C. difficile Prevention Partnership Collaborative

Clostridium difficile Management in Healthcare Facilities

January 19, 2012

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Clostridium difficile Management in Healthcare

Facilities

Phenelle Segal, RN CIC

Modification of Presentation by Gail Bennett, RN, MSN, CIC

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Clostridium difficile Clostridium difficile Infection (CDI)Infection (CDI) - - ObjectivesObjectives

Describe the changing epidemiology of Clostridium difficile.

State two differences between acute care and long term care in managing patients/residents with C. difficile infection.

List three important strategies for preventing transmission of C. difficile within healthcare facilities.

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Clostridium difficile Clostridium difficile Infection Infection (CDI) (CDI) Antibiotic induced diarrhea May cause approximately 30% of all cases

of healthcare associated diarrhea Most common cause of acute infectious

diarrhea in nursing homes Disease may be a nuisance or cause life

threatening pseudomembranous colitis Increasing numbers of cases

Cases tripled in US hospitals from 2000 until 2005

Increasing disease severity and mortality

Background: Impact

• Hospital-acquired, hospital-onset: 165,000 cases, $1.3 billion in excess costs, and 9,000 deaths annually

• Hospital-acquired, post-discharge (up to 4 weeks): 50,000 cases, $0.3 billion in excess costs, and 3,000 deaths annually

• Nursing home-onset: 263,000 cases, $2.2 billion in excess costs, and 16,500 deaths annually

Campbell et al. Infect Control Hosp Epidemiol. 2009:30:523-33. Dubberke et al. Emerg Infect Dis. 2008;14:1031-8.

Dubberke et al. Clin Infect Dis. 2008;46:497-504. Elixhauser et al. HCUP Statistical Brief #50. 2008.

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Clostridium difficile Clostridium difficile Colonization vs InfectionColonization vs Infection Colonization: presence of microorganisms

without tissue invasion or damage, therefore no signs or symptoms

Colonization rate of C. difficile About 10-25% of hospitalized patients About 4-20% of long term care residents Antibiotic therapy may disrupt normal colonic flora in

colonized patients and C. difficile proliferates, producing toxins and symptomatic disease

Infection: presence of microorganisms with tissue invasion and damage, therefore signs or symptoms

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Background: EpidemiologyRisk Factors

Antimicrobial exposure Acquisition of C. difficile Advanced age Underlying illness Immunosuppression Tube feeds ? Gastric acid suppression

Main modifiable risk factors

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Antibiotics most often associated with Clostridium difficile

Ampicillin Amoxicillin Cephalosporins Clindamycin Fluoroquinolones

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Testing for Clostridium difficile

Toxin testing Quick – same day

Stool culture Takes 48-96 hours

Testing for C. difficile should be done on unformed (liquid) stool only unless ileus is suspected

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Treatment Options

Discontinue antibiotics if possible Fluid and electrolyte replacement Do not use antimotility agents (e.g. opiates) Metronidazole (Flagyl) 250 mg QID or 500 mg TID

for 10-14 days Vancomycin 125 mg QID for 7-10 days - used if

resident does not respond to or cannot take Flagyl; may be used first if severe disease

New drug: Dificid (Fidaxomicin) – 200 mg bid for 10 days

Experimental fecal transplant (enemas)

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Recurrent Clostridium difficile infection

Rates of recurrence 20% after 1st episode 45% after 1st recurrence 65% after two or more recurrences

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C. difficile in Acute vs. Non-acute Settings

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Tiered Approach to Clostridium difficile Infection (CDI) Transmission Prevention

Basic/Core/Routine Approach: C. difficile transmission prevention activities during routine infection prevention and control responses

Enhanced/Supplemental/Heightened Approach: C. difficile transmission prevention activities during heightened infection prevention and control responses

Evidence of ongoing transmission of C. difficile an increase in CDI rates and/or evidence of change in the pathogenesis of CDI (increased

morbidity/mortality among CDI patients) despite routine preventive measures

Note: many facilities choose to use the enhanced/supplemental approach all of the time.

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Infection Prevention Strategies

Hand hygieneHand hygiene Contact precautionsContact precautions Identification of casesIdentification of cases Environmental disinfection Appropriate use of antibiotics

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For basic measures, may use alcohol handrubs with C. difficile – OR use soap and water

Perform hand hygiene

before contact with the patient/resident

after removing gloves after contact with the

environment

Hand Hygiene for Clostridium difficile

Hand Hygiene – Soap vs. Alcohol gel

Alcohol not effective in eradicating C. difficile spores

However, one hospital study found that from 2000-2003, despite increasing use of alcohol hand rub, there was no concomitant increase in CDI rates

Discouraging alcohol gel use may undermine overall hand hygiene program with untoward consequences for HAIs in general

Boyce et al. Infect Control Hosp Epidemiol 2006;27:479-83.

CDC adds: Because alcohol does not kill Clostridium

difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs.

However, early experimental data suggest that, even using soap and water, the removal of C. difficile spores is more challenging than the removal or inactivation of other common pathogens.

