Reflections and Practicum on Clostridium difficilewp.cune.org/cynthiazips/files/2015/06/Reflectionsand... · Web viewClostridium difficile is spore-forming gram positive bacilli that

Running head: REFLECTIONS AND PRACTICUM ON CLOSTRIDIUM DIFFICILE 1

Reflections and Practicum on Clostridium difficile

Cynthia Zips

Concordia

Practicum

MPH 599

Dr. Janousek

June 24, 2015

REFLECTIONS AND PRACTICUM ON CLOSTRIDIUM DIFFICILE 2

Abstract

In healthcare people are at risk of acquiring healthcare-associated infections (HAIs).

Clostridium difficile is a very serious healthcare-associated infection and it is estimated that

almost 500,000 infections in 2011. In that same year, it is estimated that 29,000 people died

within 30days of being diagnosed with Clostridium difficile (Centers for Disease Control and

Prevention [CDC], 2015). The project involved analysis of data collected from a list of

patients who had tested positive for Clostridium difficile in 2014 at a 179 bed hospital

located in California. During 2014, a list had been maintained that contained the medical

record numbers, admission date, positive Clostridium difficile test date, diagnosis on

admission, date of previous admission, and whether the patient had been admitted from home

or a nursing home. All patient names were omitted in order to protect the privacy of the

patient. There were 195 patients who were positive for Clostridium difficile in 2014. 98 of

the 195 (50.2%) tested positive for Clostridium difficile within three days of admission.

Those who were positive for Clostridium difficile within three days were considered to be

community-onset, according to the definition of community onset as determined by the

National Health and Safety Network (NHSN), which has established definitions for the

determination of healthcare associated infections (HAI) (Centers for Disease Control and

Prevention [CDC], 2015). 14 of the 98 (14.3%) who were positive for Clostridium difficile

had tested as positive for Clostridium difficile on a previous admission. Regarding proton

pump inhibitors, I found that 101 (51.8%) of the 195 patients had taken proton pump

inhibitors prior to being tested for Clostridium difficile.



Reflections and Practicum on Clostridium difficile

Introduction

In healthcare people are at risk of acquiring healthcare-associated infections (HAIs).

Clostridium difficile is a very serious healthcare-associated infection and it is estimated that

almost 500,000 infections in 2011. In that same year, it is estimated that 29,000 people died

within 30days of being diagnosed with Clostridium difficile (Centers for Disease Control and

Prevention [CDC], 2015).

Clostridium difficile is spore-forming gram positive bacilli that causes

pseudomembranous colitis, diarrhea, toxic megacolon, and sepsis. The incidence of

Clostridium difficile infections has more than doubled since 2009 (Centers for Disease

Control and Prevention [CDC], 2012). In recent years, healthcare-associated infections due

to other causes have decreased, while Clostridium difficile infections have increased.

Because many of the infection prevention strategies that have been used to fight other causes

of healthcare-associated infections have also been used to fight Clostridium difficile, many

were frustrated to find that standard infection prevention practices were not enough.

Part of the problem is that Clostridium difficile is different from most other bacteria

that cause healthcare-associated infections. Clostridium difficile has a spore, which makes

eradicating the organism a more difficult task (CDC, 2012). In addition, Clostridium difficile

is transmitted fecal-orally, which means that the organism has to be ingested. Because most


Clostridium difficile is acquired within a hospital, it is assumed that transmission of

Clostridium difficile is due to cross-contaminated in the healthcare environment.

Because Clostridium difficile has been found to be viable for months on surfaces in

the environment, there has been a lot of focus upon environmental cleaning. For years many

healthcare facilities used quaternary-ammonium compounds for cleaning and disinfection

within the healthcare environment. Once it became known that Clostridium difficile spores

were not killed by quaternary-ammonium compounds, then more and more attention was

given to bleach products. It was found that bleach products do kill Clostridium difficile

spores, however, there has been a lot of resistance to using bleach products because bleach

products are highly corrosive to patient care equipment.

Because it is believed that Clostridium difficile is transmitted by contaminated hands

of healthcare workers, a lot of focus was placed upon hand hygiene. It was found that the

alcohol hand rubs that had become so popular across the country was ineffective against

Clostridium difficile. Because of this, hand hygiene with soap and water is encouraged with

patients that have Clostridium difficile, in order to mechanically force the Clostridium

difficile spore go down the drain.

Antibiotic stewardship is another area of focus in the fight against Clostridium

difficile. Clostridium difficile enters the mouth and passes through the digestive tract until it

reaches the colon. Once it reaches the colon, it resides there among the normal intestinal

flora. When the patient takes antibiotics, the patient’s normal intestinal flora is at risk of

being killed by the antibiotic, along with the bacteria causing the patients infection. Once the


patient’s normal intestinal flora is gone, the Clostridium difficile has the potential for

becoming a pathogen, producing toxin that causes harm to the patient. Because of this, there

has been a lot of attention given to how to prevention Clostridium difficile infection by

controlling antibiotic selection, the duration of the antibiotic and deescalating antibiotic

selected whenever possible.

In addition to antibiotic stewardship, it has been found that proton pump inhibitors

that decrease gastric acid secretions. It has been determined that gastric acid in the stomach

helps to fight Clostridium difficile, but when the gastric acid is suppressed Clostridium

difficile infection is more likely to develop.

Discussion

Introduction

The project involved analysis of data collected from a list of patients who had tested

positive for Clostridium difficile in 2014 at a 179 bed hospital located in California. During

2014, a list had been maintained that contained the medical record numbers, admission date,

positive Clostridium difficile test date, diagnosis on admission, date of previous admission,

and whether the patient had been admitted from home or a nursing home. All patient names

were omitted in order to protect the privacy of the patient.

Method


The purpose of the project was regarding the cause of Clostridium difficile, therefore,

information was needed to determine if the patient had the patient had received antibiotics

prior to admission or proton pump inhibitors prior to admission. Because this information

was not previously known, I spent much of the project searching patient medical records

reviewing the history and physical to determine if the patient had received antibiotics or

proton pump inhibitors prior to admission. I also received the pharmacy records to determine

if the patient had received antibiotics or proton pump inhibitors after admission.

Results

There were 195 patients who were positive for Clostridium difficile in 2014. 98 of the

195 (50.2%) tested positive for Clostridium difficile within three days of admission. Those

who were positive for Clostridium difficile within three days were considered to be

community-onset, according to the definition of community onset as determined by the

National Health and Safety Network (NHSN), which has established definitions for the

determination of healthcare associated infections (HAI) (Centers for Disease Control and

Prevention [CDC], 2015). 14 of the 98 (14.3%) who were positive for Clostridium difficile

had tested as positive for Clostridium difficile on a previous admission.

Because Clostridium difficile is a spore-forming bacteria, it is very difficult for

patients to achieve 100% cure even after antibiotics. It was determined that 33 patients

(16.8%) had reoccurrences of Clostridium difficile, where 24 patients (12.2%) had one

reoccurrence, 6 patients (3%) had two reoccurrences, two patients (1%) had three

reoccurrences, and one patient (0.5%) had five reoccurrences.


