healthcare Settings(MMWR 2002, vol.51, no. RR16)
Conversation and Questions
What has worked for you? If you have alcohol handrubs
mounted in each room, how do you prevent its use with C. diff?
Questions?
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Infection Prevention Strategies
Hand hygiene Contact precautions Identification of casesIdentification of cases Environmental disinfection Appropriate use of antibiotics
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Contact PrecautionsContact Precautions
Designed to reduce the risk of transmission of microorganisms by direct or indirect contact
Direct contact skin-to-skin contact physical transfer (turning patients/residents,
bathing patients, other patient/resident care activities)
Indirect contact Contaminated objects
Equipment Linens High touch surfaces
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Patient or Resident placement Private room preferred 2nd option: Cohorting with other patient/resident with
C. difficile 3rd option: In LTCFs, consider infectiousness and
resident-specific risk factors to determine rooming with a low risk roommate and socializing outside the room
Consider: Clean Contained Cooperative Cognitive
Patient care equipment dedicated to single patient/resident if possible. If not, disinfect equipment prior to leaving the room.
Contact PrecautionsContact Precautions
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Tiered Approach for Contact Precautions: Basic
Contact Precautions - gloves and gowns to enter room or cubicle
Do not re-use gowns Supplies outside the room
Tiered Approach for Contact Precautions: Basic (continued)
In semi-private room, keep cubicle curtain drawn to limit movement between cubicles and as a reminder of precautions
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Contact Precautions: Basic Contact Precautions: Basic (Continued)(Continued)
Use dedicated equipment; if not feasible – decontaminate prior to use on another patient/resident
Maintain adequate supplies for contact precautions
Do not isolate asymptomatic carriers
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Contact Precautions: Basic Contact Precautions: Basic (Continued)(Continued)
May discontinue precautions when diarrhea ceases (may consider 48 hours without loose stool)
Do not do a toxin “for cure” once diarrhea has stopped
Lab should not accept stool for toxin if the stool is formed
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After treatment, repeat C. difficile testing is not recommended if the patient’s symptoms have resolved, as patients may remain colonized.
http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html
From the Horse’s Mouth:CDC’s Web Site
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Tiered Approach for Contact Precautions: Enhanced
May consider alternative signage to ensure staff awareness
Evaluate current system for patient/resident placement
Consider contact precautions for all patients/residents that develop diarrhea until CDI is ruled out
Increase monitoring of isolation precautions and hand hygiene
Extend use of contact precautions even when diarrhea stops
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Why contact precautions for Why contact precautions for C. C. difficiledifficile????
Environmental contamination
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The Inanimate Environment Can Facilitate Transmission
~ Contaminated surfaces increase cross-transmission ~Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.
X represents VRE culture positive sites
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Signage for Precautions
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Infection Prevention Strategies
Hand hygieneHand hygiene Contact precautionsContact precautions Identification of casesIdentification of cases Environmental disinfection Appropriate use of antibiotics
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Identification of Cases
Colonization or asymptomatic fecal carriage of C. difficile May be common in healthcare
facilities Do we care?
C. difficile infection Acute diarrhea
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CDI Collaborative Definition (see separate handout)
A case of C. difficile is defined as a case with the symptom of diarrhea without other known etiology
The stool sample will yield a positive result for laboratory assay for C. difficile toxin A and/or B
For this collaborative, CDI is limited to lab confirmed cases
Will track healthcare associated CDI
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CDI Collaborative Definition of Healthcare Associated
This collaborative will track laboratory confirmed cases of Health Care Facility C. difficile.
A laboratory confirmed case of C. difficile is defined as a patient with diarrhea characterized by unformed stool, without other known etiology, and associated with a positive laboratory assay for C. difficile toxin A and/or B on the stool.
Count each case of CDI only once Episode of CDI that occurs eight weeks or less after
the onset of a previous episode, provided the symptoms from the prior episode resolved.
