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11/11/2019 1 Preventing Clostridioides difficile Infection with Infection Control and Appropriate Antibiotic Use Renuga Vivekanandan, MD Associate Professor Medical Director Antimicrobial Stewardship Hospital Epidemiologist CHI Health Creighton University @RVivekanandanMD Disclosures • MDstewardship -consultant 2 1 2

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Page 1: 1. Vivekanandan - Preventing CDI with IC and Appropriate ... · í í l í í l î ì í õ ó 5LVN IDFWRUV IRU &', UHFXUUHQFH À v P ~ E ò ñ Ç } v µ v v ] ] } ] µ ] v P ] v

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Preventing Clostridioides difficile Infection with Infection Control and Appropriate Antibiotic Use

Renuga Vivekanandan, MDAssociate Professor

Medical Director Antimicrobial StewardshipHospital Epidemiologist

CHI Health Creighton University@RVivekanandanMD

Disclosures

• MDstewardship-consultant

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Objectives

1) Describe the changes to the new C diff treatment guidelines2)Explain the relationship between environmental cleaning and C diff prevention3) Outline monitoring methods for environmental cleaning4) Discuss the impact on CDI rates with reduction in treatment of asymptomatic bacteriuria

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Clostridium difficile Impact & Risk

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Rick Factors for C diff

Antibiotics Exposure

Age of the patient >65

Immunosuppressed

Isolation and Hand Hygiene

Environmental Cleaning

Gastric acid suppression

• Annually in the United States:– 30% of hospital admissions due to infection– 2 million people develop HAI

• 30-50% of hospitalized patients receive antibiotics

• 50% of antibiotic orders: unnecessary or inappropriate

• Antimicrobials are 30% of hospital pharmacy budgets

Pharmacotherapy 1999;19:1369Clin Infect Dis 2007;44:159

Antibiotic Use In Hospital and Costs

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Out Patient Antibiotics Stewardship

• 30% of antibiotic prescribed in the outpatient setting are unnecessary

• Most of this unnecessary:– colds, bronchitis, sore throats caused by viruses, and even some

sinus and ear infections

• Antibiotics are the most common cause of adverse drug events in children

• A 10% decrease in inappropriate prescribing in the community– Can result in a 17% reduction in C diff infection

Open Forum Infect Dis. 2017 Oct 26;4(4):171

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Results

• N= 226 pairs• 70.4% were female• 52.2% were ≥60 years old• More case patients than controls had prior outpatient health care

(82.1% vs 57.9%; P < .0001)• Antibiotic (62.2% vs 10.3%; P < .0001) exposures

Open Forum Infect Dis. 2017 Oct 26;4(4):171

Clin Infect Dis. 2018 Mar 19;66(7):987-994

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CDI: Antibiotic Agent Cost (USD)

Dosing Duration Cost

Metronidazole 500 mg po tid 10 days 25.75

Vancomycin liquid 125 mg qid 10 days 78.85

Vancomycin capsule 125 mg qid 10 days 409.59

Fidaxomicin 200 mg bid 10 days 4,187.00

Bezlotoxumab 10mg/kg iv Single dose 3,000.00

March 2017. Northland Pharmacy, Duluth, MN

CDI Treatment

Initial Episode

Clin Infect Dis. 2018 Mar 19;66(7):987-994

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Risk factors for CDI recurrence

• Advanced age (>65 years)• Concurrent antibiotic during initial treatment of CDI• Prior infection with C diff epidemic strain(s)• Defective humeral immune response against C. difficile• Underlying co-morbid medical conditions• Continuous gastric acid barrier therapy (H2B, PPI)

Leffler et al. NEJM 2015;372:1539McDonald EG et al. JAMA Int Med 2015;175(5):784Gupta SB et al. Clin Infect Dis 2016;63:730Wilcox MH et al. NEJM 2017;376:305

CDI Treatment

Recurrence

Clin Infect Dis. 2018 Mar 19;66(7):987-994

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Fecal Microbiota Transplant (FMT)

• First reported use in 1958• Multiple studies show increased effectiveness over

continued oral Vanc for recurrent CDI• Various delivery routes and protocols that vary by

availability and institution• Preferred management for patient with third or more

bouts of nonsevere CDI (IDSA guidelines)

– Clin Infect Dis. 2018;66(7):e1.

STOOL SCREENING

• Serologic testing – viral hepatitis (A, B, and C), HIV, and syphilis

• Stool tests:– Giardia antigen, Cryptosporidium antigen– Microscopy examination for ova and

parasites and acid-fast stain microscopy– Molecular tests for norovirus and rotavirus– Bacterial culture for detection of enteric

bacterial pathogens and additional testing for multi-drug resistant (MDR) enteric organisms

– C. difficile to rule out asymptomatic carriage, even if stool is formed

– Helicobacter pylori stool antigen assay • (for FMT to be administered via upper

gastrointestinal [GI] tract)

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Preparation

• Stool is homogenized and Filtered• Donor stool suspended in normal saline• Infused into GI tract

– Colonoscopy, Enema or ND/NJ tube• Capsules• Fresh vs Frozen

– Frozen not inferior to fresh stool • Cheaper, availability, more accessible• JAMA. 2016 Jan 12;315(2):

https://www.openbiome.org/impact

Administration

ColonoscopyColonoscopy

Upper GI- NJ/NDUpper GI- NJ/ND

EnemaEnema

Oral CapsulesOral Capsules

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Nebraska HAI RatesAs of January 1, 2017

http://dhhs.ne.gov/Pages/HAI-Rates-in-Hospitals.aspx

Nationally, among acute care hospitals, the highlights in this report include

• Nebraska we had about 13% statistically significant decrease in CDI infections between 2016 and 2017