Regarding antibiotic coverage prior to testing positive for Clostridium difficile, 43 of

the patient records reviewed were either outpatient with no recent discharge, or no history

and physical was not found, and therefore there is no data regarding the antibiotic coverage

of these patients prior to the testing of Clostridium difficile. Of the patient records reviewed,

45 received no antibiotics as inpatients or outpatients prior to being test positive for

Clostridium difficile. Of those that received antibiotics, 21 received ceftriaxone prior to

testing positive for Clostridium difficile, 15 received ciprofloxacin, and 11 received

cefazolin.

Interestingly, I found that 6 patients had recent chemotherapy for cancer. While

chemotherapy is not an antibiotic, it would kill the normal flora in the intestine. Regarding

proton pump inhibitors, I found that 101 (51.8%) of the 195 patients had taken proton pump

inhibitors prior to being tested for Clostridium difficile.

Discussion of Results

Clostridium difficile is a spore forming bacilli, which is transmitted fecal-orally,

enters the patient’s mouth and then takes up residence in the intestine until the normal flora

of the patient is disrupted and then it multiplies, possibly causing Clostridium difficile

infection in the patient (Centers for Disease Control and Prevention [CDC], 2012). Knowing

which antibiotics were most likely to cause Clostridium difficile, might lead physicians to

prescribe more wisely or to choose a different antibiotic if they had the choice to reduce the

likelihood of inducing Clostridium difficile.


When patients have several episodes of diarrhea, Clostridium difficile is suspected if

the patient has been on antibiotics, and a stool is sent to the laboratory for testing. The

laboratory in this hospital, uses polymerase chain reaction (PCR) testing for the detection of

Clostridium difficile, which is highly specific. I am told that our laboratory only tests and

reports toxin producing strains, because not all strains of Clostridium difficile are toxin

producing.

According to the National Health Safety Network (NHSN), all stools found to be

positive after three days are considered hospital-onset (CDC, 2015). The theory exist that if

the patient entered the hospital with the condition present on admission, that the patient

would have been tested prior to the third day. A lot of education has taken place to inform

staff and physicians regarding the need to confirm the diagnosis of Clostridium difficile

within three days, in order for the condition to be considered community acquired rather than

hospital-onset. In the state of California, Clostridium difficile is reported to the database

owned by NHSN, and rates are compared to other hospitals across the state. Judgements

regarding care are sometimes made against hospitals with higher rates.

Knowing which antibiotics are likely to cause disruption of the normal intestinal

flora, may change prescription practices, but true analysis regarding the antibiotics will be

left to Dr. Nijjar. While I have the ability to know which antibiotics were most prescribed,

the preference of the physicians also influence this. I feel that the number of antibiotics

prescribed prior to those patients having Clostridium difficile would be greater in those

patients given an antibiotic simply because the physician favored it.


Conclusions

In conclusion, I could see that antibiotics are a contributing factor to Clostridium

difficile infection. I feel that the results regarding proton pump inhibitors will benefit Dr.

Nijjar as he work to change order sets to reduce proton pump inhibitors used in patients, and

will serve as evidence to convince his peers. In addition, the incidence of community onset

Clostridium difficile was higher than expected, but needs more analysis, to determine contact

with physician offices, other hospitals, nursing homes, and clinics.

References

Centers for Disease Control and Prevention . (2012). Vital signs: Preventing Clostridium difficile

infections. Retrieved from

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6109a3.htm

Centers for Disease Control and Prevention. (2015). Healthcare-associated infections (HAIs):

Clostridium difficile infection. Retrieved from

http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html

Centers for Disease Control and Prevention. (2015). Multidrug resistent organism & Clostridium

difficile infection (MDRO/CDI) module. Retrieved from

http://www.cdc.gov/nhsn/PDFs/pscManual/12pscMDRO_CDADcurrent.pdf


Appendices

Table 1. Data from patients positive for Clostridium difficile

Date + for C.diff

Admission Date Admitting DX Location D/C date

Previous + c.diff/date Reoccurences

1 6/30/2014 6/27/14

a flutter w/rvr, diarrhea

w/dehydration 482B n/a n/a 7/25/2014

2 9/8/2014 9/8/14 diverticulitis 108A n/a n/a 10/31/2014 12/7/2014

3 6/24/2014 outpt diarrhea outpt n/a n/a

4 2/25/2014 2/25/14 diarrhea, c diff outpt? n/a none prior

5 3/8/2014 3/7/14 COPD/diarrhea 307/303 3/14/2014 none prior

4/15/2014 06/20/2014110/22/201

4

6 8/4/2014 8/3/14

chronic pancreatitis w/ abdominal pain

and dehydration 307A n/a n/a

7 5/3/2014 5/3/14dirreha, possible

c.diff 212B n/a none prior 06/20/2014 07/15/2014

8 6/20/2014 6/18/14acute colitis, hypotension 212B n/a n/a


9 12/2/2014 12/2/14

shock, aki pe, hypokemia, copd,

cdiff, colitis 375A n/a 11/13/2014

10 8/6/2014 8/3/14

chest pain r/o mi hyponatremia

hepatitis c w/ esld w/ ascites anemia 381A n/a n/a

11 10/10/2014 10/7/14 chf 318A n/a n/a

12 9/28/2014 9/25/14 sepsis 212B n/a n/a

13 5/4/2014 4/11/14bilateral pneumonia

pos aspiration 302A/376A/204B/205B n/a none prior

14 2/16/2014 2/16/14rectal/anal

hemorrhage outpt outpt none prior

15 7/1/2014 6/25/14 jaw infection 389A n/a n/a

16 3/27/2014 3/25/14abd pain/N/V, CA

breast 205A none prior

17 6/12/2014 6/9/14

gi bleeding possible sepsis abd pain chest

pain 391A 6/14/2014 n/a

18 10/3/2014 10/3/14acute

encephalopathy 389A n/a n/a

19 7/23/2014 7/23/14weakness, physical

deconditioning 388A n/a n/a

20 1/5/2014 1/5/14diarrhea/abd pain/

renal failure 315 1/13/2014 none prior


21 5/24/2014 5/30/14

gastroenteritis, acute on chronic

renal failure 390A n/a 2/8/2014

22 2/9/2014 2/1/14 pneumonia 215 2/12/2014 none prior

23 6/28/2014 6/17/14intoxication, status

pos fall 384B n/a n/a 8/14/2014

24 10/12/2014 10/10/10sirs, fever, r/o

bacterial sepsis 489A n/a n/a

25 6/20/2014 6/19/14hypotension,

possible sepsis 390A n/a 3/25/2014

26 10/25/2014 10/24/14rt. leg cellulitis, sepsis, diarrhea 205B n/a n/a

27 2/14/2014 2/13/14 pneumonia 381 n/a none prior

28 2/3/2014 outptint inf clstradium

dfcile outpt na none prior

29 11/8/2014 11/7/14

rll, pneumonia, fever, leukocytosis, 2

dirs criteria, hypokalemia 386A n/a n/a

30 9/9/2014 9/10/14 pneumonia 314B 9/14/2014 8/23/2014

31 2/20/2014 2/20/14 chest pain outpt outpt none prior

32 1/6/2014 outpt unknone priorwn outpt na none prior


33 8/9/2014 8/8/14 r/o cva 485A n/a 6/30/2014

34 8/1/2014 8/10/14 copd 489A, 490A, 483A n/a 8/9/2014

35 8/9/2014 8/1/14 copd 377A 8/27/2014 n/a

36 5/22/2014 5/20/14

diarrhea on admission;alocholic

encephalopathy ams cirrhosis gi bleed 387A n/a n/a

37 1/28/2014 1/27/14

abominal pain, diarrhea colitis,

possible diverticulitis 318A 2/13/2014 none prior

38 7/6/2014 7/6/14 abdominal pain 391 n/a

39 11/27/2014 11/26/14 copd, exacerbation 212B 11/29/2014 n/a

40 9/14/2014 9/11/14

diarrhea on admission;

