Antibiotic Stewardship and the Relationship to C.Difficile Resources/April 2016/PDF Slides...Antibiotic Stewardship Programs ... ejection fraction of 30 percent per record, osteoarthritis,

Antibiotic Stewardship and the Relationship to

C.Difficile

CDCs Core Elements of Hospital Antibiotic Stewardship Programs

Leadership Support


Accountability


Drug Expertise


Actions to Support Optimal Antibiotic Use


Tracking: Monitoring Antibiotic Prescribing, Use and Resistance


Reporting Information to Staff on Improving Antibiotic Use and

Resistance


Education

Clostridium difficile

C

Clostridium difficile Colonization vs. Clostridium difficile Infection

Clostridium difficile colonization patient exhibits NO clinical symptoms patient tests positive for Clostridium difficile organism

and/or its toxin more common than Clostridium difficile infection Clostridium difficile infection patient exhibits clinical symptoms patient tests positive for the Clostridium difficile organism

and/or its toxin

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

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

Patients at Greatest Risk for CDI

The risk for CDI increases in patients with:

Antibiotic exposure

Proton pump inhibitors

Gastrointestinal surgery/manipulation

Long length of stay in healthcare settings

A serious underlying illness

Immunocompromising conditions

Advanced age http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html#a4

http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html#a4http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html#a4http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html#a4

Proper Use of Handwashing and PPE

Proper Use of Handwashing and PPE

http://www.safecarecampaign.org/cdifficile.html

http://www.bing.com/videos/search?q=understanding+CDiff+video&view=deta

il&mid=F37443F6DF9F6A93E2ADF37443F6DF9F6A93E2AD&FORM=VIRE

http://www.safecarecampaign.org/cdifficile.htmlhttp://www.safecarecampaign.org/cdifficile.htmlhttp://www.bing.com/videos/search?q=understanding+CDiff+video&view=detail&mid=F37443F6DF9F6A93E2ADF37443F6DF9F6A93E2AD&FORM=VIREhttp://www.bing.com/videos/search?q=understanding+CDiff+video&view=detail&mid=F37443F6DF9F6A93E2ADF37443F6DF9F6A93E2AD&FORM=VIREhttp://www.bing.com/videos/search?q=understanding+CDiff+video&view=detail&mid=F37443F6DF9F6A93E2ADF37443F6DF9F6A93E2AD&FORM=VIRE

Appropriateness of Diagnostic Testing

Testing procedures at your facility

Who has authorization to send specimen?

What type of tracking is in place to insure appropriate stool testing for CDI?

Staff Education/Competencies

Mechanism in place to determine staff training related to CDI, isolation, PPE?

What does that look like at your facility?

At what point does education and re-education occur?

Proper Environmental Cleaning

CDI Team Composition

Do you have a CDI team in place at your institution?

Is it a multi-disciplinary team?

Which departments are represented?

Patient and Family Education

Discharge from the Hospital Communication of diagnosis is key

whether unit to unit or facility to agency/facility

Testing for cure?

Treatment plans

Environmental Cleaning

C difficile and Environmental Service Case #1

Name: WG Admission: 12/10 HPI: 66yoF initially admitted for encephalopathy d/t CVA vs SNS infection vs sepsis. D/t

pacemaker no MRI. Patient received 48hours of meningitis combo 12/14-12/16 12/17 started empiric high dose steroids for empiric treatment of possibility of

autoimmune CNS vasculitis, initially patient improved 12/20 condition worsened, was found to have a large L-sided retroperitoneal hematoma

(in Coumadin INR 4.1), not a surgical candidate, ->hemorrhagic shock-> on 4 pressors and continued to be hypotensive

PMH: (1) COPD Acute and chronic respiratory failure with hypercapnia (2) Pseudomonas pneumonia

(3) Clostridium difficile diarrhea (4) Atrial fibrillation, chronic (5) Toxic metabolic encephalopathy (6) Chronic systolic CHF (congestive heart failure) (7) On mechanically assisted ventilation for which she ultimately required tracheostomy with subsequent decannulation (8) Acute renal failure superimposed on stage 3 chronic kidney disease (9) Pulmonary hypertension assoc with unclear multi-factorial mechanisms (10) CAD (coronary artery disease)

C difficile and Environmental Service cont.

Cultures: all no growth, viral panel negative Antibiotics:

acyclovir 555mg Q 12H 12/14-12/16 ampicillin 2gQ4 hours 12/14-12/16 cefepime 2gQ12 hours 12/14-12/16 vancomycin 12/12-12/16

Laxatives: docusate 100mg BID 12/14-12/15 Bowel Movement: 12/10-12/14 No symptoms, 12/15 (liquid brown Q3-6h)

12/16 (green liq Q1-2h)12/17 (liq brown Q3-6h, then 1-2h) 12/18 no GI sxs, 12/19-12/20 (liq brown Q 1-2 h, bloating)

12/20 diagnosed with C diff Initial assessment: She had C diff Hx, received antibitics,

very poor prognosis, very complicated patient...


Name: JM Admission: 12/9 HPI:

12/9 The patient is a 79-year-old female who was admitted on for AMS change and malignant hypertension. She was initially treated with anti-hypertensives in the ER and then had severe hypotension requiring ICU transfer and epinephrine. She was also found to have Escherichia coli urinary tract infection, pan-sensitive was treated with ceftriaxone x3 days.

