C. difficile in Long Term Care - Peel Region · 2016. 9. 8. · Nadine Sitaram RN BScN Program...

O U R S T O R Y …

C. difficile in Long Term Care

Nadine Sitaram RN BScN Program Support NursePeel Long Term Care

April 2016

Introduction

• August 2015 Malton Village declared a unit specific outbreak of C. difficile

• Total of 5 cases

• 1 death

• No staff cases

• Outbreak declared over October 2015

Goal: Information Transfer

• Experience

• Challenges

• Impact

• Outcome

• Recommendations

• Next steps

Timeline of Events

• Index case: 65 year old male who has lived in our long term care facility for 11 years. He has a medical diagnosis of Type 2 DM, Schizophrenia, HTN, CVA, Hemiplegia and Vascular Dementia

• He resides on the 2nd floor of our facility

• Hospitalized April 12th, 2015 for urinary retention and diagnosed with a UTI, treated with a/b and returned to LTC

Timeline of Events

April 19, 2015

• Presented with loose stools, one week after antibiotics for UTI• Results positive for C. difficile toxin

May 1-5, 2015

• Transfer to hospital C. difficile enteritis, treated with Metronidazole & Ceftriaxone, return to LTC

June 1st, 2015 (Relapse)• Re-tested for C. difficile, positive result • Treated with Vancomycin for 10 days

July 3rd, 2015 (Relapse)• Re-tested for C. difficile, positive result • Treatment protocol restarted

July 18, 2015

• Becomes a case in respiratory outbreak

Outbreak Development

• August 1st – 12th, 2015

• 4 cases in the respiratory outbreak presented with frequent loose stools

• 3 of the 4 residents treated with antibiotics for a secondary pneumonia

• Stool collected:

• All results positive for C. difficile toxin

Declaring the OutbreakCase Number Date Symptom

Onset

Date Contact

Precautions Initiated

Date of Specimen

Collection

Date of C. Difficile

Isolation/Result

1 Relapsing;

July 1, 2015

July 1, 2015 July 4, 2015 July 7, 2015

2 July 30, 2015 July 30, 2015 August 4, 2015 August 5, 2015

3 July 30, 2015 July 30, 2015 August 4, 2015 August 5, 2015

4 August 4, 2015 August 4, 2015 August 6, 2015 August 7, 2015

5 August 9, 2015 August 9, 2015 August 10, 2015 August 11, 2015

August 14th, 2015:

C. difficile outbreak declared on 2nd floor unit

Case Control Measures

• Contact precautions and isolation

• Private room accommodation (4 out of 5)

• Affected residents received bed baths

• Dedicated equipment disinfected with sporicidal wipes

• Appropriate treatment of cases

Outbreak Control Measures

• Enteric outbreak measures

• Surveillance for new suspect and confirmed cases

• Appropriate and timely specimen testing

• Staff cohorted to cases

• Activation staff only 1:1 visits

• Appropriate and timely specimen testing

• Antimicrobial stewardship initiated by Medical Director

Communication and Education

• Daily staff education and review of outbreak minutes every shift

• review of PPE application/removal every shift and audits of staff and cleaning procedures daily all shifts

• family education and updates

Cleaning and Disinfection

• Increased frequency of environmental cleaning• Twice daily cleaning and disinfection of

case rooms and bathrooms • Use of sporicidal disinfectant in all rooms and

common areas• Double cleaning with sporicidal when

discontinuing precaution (terminal clean)• Additional environmental services staff

scheduled

Additional Control Measures

• Potential reservoirs of bacterial spores (i.e. live plants, upholstered furniture) were removed from the affected unit.

Challenges

Infection Control Audits

• Gastroenteritis outbreak audit

• Intense cleaning, hand hygiene and PPE audits were conducted

Infection Control Audits

Sporicidal Disinfectant

• Sporicidal cleaning agent not implemented with index case of active C. difficile NOR during onset of C. difficile outbreak

• We were utilizing 0.5% accelerated hydrogen peroxide based cleaner as per respiratory outbreak protocol, but not effective against C. difficile

• A 4.5 % hydrogen peroxide based cleaner and disinfectant purchased to eliminate C. difficile

Infection Control Audits

Cleaning and Disinfection

• Glow germ audits revealed high touch surfaces missed during cleaning routine

• Cleaning missed on various pieces of equipment revealed the need to review roles and responsibilities of nursing and housekeeping staff

• Re-education of all environmental services staff on high touch surfaces, use of friction, cleaning protocols, product use

Infection Control Audits

Personal Protective Equipment

• Staff and visitor compliance with proper PPE use

Hand Hygiene

• Use of resident sinks to wash hands

• Identified with staff the need to wash hands with soap and water in addition to using Alcohol Based Hand Rub (ABHR) at point of care

Infection Control Audits

Laundry Services

• Heavily soiled items were pre-cleaned on the unit increasing risk of contamination

• Review and address the handling and transporting of soiled laundry in the home area and to the laundry department

CLOTHING LINEN GARBAGE

Against all odds…

• Noted treatment failure in all 4 cases - no resolution of symptoms.