dehydration 212B n/a n/a 10/03/2014 12/27/2014

41 5/30/2014 6/4/14abdomenial pain,

dirrhea 205A 6/4/2014 n/a

42 1/22/2014 outpt diarrhea outpt na none prior

43 4/9/2014 4/9/14 dirreha outpt 4/9/2014 none prior 5/12/2014

44 6/10/2014 6/10/14nausea/vomiting, dirrhea persistant 108B n/a n/a 6/27/2014 07/14/2014


45 4/10/2014 4/4/14acute anemia, r/o GI

bleed 231A/110A/112B n/a none prior

46 9/18/2014 9/18/14left side weakness,

possible cva 387A n/a n/a

47 8/26/2014 8/26/14gastroenteritis, hyponatremia 301B n/a n/a 12/25/2014

48 2/10/2014 2/9/14 confusion 391 2/13/2014 12/30/2013

49 8/14/2014 outpt diarrhea outpt outpt n/a

50 12/5/2014 11/23/14

head trauma, hemota l>r, acute

resp. failure 390A 3/11/2015 n/a

51 2/28/2014 2/28/14dehydration, renal failure, cdiff cloitis 212A n/a none prior

52 4/3/2014 4/3/14

hematochezia, ulcerative proctitis,

small external herrhoids Feather River Surgery 4/3/2014 none prior

53 10/17/2014 10/13/14 belly ache 473A 10/18/2014 n/a

54 3/8/2014 3/8/14

fever/nausea, none prior vomiting, none

prior diarrhea 208A 3/9/2014 none prior

55 6/2/2014 6/2/14 c.diff, copd, anxiety 308B n/a n/a 07/11/2014 08/03/2014

56 3/30/2014 3/18/14plueral effusion CHF

hyponatremia 479A/372A n/a none prior


57 12/1/2014 11/25/14afib w rvr, back pain,

leucocytosis 320B n/a n/a

585/20/13 as

outpt 5/26/13abd pain/diarrhea X

2 wks 108 5/31/2013 none prior

59 12/16/2014 12/16/14spetic shock, uti,

c.diff, colitis 475A n/a n/a

60 12/4/2014 12/2/14 hip fracture 215A n/a n/a

61 1/8/2014 1/8/14 diarrhea 314 1/20/2014 4/7/2014

62 4/30/2014 4/28/14

urosepsis w/ sirs criteria, altered mental status 478A/470A n/a 4/18/2014

63 10/16/2014 10/7/14encephalompathy,

mastoiditis 319A n/a n/a

64 11/28/2014 11/27/14

abdominal pain, colitis, persistant

nausea, vomitting, hx chronic back pain 205B 11/30/2014 n/a

65 7/12/2014 6/22/14 colitis 372A n/a n/a

66 5/16/2014 n/a diarreha outpt n/a n/a 7/16/2014

67 3/23/2014 3/23/14 diarrhea/abd pain 111A none prior

68 5/29/2014 5/18/14wound hematoma

ascites 381A n/a n/a


69 12/30/2014 12/30/14 diarrhea, r/o c.diff 302B n/a n/a

70 2/8/2014 2/6/14

physical deconditioning

dyspenea general 388A 2/14/2014 none prior

71 5/6/2014 5/3/14

vomiting dehydration

uncontrolled dm 485A n/a none prior

72 5/14/2014 outptc.diff colitis acute on

ckd EDA-23 n/a none prior

73 1/30/2014 outptint inf clstradium

dfcile outpt na none prior

74 7/11/2014 7/11/14

acute diverticulitis, r/o clostridium

difficile 387A/111B n/a n/a

75 6/6/2014 6/1/14sdh systemic

anticoagulation 388A n/a n/a

76 3/18/2014 3/8/14abd pain/abd perforation 374 none prior 4/19/2014

77 7/15/2014 7/15/14 diarrhea outpt n/a n/a

78 5/17/2014 5/17/14acute diverticulitis,

renal failure n/a n/a n/a 8/7/2014

79 3/12/2014 3/7/14

abd pain s/p L hip replacement @ Sutter Surgical Center on 2/28 370/494 3/20/2014 none prior

