C Diff: The Latest Scope on

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1 C Diff: The Latest Scope on the Poop Kathleen M. Vollman MSN, RN, CCNS, FCCM, FAAN Clinical Nurse Specialist / Consultant ADVANCING NURSING kvollman@comcast.net Northville Michigan ADVANCING NURSING LLC 2017

2 C diff Clostridium difficile (C. difficile) is an anaerobic, spore forming bacteria spread through fecal oral transmission C. difficile infection (CDI) colonizes the large intestine and releases two toxins Causes a number of illnesses; diarrhea, colitis and sepsis. Transmission: contaminated environments and health care personnel hands Antimicrobial therapy most important risk factor for CDI infection longer courses multiple antibiotics Fluoroquinolones the risk. Other drug may disrupt colonic flora; gastric acid suppression*, chemotherapy Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at hiin.org. Howell MD, et al. Arch Intern Med. 2010;170(9):

3 Burden in Australia/New Zealand Internationally, the incidence of CDI has increased significantly over the past 10 years Upward trend in CDI rates cases of hospitalidentified CDI, giving an aggregate with incidence of 3.65/ patient days. Community associated CDI: 1.08 per patient days US 3 rd leading infection 2 major virulence factors: toxin A (an enterotoxin) toxin B (a cytotoxin) 3rd binary toxin Magill SS, et al. New England Journal of Med, 2014;370: Mitchell BG and Gardner A. Antimicrobial resistance and infection control. 2012; 1: 20. Lessa FC, Gould CV and McDonald LC. Clinical Infectious Diseases. 2012; 55: S65 S70 Mitchell BG, et al. Healthcare Infection. 2012; 17:

4 Clostridium difficile Infection is Costly Attributable cost/patient: $6,100 11,300 Associated with longer length of stay (~3 days increase) and readmissions Attributably mortality 6% to 7% CDI reoccurs in 15 35% of pts with 1 previous event, 33 65% in pts with > 2 episodes of CDI Costs related to CDI are estimated at US $4.8 billion for acute care facilities alone Dubberke ER, et al. Clin Infect Dis 2012;55:S88 92; Zimlichman E, et al. JAMA Intern Med 2013;173(22): Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at hiin.org. Butler M,et al. Early Diagnosis, Prevention, and Treatment of Clostridium difficile: Update. Comparative Effectiveness Review No AHRQ Publication No. 16 EHC012 EF. Rockville, MD: Agency for Healthcare Research and Quality; March 2016 MitchellBG andgardnera. MortalityandClostridium difficileinfection: a review. Antimicrobialresistance andinfection control. 2012; 1: 20.

5 CDI Prevention Efforts Should Focus on Community and Facility based Antimicrobial Stewardship and Preventing Disease & Transmission.

6 Tier 1: First Steps to Address C. diff. C. diff surveillance Appropriate & timely testing of suspect cases > 3 days HO, <3 day CO (US) Australia uses 48hrs Appropriate testing Clinically significant diarrhea without other obvious causes. Use recommended stepwise testing method Antibiotic Stewardship Eliminate unnecessary antibiotic use Use antibiotics with lower risk for promoting CDI Contact Precautions; order at time of ordering C. diff. test Hand Hygiene Glove and Gown use Patient specific equipment and disinfection prior to use with others Effective and thorough cleaning and disinfection processes Effective Hand Hygiene Program Environmental Cleaning

7 Stewardship and CDI Testing Only test symptomatic patients >3 unformed stools per day within 1 to 2 days Lab should refuse formed stools test Asymptomatic colonization rates high (10%) Don t test if received laxatives within past 24 hrs Don t retest within 7 days/lab hard stop Discontinue test if not collected within 24 hrs Time of test = placement into contact precautions Timely recognition of symptoms Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at hiin.org. Dubberke ER, et al. Infection Control and Hospital Epidemiology, 2014;35(6):

8 Strategies for CDI Testing Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at hiin.org.

9 CDI Testing Rapid diagnosis will lead to prompt treatment & implementation of contact precautions that can limit the spread of CDI in the environment of care Polymerase chain reaction (PCR) tests have a sensitivity of 90 percent or greater and a specificity of 95 percent or greater More facilities use a two step approach as a method of detection: 1) the stool is first tested for GDH and toxins and 2) indeterminate results then undergo PCR analysis. (Use of a secondary method reduces the number of false positive results CDI is a clinical Diagnosis; no test makes the diagnosis of CDI Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at hiin.org.

10 Antibiotic Stewardship Program that promotes appropriate selection, dose, route and duration of antimicrobial therapy Primary goal: optimize clinical outcomes while reducing unintended consequences of antimicrobial use Toxicity colonization of pathogenic organisms Antibiotic resistance Secondary goal: reduce health care costs associated with diseases such as CDI and antimicrobial resistance % of all antibiotic use is inappropriate Comprehensive programs both large & small hospitals shown in an microbial use between 22% 36% with annual savings of $200,000 to $900,000. Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at hiin.org.