• Medical Director reached out to Medical Officer of Health for additional support and recommendations on treatment of cases

INNOVATIVE TREATMENT FOR C. difficile

FECAL MICROBIAL TRANSPLANTS(FMT)

Collaborative Efforts

• Outbreak Management Meeting with Peel Public Health and Malton Village representatives

• Referral made to Infectious Disease Specialist at William Osler Health System

• The attending physician connected with Infectious Disease Specialist, Dr. Lee at St. Joseph’s Health Care in Hamilton

Collaboration with Infectious Diseases Specialist

• Dr. Lee's research interests include optimal laboratory methods to diagnose and treat Clostridium difficile — associated diarrhea

• Dr. Christine Lee’s clinical focus:

• treatment of refractory Clostridium difficile

infection using fecal transplants

Collaboration with infectious disease specialist

• We began discussions to transfer the index case for a fecal transplant in Hamilton by Dr. Lee

• Dr. Christine Lee agreed to perform a fecal transplant on all 4 active cases IN HOUSE!!!

• Consents obtained from families

• Health history for cases sent to Dr. Lee

• Protocols implemented prior and post treatment

Fecal Microbial Transplants (FMT)

• The human gut contains trillions of bacteria

• The gastrointestinal microbiome (GIMb) may be considered an additional organ of the body

• When GIMb is disturbed, it is possible to restore normal function with FMT

• The first use of FMT dates back to Ge Hong 2000 years ago

Fecal Microbial Transplants

• FMT is a procedure which fecal matter is collected and tested from a donor, mixed with saline solution, strained and placed in patient, by colonoscopy, endoscopy, sigmoidoscopy or enema

• Purpose is to replace good bacteria that has been killed or suppressed by antibiotics-causing bad bacteria bad i.e. c. diff to over –populate the colon

Fecal Microbial Transplants

Pre-Treatment Preparation:

• Antibiotics are stopped 24 hours before the procedure

• Collection of stool specimens and confirm CDI

• Blood work analysis (WBC analysis)

Fecal Microbial Transplants

Treatment:

• A pre-filled syringe containing FMT liquid is inserted into the rectum

• Process takes less than 3 minutes

• Patient lies flat for 30-45 minutes

Fecal Microbial Transplants

Post- Treatment:

• Close monitoring of cases symptoms

• Daily Bristol stool scale

• Blood work monitoring every other day

• Do not resume antibiotic treatment

Post Treatment

• Some results in the first week

• 2nd treatment performed one week later

• Analysis of previous stool compared to present stool was done

Overall Impact - Residents

• Residents socially isolated – unable to participate in group activities

• Meals in rooms- deprived of the dining experience

• Loss of dignity

• Skin Breakdown- fecal incontinence

• Poor appetite, weight loss and general malaise

• Physical discomforts

Overall Impact - Families

• Additional stressor

- limited knowledge

- Increased visits - assistance during meals, and blood work

- Extra precaution /ensure their family’s safety

- Exhaustion due to the length of outbreak

- Anxiety re: new treatment proposed

- Impact of treatment

Overall Impact - Staff

• Low staff morale

• Fear of contracting C. difficile

• Staff exhaustion-workload issues for registered staff

• Staff under the microscope – auditing and enhanced cleaning

Financial Implications

• Outbreak declared August 14, 2015

• Outbreak declared over October 20th , 2015

• Total of 2158 hours of extra labor:

1634 hours – PSW

72 hours – Registered Practical Nurse

452 hours - Housekeeping

Other Costs

• Nursing Department:

• Cost of gowns, gloves, masks and disinfectant wipes in addition to weekly regular orders

• Approximately $5500

• Housekeeping Department:

• Disinfectant wipes, liquid and gel

• Approximately $4200

•Cost of supplies: appx $10,000

Lessons Learned

Lessons Learned

C. difficile in long term care

• Prevent Transmission of C. difficile

-Ensure new cases of C. difficile are managed

as per the PIDAC: Testing Surveillance and Management of Clostridium difficile guidelines