80 10/8/2014 outpt back pain outpt outpt n/a


81 2/19/2014 2/18/14 abdominal pain, 302A n/a 5/8/2014

82 5/25/2014 5/19/14infection left heel, dementia, IDDM 112B n/a n/a

83 1/10/2014 1/10/14 flu, ascites, sepsis 111 1/21/2014 5/21/2013 2/16/2014

84 4/23/2014 4/23/14 fever, diarrhea, uti 114B 4/29/2014 none prior

85 3/11/2014 3/10/14

abd pain/hematemesis,

colitis 318A 3/14/2014 none prior

86 3/8/2014 3/8/14 diarrhea x 4 d 210B 3/13/2014 none prior 10/22/2014

87 11/10/2014 11/10/14encephalopathy,

acute on ckd 312A n/a n/a

88 9/8/2014 9/4/14 rt. leg cellulitis 212B n/a n/a 10/10/2014

89 5/1/2014 outpt infectious diarrhea outpt n/a none prior

90 1/18/2014 1/17/14Hep B cirrhosis w/

ascities 212B 1/23/2014 none prior 5/18/2014 12/17/2014

91 6/29/2014 6/28/14

encephalopathy due to nh3 &

hypoglycenmia likely aspiration

pneumonia 111A 7/3/2014 n/a 9/27/2014

92 2/27/2014 3/3/14 outpt n/a 3/14/2014


93 1/24/2014 outptabdmnal pain unspcf

site outpt na none prior

94 10/31/2014 10/31/14nausea, vomiting,

gerd 389A 11/1/2014 9/29/2011

95 2/15/2014 outpt loose stool outpt outpt none prior 3/13/2014

96 3/12/2014 3/11/14 abd pain/colitis 312B 3/13/2014 none prior

97 10/15/2014 10/14/14

severe hypokalemia, dehydraton,

increased urine output, possivle uti 391A n/a n/a

98 11/6/2014 10/26/14 cva 387A n/a n/a

99 12/11/2014 12/2/14

rll infiltrate likely asp prn abdominal wall

infectin cellulitis from pos 308B n/a 11/9/2014

100 6/13/2014 6/9/14pneumonia, abd

pain and vomiting 210A n/a 2/11/2014

101 1/27/2014 outpt diarrhea, vomiting outpt na none prior

102 8/6/2014 outpt Unknone priorwn outpt outpt n/a

103 5/18/2014 5/18/14 uti r/o sepsis 205B n/a 4/15/2014

104 4/2/2014 4/1/14respiratory failure CHF lactic asitoisis 370A n/a none prior



106 9/7/2014 9/8/14 gi bleed, cva 389A n/a n/a

107 1/13/2014 1/7/14 hip fracture 377 1/31/2014 none prior

108 4/17/2014 4/13/14small bowel obstruction 1 West none prior

109 2/9/2014 2/2/14 lt lung opacification 318 none prior

110 6/26/2014 6/26/14

altered mental status, uti,

dehydration 315A, 303A 7/13/2014 n/a 7/4/2011

111 2/13/2014 outpt na na na none prior

112 2/20/2014 2/20/14clostridium difficie

colitis 318A n/a none prior

113 10/29/2014 10/14/14perforated duodenal

ulcer 371A 11/10/2014 n/a

114 5/8/2014 outpt diarrhea outpt n/a none prior

115 5/5/2014 5/5/14 abominal pain 318A n/a none prior

116 10/22/2014 outpt diarrhea ER n/a n/a


117 8/19/2014 8/19/14ulcerative colitis

flare 318A n/a n/a

118 7/11/2014 6/28/14cellulitis rt. leg/rt.

hand 301A/202A/205B n/a n/a

119 9/27/2014 9/8/14seziure, mastoidits,

leukemia 386A n/a 9/13/2014

120 4/17/2014 4/11/14aspiration pneumo

brain cancer 480 none prior

121 1/21/2014 outpt Unknone priorwn outpt ns none prior

122 4/22/2014 4/22/14 C diff 112 none prior

123 9/15/2014 9/15/14 dehydration 389A n/a n/a

124 1/18/2014 1/15/14

hepatic encephalopathy

acute ESRD 110B 1/22/2014 none prior

125 6/7/2014 6/3/14caradic arrest,

respiratory failure 479A 6/8/2014 n/a

126 2/20/2014 2/16/14

cardio pulmonary arrest, respiratory

fluid 374A n/a none prior

127 4/18/2014 outpt diarrhea outpt none prior

128 10/16/2014 9/27/14 respiratory failure 373A n/a n/a


129 1/4/2014 outpt weakness ED outpt 12/2/2013

130 7/21/2014 outpt outpt outpt outpt n/a

131 5/30/2014 5/30/14c.diff, colitis,

vomiting, dirrhea 212B 6/4/2014 11/3/2014

132 11/23/2014 11/9/14

respiratory failure, acute chronic renal

failure 110B n/a 10/28/2014

133 12/26/2014 12/9/14poss interstitial lung

diease 318A n/a n/a

134 8/25/2014 8/22/14 r/o tb 386A n/a n/a

135 7/13/2014 6/28/14

hyperglycemia latic acidosts possible

sepsis 307B 7/24/2014 10/4/2013

136 7/17/2014 7/13/14 fungemia 208/B n/a n/a

137 7/28/2014 7/28/14 dehydration 301B n/a n/a

8/20/2014 09/26/2014 10/19/2014 10/31/2014

11/24/2014

138 8/10/2014 8/10/14

intra abscess hypokalemia gi

bleeding 388A n/a n/a

139 3/24/2014 3/16/14abd pain, perforated divertic/peritonitis 479/389A none prior

140 3/26/2014 3/26/14 abd pain/diarrhea 112B none prior


141 6/29/2014 6/29/14 c.diff, colitis, spesis 315B n/a 6/5/2014

142 5/2/2014 4/30/14 Upper gi bleed 301A/202A/205B 5/4/2014 none prior

143 2/9/2014 outpt abdominal pain outpt 2/9/2014 none prior

144 3/15/2014 3/10/14 colitis, abd pain 310/111 3/20/2014 12/5/2013

145 3/16/2014 3/15/14

abd pain/diarrhea x 5 d, Hx ETOH. In

Tahoe hosp x 5 d, d/c 3/15. 212A 3/18/2014 none prior 4/12/2014

146 9/11/2014 9/11/14

possible sepsis, neutropenia,

abdominal pan, chest pain 212B n/a 8/18/2014

147 10/28/2014 outpt mucous stool outpt n/a n/a

148 2/22/2014 2/21/14ams uti left pleural

effusion 388A 2/23/2014 none prior

149 3/31/2014 3/31/14

GI bleed, ESRD on hemodialysis,

hyperkalemia, HTN 387A n/a none prior

150 3/26/2014 3/25/14abd pain,

fever/chills/diarrhea 110A none prior

151 2/8/2014 2/4/14 seizure disorder 310B 2/10/2014 none prior

152 6/15/2014 6/15/14gastroenteritis sirs

arf-ivf+ ab xs 3 days 212B n/a n/a


153 2/27/2014 outptdigestive syst symptm nec outpt n/a none prior

154 8/4/2014 8/4/14sepsis dehydration

cellulitis 375A n/a 4/1/2014

155 3/23/2014 3/16/14 N/V, c.diff colitis 111B

positive at anone

priorther facility ?