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Definition (continued)HAI-CDI (INDEX FACILITY)A patient classified as having a case of healthcare facility associated C. difficile attributable to YOUR facility is defined as a patient who develops diarrhea on or after the 4th day of admission.ORA patient classified as having any symptoms that develop on or before the 4th day after your discharge to another healthcare facility. ORA patient discharged to home with lab confirmed C.diff. within 28 days from the day of discharge and no intervening admissions. (Day of discharge counts as day 1) Also counts if C.diff is identified on readmission to your facility within that 28 day period.
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Definition (continued)
HAI-CDI (OTHER FACILITY)A patient classified as having a case of healthcare facility associated C. difficile attributable to another health care facility is defined as a patient who develops diarrhea before the 4th day of admission
after transfer from another health care facility OR:
within 28 days of discharge from another health care facility
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48 hours - example Admission = day 1 – Monday Day 2- Tuesday Day 3- Wednesday Day 4- Thursday at 12:01 a.m. is the
cutoff. After Thursday at 12:01, it counts for your facility. Prior to that time, it is considered “community acquired” which includes any location other than your facility.
Exception – home care – 28 days
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Facility Healthcare Associated CDI Rate # of HA CDI cases divided by
patient/resident days X 10,000 = ___ HA CDI per 10,000 patient/resident days
Example: 3 cases HA CDI divided by 3,585
patient/resident days = .0008368 X 10,000 =8.368 or 8.4 cases of HA CDI per 10,000 patient/resident days
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Identification of Cases
Basic Strategy: With cases of diarrhea, consider C.
difficile Take a detailed history for risk factors
Norovirus, dietary changes, medications, and other things may also be causes of diarrhea
Notify physician Watch for dehydration
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Identification of Cases
Enhanced Strategy: Automatic contact precautions for all
patients/residents with orders for C. difficile labs AND for all patients/residents with a known history of CDI
Consider allowing nurses to initiate the lab order and contact precautions
Conversation and Questions
How does this show up in
your facility? What are you doing? What
are you worried about? Questions?
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Infection Prevention Strategies Contact precautions Hand hygiene Identification of casesIdentification of cases Environmental disinfection Appropriate use of antibiotics
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Environmental Survival and Contamination
Vegetative form survives for only 15 minutes on dry surfaces in room air
May remain viable up to 6 hours on moist surfaces Spores are highly resistant to drying, heat, and
chemical and physical agents Can exist for five months on hard surfaces
One study (McFarland et al, 1989) found spores in: 49% of rooms occupied with CDI 29% in rooms of asymptomatic carriers
Heaviest contamination on floors and in bathrooms
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Environmental Survival and Contamination (continued)
Spores have been isolated from the air and aerosol dissemination may, in part, account for widespread environmental contamination
The frequency of positive personnel hand culture has been strongly correlated with the intensity of environmental contamination
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Environmental Contamination
Examples of items that may become contaminated: Electric thermometers Blood pressure cuffs Bedrails Call buttons Tube feedings Flow-control devices
for IVs or tube feedings Bed sheets
Overbed table Commodes Toilets Scales Telephones TV controls Light controls Window sills
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Evidence of the role of environmental transmission
Frequency of C. difficile acquisition has been linked with the level of environmental contamination
Patients admitted to a room previously occupied by a patient with C. difficile have a higher risk for C. difficile acquisition
Improved room disinfection has led to decreased rates of C. difficile infection
Environmental Disinfection: Tiered Approach
Basic:Use EPA approved
germicide for routine disinfection during non-outbreak situations
Ensure staff training and contact time
Disinfect shared items between patients/residents
Monitor environmental cleaning
Enhanced:Use 10% sodium
hypochlorite (bleach) for disinfecting room and equipment (or use EPA registered sporicidal agent)
In outbreak, consider bleach solution for cleaning all rooms
Use bleach wipes as an adjunct to cleaning
Monitor and enforce adherence for cleaning
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Disinfectants
Commonly used disinfectants are not sporicidal Some may actually encourage sporulation
(the changing of the organism to the spore state)
Sporicidal disinfectants: Chlorine-based disinfectants High-concentration, vaporized hydrogen
peroxide Recently approved EPA registered
disinfectants that kill C. diff spores
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Disinfectants Chlorine-based disinfectants - disadvantages:
Can be corrosive to equipment or surfaces over time Can cause respiratory or other health problems in workers