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• Odds ratio for study pathogens was 2.14 [95% confidence interval (CI): 1.65-2.77]

– Methicillin-resistant Staphylococcus aureus (MRSA)– Vancomycin-resistant enterococcus (VRE)– Clostridium difficile– Acinetobacter– Extended-spectrum b-lactamase-producing organism (ESBL)– Pseudomonas

• Gram-positive and Gram-negative organisms, the pooled acquisition odds ratio for Gram-negatives was 2.65 (95% CI: 2.02-3.47) and 1.89 (95% CI:

1.62-2.21) for Gram positives

J Hosp Infect. 2015 Nov;91(3):211-7. doi: 10.1016/j.jhin.2015.08.005. Epub 2015 Aug 22

J Hosp Infect. 2015 Nov;91(3):211-7. doi: 10.1016/j.jhin.2015.08.005. Epub 2015 Aug 22

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Impact of routine use of a spray formulation of bleach on Clostridium difficile spore contamination in non-C difficile infection rooms• Ng Wong YK, Alhmidi H, Mana TSC, Cadnum JL, Jencson Al, Donskey CJ.

Am J infect Control 2019 Jan 31. pii: S0196-6553(18)31205-7. doi: 10.1016/j.ajic.2018.12.023

C diff & MRSA in Rooms with Ammonium Disinfectant and Spray Bleach Disinfectant

Am J infect Control 2019 Jan 31. pii: S0196-6553(18)31205-7. doi: 10.1016/j.ajic.2018.12.023

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Results

• Suggest that use of sporicidal disinfectants for all post discharge room disinfection might be helpful in reducing the risk for C diff transmission from contaminated surfaces

• Future studies are needed to determine if routine use of sporicidal disinfectants in non-CDI rooms will result in a reduction in rates of CDI

Modern technologies for improving cleaning and disinfection of environmental surfaces in hospitals• John M. Boyce

Antimicrobial Resistance & Infection Control 2016

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Fluorescent Marker “Black Light” On High Touch Surface

High Touch Surface Monitoring

• Fluorescent Markers– Fluorescent gel, powder, and lotion - marking high

touch objects prior to room cleaning• Fluorescent gel dries transparent on surfaces,

resists abrasion– there are several studies demonstrating the accuracy

of the system • Fluorescent markers are all designed to indicate

physical removal of an applied substance– surfaces that are effectively disinfected but less

effectively cleaned may be more likely flagged as failing to meet a quality standard

https://www.cdc.gov/hai/pdfs/toolkits/Environ-Cleaning-Eval-Toolkit12-2-2010.pdf

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ATP Bioluminescence For Monitoring Cleanliness

High Touch Surface Monitoring with ATP

• Measurement of organic ATP on surfaces using a luciferase assay and luminometer

– been used to evaluate cleanliness of food preparation surfaces for >30 years

• Total amount of ATP, both microbial and non-microbial– quantified and expressed as relative light units

• Although readout scales vary more than 10 fold and sensitivity varies between commercially available systems

– very low readings are typically associated with low aerobic colony counts (ACCs)– very high readings may represent either a viable bioburden, organic debris

including dead bacteria or a combination of both

• ATP system shown – significant improvement in daily cleaning– quantitative measurement to indicate the level of cleanliness of high touch

surfaces

https://www.cdc.gov/hai/toolkits/appendices-evaluating-environ-cleaning.html

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Persistence of Skin Contamination & Environmental Shedding of C diff During and after Treatment

Ajay Sethi, Wafa Al-Nassir, Michelle Nerandzic, Greg Bobulsky and Curtis Donskey

• Skin contamination and environmental shedding remained high at the time of resolution of diarrhea (60% and 37%)

• Lower at the end of treatment C diff treatment (32% and 14%)

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Process For Hospitalized Patient When CDI Resolves

1) Move patient with CDI to new room once symptoms resolve2) Educate patient & family about need to move out of contaminated environment to clean one3) Bathe or shower patient before moving to clean room4) Unit staff will request a room transfer within 24hrs5) Leave isolation caddy on door until Hospitality has completed Discharge cleaning6) If patient cannot be transferred to a new room

– patient continues on contact precautions in existing room until room change or discharge

– existing room is cleaned with bleach-based cleaner

https://infectioncontrol.ucsfmedicalcenter.org

Impact on CDI rates with Reduction in Treatment of Asymptomatic Bacteriuria

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• 11% of nursing home residents were on antibiotics on any single day

• 1 in 3 of these antibiotic prescriptions was for the treatment of urinary tract infections– At least ½ of these prescriptions were for either

the wrong drug, dose, or duration

https://www.cdc.gov/antibiotic-use/stewardship-report/pdf/stewardship-report.pdf

Massachusetts Department of Public Health: Reducing C diff

• Educational Interventions in Nursing Homes• 16 nursing homes implemented multi-faceted

educational interventions to reduce unnecessary antibiotic use for asymptomatic bacteriuria

• Conducted in-person trainings on antibiotic use for UTI

• 1 year later– 28 % decrease in unnecessary urine cultures for patients– 37 % reduction in antibiotics given to patients experiencing

asymptomatic bacteriuria– 47% percent reduction in healthcare-acquired CDI

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Q + A

@[email protected]

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