Date

156 12/30/2014 12/24/14 acute renal failure 397A n/a 9/16/2014

157 2/19/2014 2/15/14

left lower lobe pneumonia, cerebal

palsy 316B n/a none prior

158 2/9/2014 2/7/14urinary trac infection

hyponutremia 111B none prior

159 4/17/2014 outpt outpt n/a none prior 4/25/2014


161 6/20/2014 6/19/14hyponatremia,

weakness 312A n/a n/a

162 12/14/2014 12/8/14 anasarca 472A n/a n/a

163 7/7/2014 7/6/14 vomitting, diarrhea 496A n/a 7/9/2013 8/18/2014

164 9/23/2014 9/21/14c.diff, coliti, diverticulitis 208B n/a n/a


165 3/21/2014 3/20/14fever, chills,

diarrhea, pneu 303 none prior


167 10/14/2014 10/12/14

alcoholic pancreatitis, dehydration,

possible infection 321B n/a n/a

168 9/17/2014 9/15/14hypoglycemia, sepsis, dm, cad 496A n/a n/a

169 6/7/2014 outpt dirreha outpt n/a n/a 8/25/2014


171 7/14/2014 7/14/14

hepatic, encephalopathy

respiratory failure 480A n/a n/a

172 6/20/2014 6/17/14

gi bleed, hypokalemia

anemia, etoh abuse 321A n/a n/a 7/18/2014

173 3/17/2014 outptquad, diarrhea x 4 d,

UTI EDA 3/21/2014 none prior

174 8/30/2014 8/30/14 diverticulitis 114B 9/2/2014 n/a

175 2/26/2014 2/25/14hypotension,

weakness, ESRD 231A n/a none prior 12/20/2014

176 2/19/2014 2/19/14 dehydration 302B n/a none prior


177 5/20/2014 5/20/14pain abdomen, dirreha, c.diff 312A n/a n/a 6/16/2014

178 3/15/2014 3/14/14

Quad, lethargy, Inc weakness x 3 d,

diarrhea 318A/208B none prior

179 3/27/2014 3/24/14abd pain, N/V,

diarrhea 486 none prior

180 2/18/2014 2/13/14

status post fall, fracture left knee

and right hip 205A n/a none prior

181 9/29/2014 9/28/14

gib, red liquid stooks, bilateral

chronic celluilitis w hx osteomyelitis 302B n/a n/a

182 6/23/2014 outpt diarrhea ER 6/24/2014 n/a

183 1/8/2014 1/5/14

altered mental status- none prior

diarrhea, none prior nausea, none prior

vomiting 391 1/12/2014 none prior

184 6/15/2014 outpt mild bloody diarrhea ED 6/15/2014 n/a

185 3/13/2014 outpt n/a n/a n/a none prior 4/8/2014

186 1/27/2014 1/27/14 diarrhea, c diff 210 2/3/2014 none prior

187 8/2/2014 outpt diarrhea outpt outpt na

188 3/11/2014 3/10/14 fever/anemia 212B 3/23/2014 none prior


189 2/21/2014 2/18/14

frequent falls, generalized weakness 314A 2/24/2014 none prior

190 3/26/2014 3/24/14 fever/UTI 371 none prior

191 5/8/2014 5/9/14 lower gi bleed 5/10/2014 none prior

192 5/22/2014 5/21/14acute hemorrhaging

cva diarrhea 212A n/a n/a

193 7/7/2014 6/24/14 respiratory failure 486 n/a07/21/2014 08/05/2014

08/11/2014

194 8/8/2014 8/7/14encephalopathy,

pneumonia, sepsis 374 n/a n/a

195 8/25/2014 outpt diarrhea outpt outpt n/aPrevious Adm

dates Previous Adm DX Locations Came from SNF? protonix Antibiotics


Table 1. Data from patients positive for Clostridium difficile

Previous Adm dates Previous Adm DX Locations protonix Antibiotics

1 5/4/14-5/9/14 left hip fracture 200A/205B

06/27/2014 6:00:00 PM to 06/30/2014 11:04:00 AM

none prior

2 7/31/2014 n/a ED none prior none prior

3none prior

inpatient visits n/a n/a4 7/24/11-7/29/11 shigella sonnei 117B none prior 10 days augmentin 4 days ago

5 2/10 - 2/14/14abd pain/diarrhea,

n/v 389/301 prior to admit\previous hospital visit-none priort during discharge?

6 7/4/14-7/6/14

recurrent abdominal pain

woth abuse pancreatitis w

evaulated amylase 302B prior to admit

prior to -CURRENT MEDICATIONSInclude:1. Metronidazole 500 mg t.i.d.2. none priorrco one tablet every 4 hours.3. Prilosec 40 mg p.o. daily.4. Florastor 250 mg t.i.d.5. Trazodone 100 mg at bedtime

7 7/11/13-8/5/13 chf none priors 487A/482A/484A none prior none prior

8 5/17/14-5/19/14dvt, pulmonary

embolism 321A/316B

Omeprazole 20 mg daily; protonix 6/18-6/23

ceftriaxone 6/18-6/20; vanc 6/18-6/23

910/23/14-11/12/14

hypotemia, aki, trooin, leak

leukocytosis, hyperglycemia 312B/ 475A/ 302A 12/2-12/5 none prior data

10 7/2/14-7/9/14

hepatic encephalopathy hyponatremia 482B 8/1-8/8

cipro 7/31- 8/5; aztreonam 8/5-8/7; levofloxacin 8/6-8/7; vanc 8/5-8/7; rafaximin 7/31-8/8

11 3/7/14-3/13/14

chest pain, r/o acs, elevated tropoin,

abd. Pain 439B none prior none prior12 6/9/14-6/12/14 gi bleed 202B records donone priort match

13 5/13/04-5/18/04intertrochanteric fx-

cl n/a 4/11-5/10

ceftriaxone 04/13-4/18; cefazolin 4/29;moxifoloxican 4/13-4/28; zosyn 4/12-4/13; vanc 6/18-6/23

14 1/26/06-1/30/03 artial flutter none prior data

15 5/20/14-5/23/14right jaw cellulitis

w/probable abscess 314A/304B none prior

clindamycin 6/16 -6/25; pip/tazo 6/25-7/2; rafampin 6/29-7/7; vanc 6/25-7/7

16 n/a n/a n/a 3/25-3/28cipro and flayl 3/5 for 10days????; zosyn 3/25-3/26

17 2/26/13-3/12/13respiratory failure

and spesis 475A/311A/306A none prior data

1812/26/12-12/30/12

uti, hyponatremia, pain pump 117A none prior none prior

19 6/18/14-6/21/14 weekness, pneumonia,

hepatocellular

314B,305B Nexium none prior


carcinone priorma

2011/27/2013-11/30/2013 diarrhea/rotavirus 319 Prilosec none prior

21 1/31/2013fever r/o

pneumonia viral 371A none prior

cefepime 7/9-7/22; cefoxitin 6/21-6/26; ertapenem 7/3; vanc 6/28-6/29

224/21/2012-04/24/2012

altered mental status 211 2/1-2/10

azithromycin 2/1-2/10; ceftriaxone 2/2-2/10

23 4/28/14-5/8/14 alochol withdrawal 320A 6/17-6/29 clindamycin 6/17-6/28

24 3/12/10-3/14/10generalized weakness 320 none prior data

25 3/25/14-4/1/14spesis, renal failure,

tachycardia 487A/383B none prior data

26 3/11/14-3/16/14

gravis w/ possible exacebtation leukocytosis 319A none prior data

2711/9/13-

11/12/2013hypoglycemia

encephalopathy 315 none prior none prior

28 5/14/13-5/16/13cardiac

dysrhythmias 493B none prior data29 5/27/14-5/30/14 rt. rib fracture 392A none prior none prior30 6/27/13-7/1/13 cellulitis 383B none prior zithromax 9/9 and rocephin31 4/8/13-4/11/13 c.section 201 (fremont) none prior data32 n/a n/a n/a none prior data

33 6/23/14-7/9/14altered mental

status pneumonia474A/473A/104B/111A/

115A prior to admit none prior

34 2/11/14-2/21/14

copd in acute exacebration

pneumonia htn 209B, 204B

35 2/11/14-2/21/14worsening

shortness of breath 209B/204Bprotonix 8/1-8/10; 8/15-8/23

cefepime 8/05-8/10; cipro 8/8-8/9; imipenem 8/10-8/11; pip/tazo 8/1-8/5; tobra 8/4-8/8; vanc 8/1-8/4

36 1/23/97-1/25/97mild/none priors preeclamp deliv OB 5/21-5/26 ceftriaxone 5/21-5/22

37 n/a n/a n/a none prior none prior38 n/a n/a n/a none prior none prior

39 4/27/14-5/2/14

cvt, hypoxemia, second copy,

exacebraton uti 485A/110B none prior none prior

40 4/9/14-4/12/14 jaundice 395Anone prior on admit; 911-9/18

none prior; recent chemo and radiation; rafaximin 9/14-9/20

41 4/29/14-5/5/14 rt hip osteoarthritis 210B none prior data

42 3/21/13-3/23/13

altered mental status cellulitis UTI

AFIB 315A none prior data43 n/a n/a n/a none prior data

44 4/16/14-4/19/14

cellulitis arms, pemphiogoid back

pain 388A nexium none prior

45 12/31/13-1/8/14left tibia none

priornunion fracture 204A/228A 4/4-4/17 none prior

46 12/4/13-12/10/13abd pain,

leukocytosis, esrd 108B/472A/488A none prior none prior

47 7/30/14-8/1/14fever, metastic ovarian cancer 315A none prior none prior

4812/23/2013-

1/1/2014 end stage renal 229 pepcid levaquin for uti

4911/12/13-11/13/13

chest pain r/o mi new onset afib 483B none prior data

50 12/28/13-12/30/13

abscess left arm 316B 11/23-11/29t cefazolin 11/23; ceftriaxone 12/1-12/5; moxifloxacin 11/25-