11 Australian National Antimicrobial Stewardship Network Established by the Commission to facilitate communication relating to AMS between the Commission, states and territories and private and paediatric sectors. Goal: Provide a means to implement AMS activities nationally Assist in identifying resources suitable for national development To share materials and lessons learned Provide advice to the Commission via the Antimicrobial Stewardship Advisory Committee work/healthcareassociated infection/antimicrobial stewardship/nationalantimicrobial stewardship network/

12 Antibiotic Use Among 323 U.S. Hospitals Model estimates that 30% reduction in use of broad-spectrum antibiotics will result in a 26% reduction in CDI. Greatest Risk MMWR March 7, 2014 / 63(09);

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14 Key Prevention Action Steps Monitor Healthcare Effectiveness Data and Information Set (HEDIS) performance measures on antibiotic utilization in pharyngitis, upper respiratory infections and acute bronchitis. Eliminate (1) Remove redundant unnecessary combination antibiotics antimicrobial from therapy Adopt formulary, guidelines (2) for restrict managing options CAP using for a duplicate shorter course Educate antibiotics prescribing and clinicians antibiotics about for appropriate special selection, use dose, circumstances, timing and duration (3) provide of treatment ongoing surveillance of Focus antibiotic efforts on use reducing by pharmacy, the use of and certain (4) antibiotic escalate classes to associated physician with leaders CDI, such as as necessary all cephalosporins, of clindamycin which leads and fluoroquinolones to improved accuracy of antibiotic use. Limiting the formulary and requiring pre authorization for certain antibiotics is a key strategy in reducing unnecessary use of antibiotics Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at hiin.org.

15 Proper Hand Hygiene and disinfection of surfaces can help prevent the spread of C diff Trinity Health 15

16 Hand Hygiene is the Single Most Important Factor in Preventing the Spread of Infection Jullian Desayes I, et al American Journal of Infection Control 45 (2017) 51 8

17 Australian & New Zealand Hand Hygiene Compliance Rates Australia 2017 New Zealand data for 2017.aspx programmes/infection prevention and control/news and events/news/2993/

18 When hands visibly soiled or exposure to potential spore forming organisms, wash with either a non antimicrobial or antimicrobial soap & water (40 60 seconds) (II). Can still use ABH in nonoutbreak C diff settings C diff wear gloves & gown/both methods of hand hygiene are not real effective CDC. Hand Hygiene Guidelines: MMWR 2002; 51(No. RR- 16):[1-45] WHO Hand Hygiene Guidelines 2009 Ellingson K, et al. Infect control & Hosp Epidemiology, 2014;35(2): S155-S178

19 Contact Precautions Order at time of ordering C. diff. test Hand Hygiene Glove and Gown use Patient specific equipment and disinfection prior to use with others Use disposable equipment or dedicate equipment to a single patient (e.g., blood pressure cuffs, thermometers, commodes). Use commode liners to limit splashing or contamination when emptying Effective and thorough cleaning and disinfection processes Define who is responsible for cleaning ventilators, IV pumps and other critical patient care equipment. Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at hiin.org.

20 C Diff Environmental Impact CDI spores can survive on surfaces for as long as five months. CDI spores were found in 49% of the hospital rooms occupied by patients diagnosed with CDI, 29 % of the rooms of asymptomatic CDI carriers The most heavily contaminated areas were hospital room floors, bed rails and bathrooms Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at hiin.org.

21 Examples of High Frequency Touch Surfaces; Patient Room Use specialized privacy curtains that can be replaced without a ladder and appropriately cleaned & Attach disposable, plastic adhesive shields to privacy curtains to prevent glove or hand contact and contamination 2017 Trinity Health 21

22 Reducing the Load in the Environment: Cleaning of Patients Room Develop procedures for routine disinfection of environmental surfaces with an EPA registered sporicidal disinfectant 1 Use a 1:10 dilution of 5.25% sodium hypochlorite Use bucket method for appropriate kill time 2 Use audible timers to ensure appropriate contact time for cleaning agents Use bleach wipes as an adjunct 2 Use a two step cleaning protocol incorporating mobile, automated equipment that releases ultraviolet C radiation or hydrogen peroxide vapor 3,4 1. Siegel JD, et al. Available at: gov/hicpac/pdf/isolation/isolation2007.pdf. Accessed April 4 th, APIC s Guide to Preventing Clostridium difficile Infections (2013). Available at the conference/new c diff guide. Accessed on April 4 th, Nerandzic MM, et al. BMC Infect Dis 2010 Jul 8;10: Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at hiin.org.

23 Effect of Ultraviolet Light on C Diff Spore Recovery vs. Bleach Alone Evaluate effectiveness of manual cleaning and UV C on inpatient hospital room surfaces Measured CFUs on 9 high touch surfaces after bleach cleaning & after UV C cleaning 3 tower system. Bathroom done daily & inpatient room on discharge Bleach alone: 13% positive for C diff > 10 CFU s Bleach & UV C:.4% positive for C diff > 10 CFU s Toilet seat and over bed table most commonly + sites Liscynesky C, et al. Infect Control & Hospital Epidol. 2017;38(9):

24 Consider Stool Containment Potential to Reduce Skin Injury IAD is a type of irritant contact dermatitis (inflammation of the skin) IAD 5x more likely to develop a HAPU Reduce Exposure to Harmful Microorganisms Giuliana K. Presented at the CAACN September th Winnipeg, Manitoba, CA Gray M. Presenting a Wound Care Conference, 2016, New York City, NY

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26 Evidence Based Review & Recommendations Jan 2009 to April articles screened 261 meet criteria for review 46 studies included Quality 82% (QI MQCS) Results: Twice daily disinfection of high touch surfaces & terminal cleaning with chlorine based products CDI 45% to 85% Bundled interventions & antibiotic stewardship showed promise for CDI Louh IK, et al. Infect Control Hosp Epidemiol 2017;38:

27 Tier 2: Enhanced Practices; Escalation of Tactics in Tier 1 Implemented but No Decrease Seen Define the opportunities for improvement Focused review of hospital onset C. diff. cases Consider prompt assessment & expedite specimen submission for testing; time to isolation? Same rooms versus different rooms? Review Antibiotic use Review Testing practices Check Timing of Contact precaution & compliance Shared equipment? Review type and practices around sporicidal surface disinfectant Consider supplemental disinfection strategies Intervene based on opportunities 27 found

28 Thank You