using them May cause bleaching/fading
APIC states use of chlorine-based disinfectants should be limited to outbreak situations and when high rates of CDI have been documented
In these situations (outbreaks and/or high rates), chlorine-based products have demonstrated benefit when used with other control measures
In other situations, routine use of chlorine-based products has not been evaluated
Physical motion of cleaning + use of routine germicides = removal and dilution of spore concentration for non-outbreak situations
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Disinfectants
10% sodium hypochlorite solution One part household chlorine bleach
mixed with nine parts water Must be mixed fresh daily
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Pre-mixed Hypochlorite Solution: Advantages and Disadvantages
Advantages: Commercially available solutions include
detergent base Cleaning as well as disinfection Eliminates dilution errors
Disadvantages of pre-mixed solutions: Solutions expire over time May be hard to store May be more costly
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Bleach and water: mixing your own solution
Cleaning and disinfection is a two-step process (must clean first, then disinfect)
Contact time of ten minutes required for disinfection (Rutala, 2008) Thorough wetting of the surface, allowed to
air dry Note: pre-mixed EPA registered
hypochlorite solutions provide cleaning and disinfection in one step
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Newer products with EPA registration against C. difficile spores
Several on the market now
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Housekeeping Germicidal Agents with Sporicidal Claims against Clostridium difficile
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Floor decontamination
Consider cleaning the C. difficile room as the last room of the day
Alternately, change the bucket, solution, and mop head after cleaning the C. difficile room and before cleaning another room
All cleaning equipment and supplies should be decontaminated prior to use on another room
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Germicidal Wipes If wipes are used:
The wipe must wet the surface being disinfected for the correct contact time as noted on label
Use the right wipes for the right type of job The user should:
Know the contact time for the germicide used Know the ability of the wipe to maintain contact
time for the task for it will be used Be involved in selection of the right type of wipes
Staff must be trained to use the wipes appropriately
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Additional thought.. Remember the cubicle curtains when doing
terminal cleaning following C. difficile infection
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Monitoring Environmental Cleaning
Consistency with recommended cleaning and disinfection procedures should be routinely monitored.
Include all surfaces and items near the patient Staff performing cleaning should use checklists
Confirm that each critical area has been cleaned and disinfected
Each item must be checked off as it is completed No need for routine environmental sampling for
Clostridium difficile If there is ongoing transmission:
May indicate non-compliance Thorough cleaning and disinfection of the environment
must be done
69http://www.cdc.gov/HAI/toolkits/Appendices-Evaluating-Environ-Cleaning.html
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APIC Guide
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Approaches to Environmental Cleaning Monitoring
Basic Program Subjective visual
assessment Deficiency
oriented Problem detection
feedback Open definition of
correctable interventions
Enhanced Program Objective quantitative
assessment Performance oriented Ongoing cyclic
monitoring Objective performance
feedback Goal oriented
structured process improvement model
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Environmental Services Training
Because of the high turnover of staff, educate personnel on proper cleaning technique frequently.
Ensure that education is provided in the personnel’s native language.
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Infection Control Strategies
Contact precautions Hand hygieneHand hygiene Identification of casesIdentification of cases Environmental disinfection Appropriate use of antibiotics
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Appropriate Use of Antibiotics: just a few thoughts
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Antimicrobial Stewardship: definition
Antimicrobial (or antibiotic) stewardship programs are interventions designed to ensure that hospitalized patients receive the right antibiotic, at the right dose, at the right time, and for the right duration (CDC definition)
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Prescriber educationStandardized antimicrobial order
formsFormulary restrictionsPrior approval to start/continue
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Pharmacy substitution or switch Multidisciplinary drug utilization
evaluation (DUE)Provider/unit performance feedback Computerized decision support/on-
line ordering
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Antimicrobial Stewardship
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CDC Fast Facts
Antibiotic overuse contributes to the growing problems of Clostridium difficile infection and antibiotic resistance in healthcare facilities.