11/29; vanc 11/23-11/25

51 12/27/13-1/15/14mal neo splenic

flexure217A, 215A, 297B, 380A,

382A/B none prior data52 1/1/14-1/3/14 pneumonia 492B/ 208A/ 205A none prior none prior data

53 2/11/14-2/15/14uremia, esrd, htn,

weakness 110B/114A 10/13-10/18none prior h&p; 10/17-10/18; vanc 10/18

54 3/3 - 3/5 14 lap hernia repair 392 prior to admit none prior

55 3/30/14-4/5/14chest pain, r/o

angina copd 308B none prior none prior

56 1/27/14-2/3/14hemorrhage complic proc 306B/223A

3/21-3/25; 3/29-3/31

azithromycin 3/18; cefepime 3/21-3/26; erythromycin 3/29-4/4; metronidazole 3/30-4/4; vanc 3/22-3/22

57 3/13/14-3/14/14

cardiac arrest, unresponsive, cad,

dm, htn 392A 11/25-12/3ceftriaxone 11/25-12/1; cipro 12/1; metronidazole 11/28

58 4/13 - 4/29/13 pneumonia CVICU, 394, 308

59 11/26/14-12/5/14acute ant, stemi w/ cfardiogenic shock 477A/230A

60 11/1/14-11/22/14

encephalopathy, hyperosmolar, none priorn ketotic coma 473A/112B/491A/308B

none prior preadmitt

none prior preadmit; cefazolin 12/2-12/3

61 n/a n/a n/a none prior augmentin

62 4/7/14-4/23/14 e coli septicemia 474A/372A/108Bprior to admit; 4/28-4/30

invanz prior to admiitt?, ceftriaxone 4/29; gentamycin4/29; metronidazole 5/2-5/6; pip 4/29; vanc 4/30

6311/14/05-11/17/05 n/a n/a 10/21-10/24

pip/tazo 10/7-10/9; vanc 10/20-10/22; cefotaxime 10/9-10/10; metronidazole 10/21-10/24; moxi 10/13-10/15; ofloxacin 10/9-10/24; pip/tazo 10/7. 10/20-10/23; vanc 10/20-10/24

64 2/6/14-2/9/14

acute encephalopathy, acute respiratory

failure 214A prior to admit keflex prior to admitterday

65 1/18/07-1/20/076/21-7/10, 7/18-7/31

cipro 6/21-6/24; impenem 7/18-7/21; metronidazole 6/21, 6/26--7/1, 7/12-7/35; pip/tazo 6/30-7/8tigecycline 7/8-7/14; vanc 7/3-7/8,7/22-7-31

66 n/a n/a n/anone prior data - none prior inpatient

67 3/19 - 3/22/14 COPD 215A antibiotic two weeks ago

68 n/a n/a n/a 5/18-6/20

ceftriaxone 6/2-6/9; clinda 6/9; genta 6/2-6/3; imipenem 5/18-5/29; vancomycin 6/1-6/3, 6/9-6/12

6912/18/14-12/23/14

acute anemia weakness 301B/108B

none prior; 12/18-12/23 during previous visit clindamycin and bactrim

7012/22/13-12/27/13

int inf cl strdium dfcile 380A

none prior past 3 weeks;2/6-2/9

none prior past 3 weeks; ceftriaxone 2/6; imipenem 2/7-2/9, metronidazole 2/7-2/9; vanc 2/9

71 4/4/13-4/8/13dmii hprosmlr uncontrolled 392A

prior to admit; 5/3-5/21

none prior; moxifloxacin 5/13; zosyn 5/3-5/6

72 1/15/14-1/24/14 acute kidney failure 200B/205B/205A/111B none prior none prior


73 8/14/12-8/19/12 cellulitis finger 217B, 106A, 106B none prior data

74 6/17/14-6/22/14

aki, fall, uti, methadone

overdose, pedal edema 308A/230A 6/17-6/22 ertapenem 6/17-6/22

75 3/24/14-3/27/14 fall on coumadin 215A/211B 6/1-6/7 metronidazole 6/6-6/8

76 1/22 - 1/26/14 ulcer/GI bleed 216A 3/8-4/8cefepime 3/21-3/29; vanco 3/8; zosyn 3/8-3/19, vanc 3/8,

77 4/2/06-4/3/06 n/a n/a none prior data

78 4/22/14-4/28/14acute resjpiratory

failure 224A prior to admit none prior

79 12/26 - 12/28/13 fx hip 216/200prior to admit, 3/7-3/12

clinda 3/11-3/12, erthromycin 3/7; gent 3/9-3/12, zosyn 3/7-3/11,

80 n/a n/a n/a none prior data

81 2/1/14-2/7/14int inf cl strdium

dfcile 302A prior to admit none prior ; cipro 2/2-2/782 4/22/14-4/26/14 press ulcer, heel 111B, 111A none prior DATA

8312/15/2013-12/18/2013 ascites 309 1/10-1/21

metronidazole 1/10-1/21, moxi 1/10-1/13; piperacillin 1/9-1/10

84 n/a n/a n/a prior to admit none prior85 1/26 - 1/30/14 gastroenteritis 318/212/391 prior to admit none prior86 1/12 - 1/22 14 penu 484 none prior none prior 2 months ago

87 10/26/14-11/1/14pneumonia, pleural

effusion 490Aprior to admit; 10/26-11/1 vanc 10/26-11/1

88 8/19/14-8/22/14 rt. leg cellulitis 110Anone prior; 9/4-9/10 , 8/19-8/22 none prior, vanc 8/19-8/21

89 n/a n/a n/anone prior data, none prior inpatient days

9012/29/13-12/31/13

anasarca hypokalemia

Cirrhosis 307B none prior none prior

91 6/15/14-6/16/14hepatic

encephalopathy 206A none prior rifaximin92 recent chemo

93none prior data, none prior inpatient days

94 9/29/14-10/3/14 abdominal pain 389A 9/30-10/3pip/tazo 9/30-10/1; vanc 9/30-10/3

95 outptAMS/UTI/possible

pyelonephritis206A, 104A, 484A, 474A,

471A, 487A none prior none prior data

96 n/a n/a n/amother is in chemo none prior

97 3/12/13-3/15/13weakness, possible

cva, brain mass 304B none prior data

98 n/a n/a n/a 10/26-11/06

vanc 10/29-11/02; cefepime 10/31-11/02, ceftriaxone 11/02-11/05; linezolid 11/5-11/06; meropenem 10/29

99 11/8/14-11/11/14

rash poss allergy to none priorrco with hx vicodin allergy ams uti hx uti strep agalacti 212A 12/3-12/11

cefazolin 12/9-12/11; cipro 12/4-12/8; levo 12/8-12/10; pip/tazo 12/3-12/4; sxt 12/11-12/13, vanc 12/3-12/7