• Importance of Antimicrobial Stewardship program

Lessons Learned

C. difficile in long term care

• Develop department specific policies and procedures on C. difficile management based on PIDAC guidelines

• Staff education and training on facility’s policies and procedures

Lessons Learned

Outbreak Management • Report cases sooner to Public Health• Establish clear roles and responsibilities • Develop an outbreak communication plan • Increased focus on environmental cleaning, hand

hygiene and PPE audits• Review audit results and provide feedback to

frontline staff• Assign a delegate Infection Control Practitioner• Facility Service Supervisor complete Infection

Control program/course for environmental cleaning

Future Plans…

• Education blitz for all staff, extended education for environmental service staff

• Create and utilize an outbreak binder

• Designate for ICP in the building

• Review policies and procedures

Questions

Contributions

• Michelle Vadori RN, Infection Control Specialist Peel Public Health

• Dr. Joseph Niedoba Medical Directory, Malton Village Long Term Care

• Tessa George Director of Care, Malton Village Long Term Care

• Sharron-Lee Zizman RN, Malton Village Long Term Care

REFERENCES

PHAC (2013). C. difficile infection: Infection Prevention and Control Guidance for Management in LTC facilities. http://www.phac-aspc.gc.ca/nois-sinp/guide/c-dif-ltc-sld/index-eng.php

PHAC (2014). Fact sheet: C. difficile http://www.phac-aspc.gc.ca/id-mi/cdiff-eng.php

Public Health Ontario, Monthly Infectious Diseases Surveillance Report. Vol. 4, Issue 8. August 2015.https://www.publichealthontario.ca/en/DataAndAnalytics/Documents/PHO_Monthly_Infectious_Diseases_Surveillance_Report_-_August_2015.pdf

Infectious Disease Protocol Appendix A C. difficile http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/cdi_chapter.pdf

PHAC (2013). C. difficile infection: Infection Prevention and Control Guidance for Management in LTC facilities. http://www.phac-aspc.gc.ca/nois-sinp/guide/c-dif-ltc-sld/index-eng.php

PHAC (2014). Fact sheet: C. difficile http://www.phac-aspc.gc.ca/id-mi/cdiff-eng.php

PHAC (2014). Pathogen Safety Data Sheet: C. difficile. Retrieved from: http://www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/msds36e-eng.php

REFERENCES

Public Health Ontario. (2014). Reportable Disease Trends 2012: Chapter 10: Clostridium difficile infections (CDI) outbreaks. Retrieved from: https://www.publichealthontario.ca/en/eRepository/Reportable_Disease_Trends_in_Ontario_2012.pdf

Public Health Ontario. (2014). Reportable Disease Trends 2012: Chapter 10: Clostridium difficile infections (CDI) outbreaks. Retrieved from: https://www.publichealthontario.ca/en/eRepository/Reportable_Disease_Trends_in_Ontario_2012.pdf

Public Health Ontario. (2014). Reportable Disease Trends 2012: Chapter 10: Clostridium difficile infections (CDI) outbreaks. Retrieved from: https://www.publichealthontario.ca/en/eRepository/Reportable_Disease_Trends_in_Ontario_2012.pdf

Public Health Ontario. (2015). Reportable Disease Trends 2013: Chapter 11: Clostridium difficile infections (CDI) outbreaks. Retrieved from: https://www.publichealthontario.ca/en/eRepository/Reportable_Disease_Trends_in_Ontario_2013.pdf

References

Public Health Ontario, Monthly Infectious Diseases Surveillance Report. Vol. 4, Issue 8. August 2015. https://www.publichealthontario.ca/en/DataAndAnalytics/Documents/PHO_Monthly_Infectious_Diseases_Surveillance_Report_-_August_2015.pdf

Simor, A. (2010). Diagnosis, management and prevention of Clostridium difficile in Long Term Care Facilities: A Review. Journal of the American Geriatrics Society v. 58 (8) p. 1556-1564.

Infectious Disease Protocol Appendix A C. difficile http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/cdi_chapter.pdf

Public Health Ontario, Antimicrobial Stewardship

https://www.publichealthontario.ca/en/BrowseByTopic/InfectiousDiseases/AntimicrobialStewardshipProgram/Pages/Antimicrobial-Stewardship-Program.aspx

The Fecal Transplant Foundation 2016. http://thefecaltransplantfoundation.org/what-is-fecal-transplant/