Improving antibiotic use through stewardship interventions and programs improves patient outcomes, reduces antimicrobial resistance, and saves money.
Interventions to improve antibiotic use can be implemented in any healthcare setting—from the smallest to the largest.
Improving antibiotic use is a medication-safety and patient-safety issue.
http://www.cdc.gov/getsmart/healthcare/inpatient-stewardship.html
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Antibiotic Review for Long Term Care Facilities
F441: Because of increases in MDROs, review of the use of antibiotics is a vital aspect of the infection prevention and control program.
An area of increased surveyor focus - an area where you need to assess if you are meeting the surveyor guidance
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42 CFR §483.25(l), F329, Unnecessary Drugs Determine if the facility has reviewed with
the prescriber the rationale for placing the resident on an antibiotic to which the organism seems to be resistant or when the resident remains on antibiotic therapy without adequate monitoring or appropriate indications, or for an excessive duration
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What most likely exists currently in your program: Comparison of prescribed antibiotics with available
susceptibility reports (charge nurse and infection preventionist)
Review of antibiotics prescribed to specific residents during regular medication review by consulting pharmacist
What may be needed: Antibiotic stewardship program in the facility (CDC
recommendation – 2006 MDRO guideline) Broader overview of antibiotic use in your facility with
reporting to quality assurance/infection control committee
Right drug - Right dosage - Right monitoring - Feedback of data to MDs
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Monitoring of practices is crucial! We must observe to see that our policies and
recommended processes are being done and done correctly
Educate staff or use other appropriate measures when you see non-compliance She doesn’t know She doesn’t care It won’t work
Enforce that all staff must follow the rules for contact precautions and hand hygiene
Be cautious! If you don’t look, you don’t know!
Conversation and Questions
Thinking about your cleaning processes:
What do you think is working well?
Where could you use help? Questions?
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References Clinical Practice Guidelines for
Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)
http://azdhs.gov/phs/oids/epi/disease/cdif/documents/Clinical%20Practice%20Guidelines%20for%20C%20Diff%20Infection%20%202010%20update%20by%20SHEA-IDSA.pdf
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References APIC Guide to the Elimination of
Clostridium difficile Infections in Healthcare Settings. http://www.apic.org/Content/NavigationMenu/PracticeGuidance/APICEliminationGuides/C.diff_Elimination_guide_logo.pdf
SHEA: Clostridium difficile in Long Term Care Facilities for the Elderly http://www.shea-online.org/Assets/files/position_papers/SHEA_Cdiff.pdf
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References (continued)
Spotlight on Clostridium difficile Infection: An Educational Resource for Pharmacists
David P. Nicolau , PharmD, FCCP, FIDSAhttps://secure.pharmacytimes.com/lessons/200902-02.asp
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CDI Toolkit – CDC
Clostridium difficile (CDI) Infections Toolkit (pdf) http://www.cdc.gov/hai/organisms/cdiff/cdiff_infect.html
CDI Toolkit available in PowerPoint format
on the CDC website Clostridium Difficile
Infection (CDI) Baseline Prevention Practices Assessment Tool For States Establishing HAI Prevention Collaboratives Using ARRA Funds Using Recovery Act Funds
http://www.cdc.gov/HAI/recoveryact/stateResources/toolkits.html
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Clostridium difficile Clostridium difficile Infection (CDI)Infection (CDI) - - ObjectivesObjectives
Describe the changing epidemiology of Clostridium difficile.
State two differences between acute care and long term care in managing patients/residents with C. difficile infection.
List three important strategies for preventing transmission of C. difficile within healthcare facilities.
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Protect patients…protect healthcare personnel…promote quality healthcare!
Thank you! [email protected]
PreventionIS PRIMARY!