100 6/4/14-6/7/14

respiratory infection, abd pain,

and vomiting 210Anone prior, 6/9-6/21

none prior, pip/tazo 6/9-6/16, vanc 6/17-6/21

10112/01/2013-12/10/2013 fever, weakness 371, 485 none prior chemo

102 n/a n/a n/a none prior data103 12/17/13-1/24/14 anaerobic 114B none prior none prior


septicemia

104 2/27/14-3/11/14 speticemia 376A/231A 2/27-3/9

aztreonam 2/27-3/2, 3/6-3/7; cipro 2/27-3/3, 3/6-3/7, linezolid 3/4-3/11, metronadazole 2/27-3/4, vanc 3/2-3/4

105 n/a n/a n/anone prior data, none prior inpatient days

106 8/18/14-8/27/14

encephalopathy, r/o cva, acute renal failure, anemia 117B/114B1478A

prior to admit, 8/18-8/27

none prior, ceftriaxone 8/18-8/19, cipro 8/25-8/26; ertapenem 8/19-8/27, moxifloxacin 8/18

10712/27/2013-

1/2/2014 sternal dehisce 488 1/9-1/16

cefepime 1/8-1/13; imipenem 1/13-1/25, metronidazole 1/9, 1/13-31; tigecycline 1/10-1/13, tobra 1/8, , vanc 1/9, 1/11-1/13

1082/3/2014-2/10/2014 UTI septic shock 223 4/12-4/13

levaquin for uti, metronidazolde 4/12-4/13, 4/18, zosyn 4/14-4/16,

109 n/a n/a n/a 2/2-2/9

chemo, azithromycin 2/2-2/9, ceftriaxone 2/2-2/9, doxcycline 2/9-2/13, metornidazole 2/9-2/15,

110 6/12/14-6/19/14 right hip fracture 483Anone prior, 6/13-6/14

uti but none priorncompliant with treatment, cefazolin 6/13-6/14 cefoxitin 6/13-6/14,

1111/10/2014-1/29/2014

abdominal pain, nausea, UTI 373/316

prior to admit1/10-1/29

ceftriaxone 1/11-1/15, ertapenem 1/15-28, metronidazole 1/17-1/28

11210/21/13-10/23/13 cellulitis of leg 497A prior to admit

treated for pneumonia and finished antibiotics a few days ago

113 10/7/13-10/8/13chronic gallbladder,

gallstones 371A10/14-10/20, 10/27-11-10

clarithrimycin 10/27-10/29, piperacillin/tazo 10/14-10/20, tetracycline 10/29-11/10

114 n/a n/a n/a none prior data115 n/a n/a n/a none prior amoxicillin 2 wks ago,116 n/a n/a n/a none prior data

117 6/18/14-6/21/14

previous cescrean section w/ elective

sterilazation 212A none prior none prior

118 6/11/14-6/14/14

pneumonia, copd, acute exacerbation,

hypotension 320A none prior

amoxicillin-clavulanate 7/10-7/11, cipro 7/2-7/11, imipenem 7/7-7/11, metronidazole 7/11-7/15, pip/tazo 6/29-7/2, vanc 6/28-7/2

119 8/30/14-9/4/14 acute seizure 117A/110B/104A 9/8-9/26

vanc and zosyn prior to admission, pip/tazo9/8-9/9 vanc 9/8-9/15, 9/27,10/12

1202/3/2014-2/6/2014 aspiration pneumo 320/311

prior to admit,4/12-4/13, 4/17-4/19, 4/27

gatifloxacin 4/23-4/24, imipenem 4/23, metronidazole 4/19-4/24, zosyn 4/12-4/20, tigecycline 4/26-4/27


1224/6/2014-

04/15/2014 HF 1prior to admit also 4/6-4/15 uc davis 4 weeks ago

123 2/14/12-2/16/12

leukocytosis, r/o sepsis, dm, possible

pneumonia 206A none prior none prior124 12/24/13-1/1/14 end stage renal 396A prior to admit, metroniadazole 1/17-1/22,


diease cirrhosis ascited 1/15-1/22 moxifloxacin 1/17-1/22

125 5/28/14-6/2/14 right leg celluitis 371A/392B/394B/388A 5/29-6/2, 6/3-6/7

clinda 5/29-6/2, daptomyin 5/29-6/2, aztreonam 6/3-6/6, cetriaxone 6/6-6/7, dapto 6/3, gent 6/4 , levo 6/3-6/5, linezolid 6/3-6/7, metronidazole 6/4-6/7, vanc 6/7

126 11/30/13-12/6/13

pneumonia, organism none

priors 374A 2/16-2/21

ceftriaxone 2/16-2/17, gent 2/18-2/21, metronidazole 2/20-2/27, vanc 2/17,2/18,2/20; zosyn 2/24


128 2/28/09-3/1/09 chest pain 491Aprior to admit, 10/2-10/19

amoxicillin upon admission, azithromycin 9/26-9/27, ceftriaxone 9/27, linezolid 9/27, metronidazole 10/5-10/6, rifaximin 10/3-10/19, vanc 9/28-9/30, 10/5, 10/8, 10/16-

12912/2/2013-12/26/2013 C diff 114

prior to admit; 12/2, 12/5-12/7

cipro 12/2, metronidazole 12/2-12/12, 12/14-12/16

130 6/19/14-6/27/14fever, possible

pneumonia 202B 6/17-6/27moxifloxacin 6/20-6/27, vanc 6/19-6/23, 6/25-6/27

131 2/3/2013chest pain, r/o

myocardial infration 493A prior to admit none prior

132 10/30/14-11/8/14

metabolic & toxic encephalopathy,

hypercarbia, acute resp. failure 223A 11/10-11/24

cefepime 11/10-11/12, 11/14-11/20, metronidazole 11/23-11/24, rifaxmin 11/10-11/12, vanc 11/10-11/12, 11/16-11/23

13312/27/13-12/30/13

shorntess of breath, snyncope stroke 483B

plavix through none priorv, 12/9-12/22

cipro 12/26-12/27; levoflox 12/14-12/15, linezolid 12/17-12/19

134 7/18/14-8/7/14 cp r/o mi 391A/386A/384A 8/22-8/284 drug therapy for TB vanc 8/26-8/27

135 2/3/14-2/6/14

hyperglycemia diabetes back pain

check pain 202Aprior to admit, 6/28-7/24

ceftriaxone 7/8-7/10, ertapenem 6/28-6/29, 7/11-7/21, vanc 6/28-7/7, 7/14-7/21

136 9/12/14-6/23/14spesis, lupus, pancytopenia 387A/383B 7/13-7/22

metronidazole 7/17-7/21, vanc 7/14-7/22

137 7/13/14-7/22/14 fungemia 231A, 208Bprior to admit, 7/28-8/4 metronidazole 8/2-8/4,

138 7/21/14-7/28/14 rectal cancer 383A/382A 8/10-8/16

cipro 8/10-8/15, erthromycin 8/10, imipenemn8/10-8/15, , vanc 8/10-8/15, metronidazole 8/10-8/16,