PMH: HTN, DM, hyperlipidemia, diabetic neuropathy, anxiety Antibiotics:

Ceftriaxone 6/15-6/18

Laxatives: none Bowell Movement: 12/12: per note: at 1800 pt had one large

loose stool 12/21: 4 loose stools, pt remained hypotensive 12/21 Diagnosed with C diff


Name JP Admission 12/15 PMH: cancer with metastasis to liver, chronic non-ischemic cardiomyopathy,

ejection fraction of 30 percent per record, osteoarthritis, hypertension, rosacea, history of peptic ulcer disease

HPI: 12/15 admitted to Maury Regional Medical Center per cardiology for worsening of bilateral lower extremity edema and social displacement concerns due to being bedridden and unable to care for herself. Was found to have a upper extremity DVT.

Bowel Movement: 12/16 no mention of any of GI sxs or diarrhea in progress notes. 12/17 (soft formed Q3-6h), 12/18 (soft x3) 5/30(soft brown x9), 12/19 (soft brown 6), 12/20(soft brown 9), 12/21(soft liquid 8), 12/22 (soft liq 2)

Medications: No antibiotics Laxatives: Docusate/senna PRN not given

12/22 C diff positive

C difficile and Environmental Service

Problem: 3 cases of C diff happened with 48 hours of each other 2/3 patients received short antibiotic courses x48-72 hours, all for

appropriate indications. 1 patient had no antibiotics. WG had a Hx of C diff, JM and JP were located on the same floor. Even though WG and JM received antibiotics it was felt that there

was more to this then just antibiotic associate C diff, especially after JP, patient who did not receive any antibiotics was diagnosed.

Suspected horizontal spread. After in depth review, it was found that the patents did not share physicians, RNs, therapists, or dietary workers. The positive finding was possibly cleaning personnel.

Action Taken: Cleaning procedures updated, training provided to environmental workers, especially recently hired employees.

Proper Diagnostics

Proper Diagnosis Name BB

Admission 12/17

PMH: DM, CAD, obese, schizophrenia, bipolar disorder, recent hospitalization for A fib.

HPI: 12/17 - 51 yo F initially admitted to floor for HCAP treated with azithro/piptazo-> got worse -> 12/19 transferred to ICU with septic shock, intubated, re-cultured, PCR done-> 12/23 cxc NGx2 and PCR (+) for Human Metapneumovirus antibiotics discontinued

CXC:

12/17 Blood NGx5

12/19 BAL NGx2

12/19 PCR + for Human Metapneumovirus

ABX:

piperacillin/tazobactam 12/17-12/20

vancomycin 12/19-12/20

azithromycin 12/17-12/20

Laxatives:

docusate BID 12/19-12/30

Bowel description: 12/16-12/17 (nothing), 12/18 (constipation No BM), 12/19 -12/20 (No BM), 12/21 (soft brown large #3), 12/22-12/30 (Brown, liquid Q1-2hrs->continuous), 12/31(soft brown Q3-6H), 1/1-1/3 (soft brown Q7-12H)

1/1 C diff ordered - positive

Proper Diagnosis

Problem: Diarrhea was most likely caused by scheduled

laxatives, not C diff. Patient was likely colonized. Diarrhea resolved after laxatives were

discontinued. However, since the test was ordered and patient was diagnosed with C diff he had to be treated and the incident recorded as hospital acquired C diff.

Action Taken: After several repeated cases, nursing order for C diff was removed. Presently, C diff has to be ordered by an MD.

Antibiotic Stewardship

C difficile and Antibiotic Stewardship

Name: DN Admission: Date 9/8/14 Diagnosis: Community Acquired Pneumonia PMH: CHF, pace maker, HTN, CVA, CAD, A fib, no risk factors for resistant pathogens SH: lives at home Antibiotics:

Piperazillin/ tazobactam 9/8-9/15 levofloxacin 9/8-9/15 vancomycin 9/11-9/15 linezolid 9/8-9/11

Culture data:

9/8 Sputum norm flora 9/8 Blood NGx5

9/14 Patient started having diarrhea 9/15 C diff positive

C difficile and Antibiotic Stewardship

Problem: Inappropriate antibiotics were used. Too many, too broad, not deescalated

Action taken: Antibiotic Stewardship Implemented. Leadership support Accountability Drug Expertise Action to support optimal antibiotic use Tracking antibiotic use Reporting Educaiton

A Patients Story

http://www.bing.com/videos/search?q=c+diff+patient+experience+videos&qpvt=c+diff+patient+experience+videos&view=detail&mid=8B705EE069564D0116C58B705EE069564D0116C5&FORM=VRDGAR

http://www.bing.com/videos/search?q=c+diff+patient+experience+videos&qpvt=c+diff+patient+experience+videos&view=detail&mid=8B705EE069564D0116C58B705EE069564D0116C5&FORM=VRDGARhttp://www.bing.com/videos/search?q=c+diff+patient+experience+videos&qpvt=c+diff+patient+experience+videos&view=detail&mid=8B705EE069564D0116C58B705EE069564D0116C5&FORM=VRDGARhttp://www.bing.com/videos/search?q=c+diff+patient+experience+videos&qpvt=c+diff+patient+experience+videos&view=detail&mid=8B705EE069564D0116C58B705EE069564D0116C5&FORM=VRDGAR

Wrap-up and Questions

Documents

Antibiotic Stewardship and the Relationship to C.Difficile Resources/April 2016/PDF Slides...Antibiotic Stewardship Programs ... ejection fraction of 30 percent per record, osteoarthritis,