139 n/a n/a n/a 3/16-3/25ertapenem 3/16-3/30, metronidazole 3/23-3/30,

140 n/a n/a n/aprior to admit 3/36-4/2

keflex 10 days, ceftriaxone 3/26-3/27, metronidazole 3/26-4/2

141 6/4/14-6/9/14abdominal pain,

diarrhea 391A none prior2 weeks of oral vanc prior, rifaximin 6/29-7/3, vanc

142 4/23/14-4/26/14chr duodin ulcer w/

hem 380A/100A

prior to admit4/23-4/26, 4/29-5/2

none prior, cetriaxone 4/23-4/26,

143 1/2/14-1/14/14food/vomit

pneumonitis 230A 1/3-1/7

azrithromycin 1/2, cefazolin 1/12-1/13, cetriaxone 1/2-1/4, 1/6-1/9, moxifloxicin 1/2-1/6,

144 n/a n/a n/a none prior none prior, only cure


145 n/a n/a n/a none prior none prior

146 8/18/14-8/24/14

dehydration, uti, utielectroylte,

abnone priorrmal metastic 215A none prior

recent chemo, cipro prior to admission

14710/16/14-10/19/14 left ankle fracture 202B 10/16-10/19 none prior

148 8/17/09-8/25/09postlaminect synd

lumbar 382F check date and mr#

149 3/23/14-3/25/14 pneumonia 223Anone prior, 3/22-3/25

levaquin prior to admit, moxifloaxacin 3/22-3/25

150 n/a n/a n/a none prior none prior

151 12/28/13-12/30-13 grand mal status 3197Bnone prior, 2/4-2/10

none prior, cefazolin 2/8, pen 2/7-2/8

152 11/7/12-11/9/12lower gi bleed,

anemia 302B prior to admit none prior

153 1/13/14-1/20/14 pneumonia 215A 1/13-1/20ceftriaxone 1/14, vanc 1/17-1/18, moxifloxacin 1/14-1/20

154 4/19/14-4/20/14

diarrhea, uti, dm, hyponatremia

sizure 312B, 319A prior to admit bactrim prior

155 2/20 - 2/24/14 pneu 214A 3/17-3/25ceftriaxone 3/16-3/19, ertapenem 3/23-4/1,

15611/24/14-11/30/14

lt. hip abscess, lt. hip and knee pain,

sp removal infecdted hardware

8/15 112B/106A/215B/200B

6 weeks of vanc and ertapenem, 12/27-12/29 tobra,12/24-12/31 ertapenem, 12/24-12/31 vanc

157 11/4/13-11/6/13acute & chronic

resp fail 309B, 308Bprior to admit, 2/15-2/19

2 weeks levaquin, azithromycin 2/15-2/18, zosyn 2/15-2/19,

158 1/12/14-1/16/14 COPD chect pain 495Bnone prior, 2/7-2/21

none prior, imipenem 2/11-2/21, metronidazole 2/9-2/10, 2/12-2/21, zosyn 2/11,

15904/09/2014-04/12/2014 shoulder 212 none prior cefazolin 4/8-4/9

160 7/13/14-8/15/14 epigastric chest pain 307B/ 309A/ 208B 7/29-8/15

azitromycin 7/29-7/31, cefepime 7/31-8/5, cetriaxone 7/29-7/31, moxifloxacin 7/31, 8/6-8/12 ,vanc 7/21-8/5

161 5/14/14-5/28/14 fall left hip fracture 204B/209B none prior cefazolin 5/14-5/15,

162 12/6/14-12/16/14 l pleural effusion 485A/110B 12/8-12/19

amp/sub 12/17-12/19, cefepime 12/13-12/17, metronidazole 12/14-12/15, tobra 12/14-12/15, vanc 12/16-12/17, 12/19

163 3/6/14-3/27/14 acute stemi 480A/230A none prior

none prior but recent discharge from somewhere else

164 6/26/14-6/28/14 fecal impaction, uti 303A/310Bprior to admit, 9/21-9/24

cipro for uti 3 weeks ago, metronidazole prior, metronidazole 9/21-9/24

165 n/a n/a n/a prior to admit recent chemo166 n/a n/a n/a none prior data

167 3/29/13-4/25/13

spinal discompression

fracture 379A/384A/396B none prior data

168 8/24/14-9/5/14esrd, leukocytosis,

anemia 228A 8/24-9/5

ceftazidime 8/29-9/5, cipro 8/25-8/27, linezolid 8/25-8/27, moxi 8/27-8/29, vanc 8/24

169 3/28/14-3/29/14iv contrast pneumonia 223A/230A none prior data



171 8/2/14-8/7/12abdoman pain, gastroenteritis 388A none prior uti treated as outpt

172 n/a n/a n/anone prior, 6/17-7/2 none prior,

173 n/a n/a n/a prior to admit none prior

174 n/a n/a n/a none priorcipro regularly for diveriticulisis

175 6/24/13-7/2/13chr marginal ulcer w

hem 223A prior to admit none prior

176 7/9/13-7/12/13ac systolic hrt

failure 497B none prior none prior

177 4/22/14-4/25/14 pyelonephritis 395A none prior

UTI -augmentin 5 days 3 weeks ago, ceftriaxone 5/21, metronidazole 5/20-5/24

178 12/14 - 12/17/13 UTI 115B none prior none prior

179 2/6 - 2/23/14 CABG 474/490/485prior to admit, 3/24-4/16 metronidazole 3/27-3/31,

180 9/4/13-9/10/13acute & chronic

resp fail 304A, 304Bprior to admit2/13-2/21

cefazolin 2/14, ceftriaxone 2/14-2/21, metronidazole 2/18-2/26,

181 6/21/14-7/1/14 bactermia 221A prior to admit none prior182 n/a n/a n/a none prior data

18310/7/2013-10/21/2013 rt hip cellulitis 210 none prior

none prior azithromycin 1/6-1/7, linezolid 1/4-1/8, z0syn 1/4-1/8,

184 n/a n/a n/a none prior data185 2/6 - 2/9/14 cellulitis of LLE 209/214 augmentin and bactrim prior,186 none prior none prior none prior prior to admit none prior187 n/a n/a n/a none prior data

188 2/24 - 3/5/14anemia/CA of

prostrate 315none prior, 2/24-3/3

none prior, moxifloxiacin 2/24-2/26, vanc 2/24-3/1

189 n/a n/a n/anone prior, 2/18-2/24

none prior, metronidazole 2/21-2/24,

190 n/a n/a n/a 3/24-4/3

ampillcin 3/24-3/25, cefepime 3/24, ceftriaxone 3/24-3/27, 3/29-3/31, gent3/25-3/27, imepenem 3/31-4/2, linezolid 4/12-4/14, metronidazole 3/25-4/2, nafcillin 3/27-3/29,

191 n/a n/a n/a none prior none prior192 n/a n/a n/a none prior none prior

19306/16/2014-06/18/2014 pneumonia 397 6/24-6/25,7/3-7/7

cefazolin 7/3-7/4, cefepime 7/6-7/7, zosyn 6/25-6/26

194 n/a n/a n/a prior to admit none priort prior195 n/a n/a n/a none prior data




Evaluation





Documents

Reflections and Practicum on Clostridium difficilewp.cune.org/cynthiazips/files/2015/06/Reflectionsand... · Web viewClostridium difficile is spore-forming gram positive bacilli that