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For enhanced measures, do not use alcohol handrubs with the CDI patient/resident – use soap and water

Washing away the spores may be the optimal way to perform hand hygiene when transmission of C. difficile is occurring

Many facilities choose to use the enhanced strategy all of the time

Hand Hygiene for Clostridium difficile (continued)

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Infection Prevention Strategies

Hand hygiene Contact precautions Identification of casesIdentification of cases Environmental disinfection Appropriate use of antibiotics

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Contact PrecautionsContact Precautions

Designed to reduce the risk of transmission of microorganisms by direct or indirect contact

Direct contact skin-to-skin contact physical transfer (turning patients/residents,

bathing patients, other patient/resident care activities)

Indirect contact Contaminated objects

Equipment Linens High touch surfaces

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Patient or Resident placement Private room preferred 2nd option: Cohorting with other patient/resident with

C. difficile 3rd option: In LTCFs, consider infectiousness and

resident-specific risk factors to determine rooming with a low risk roommate and socializing outside the room

Consider: Clean Contained Cooperative Cognitive

Patient care equipment dedicated to single patient/resident if possible. If not, disinfect equipment prior to leaving the room.

Contact PrecautionsContact Precautions

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Tiered Approach for Contact Precautions: Basic

Contact Precautions - gloves and gowns to enter room or cubicle

Do not re-use gowns Supplies outside the room

Tiered Approach for Contact Precautions: Basic (continued)

In semi-private room, keep cubicle curtain drawn to limit movement between cubicles and as a reminder of precautions

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Contact Precautions: Basic Contact Precautions: Basic (Continued)(Continued)

Use dedicated equipment; if not feasible – decontaminate prior to use on another patient/resident

Maintain adequate supplies for contact precautions

Do not isolate asymptomatic carriers

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Contact Precautions: Basic Contact Precautions: Basic (Continued)(Continued)

May discontinue precautions when diarrhea ceases (may consider 48 hours without loose stool)

Do not do a toxin “for cure” once diarrhea has stopped

Lab should not accept stool for toxin if the stool is formed

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After treatment, repeat C. difficile testing is not recommended if the patient’s symptoms have resolved, as patients may remain colonized.

http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html

From the Horse’s Mouth:CDC’s Web Site

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Tiered Approach for Contact Precautions: Enhanced

May consider alternative signage to ensure staff awareness

Evaluate current system for patient/resident placement

Consider contact precautions for all patients/residents that develop diarrhea until CDI is ruled out

Increase monitoring of isolation precautions and hand hygiene

Extend use of contact precautions even when diarrhea stops

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Why contact precautions for Why contact precautions for C. C. difficiledifficile????

Environmental contamination

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The Inanimate Environment Can Facilitate Transmission

~ Contaminated surfaces increase cross-transmission ~Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

X represents VRE culture positive sites

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Signage for Precautions

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Infection Prevention Strategies

Hand hygieneHand hygiene Contact precautionsContact precautions Identification of casesIdentification of cases Environmental disinfection Appropriate use of antibiotics

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Identification of Cases

Colonization or asymptomatic fecal carriage of C. difficile May be common in healthcare

facilities Do we care?

C. difficile infection Acute diarrhea

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CDI Collaborative Definition A case of C. difficile is defined as a case with

the symptom of diarrhea without other known etiology

The stool sample will yield a positive result for laboratory assay for C. difficile toxin A and/or B

For this collaborative, CDI is limited to lab confirmed cases

Will track healthcare associated CDI

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CDI Collaborative Definition of Healthcare Associated

This collaborative will track laboratory confirmed cases of Health Care Facility C. difficile.

A laboratory confirmed case of C. difficile is defined as a patient with diarrhea characterized by unformed stool, without other known etiology, and associated with a positive laboratory assay for C. difficile toxin A and/or B on the stool.

Count each case of CDI only once Recurrent CDI: Episode of CDI that occurs eight weeks

or less after the onset of a previous episode, provided the symptoms from the prior episode resolved.

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Definition (continued)HAI-CDI (INDEX FACILITY)A patient classified as having a case of healthcare facility associated C. difficile attributable to YOUR facility is defined as a patient who develops diarrhea on or after the 4th day of admission.ORA patient classified as having any symptoms that develop on or before the 4th day after your discharge to another healthcare facility. ORA patient discharged to home with lab confirmed C.diff. within 28 days from the day of discharge and no intervening admissions. (Day of discharge counts as day 1) Also counts if C.diff is identified on readmission to your facility within that 28 day period.

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Definition (continued)

HAI-CDI (OTHER FACILITY)A patient classified as having a case of healthcare facility associated C. difficile attributable to another health care facility is defined as a patient who develops diarrhea before the 4th day of admission

after transfer from another health care facility OR:

within 28 days of discharge from another health care facility

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48 hours - example Admission = day 1 – Monday Day 2- Tuesday Day 3- Wednesday Day 4- Thursday at 12:01 a.m. is the

cutoff. After Thursday at 12:01, it counts for your facility. Prior to that time, it is considered “community acquired” which includes any location other than your facility.

Exception – home care – 28 days

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Facility Healthcare Associated CDI Rate # of HA CDI cases divided by

patient/resident days X 10,000 = ___ HA CDI per 10,000 patient/resident days

Example: 3 cases HA CDI divided by 3,585

patient/resident days = .0008368 X 10,000 =8.368 or 8.4 cases of HA CDI per 10,000 patient/resident days

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Identification of Cases

Basic Strategy: With cases of diarrhea, consider C.

difficile Take a detailed history for risk factors

Norovirus, dietary changes, medications, and other things may also be causes of diarrhea

Notify physician Watch for dehydration

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Identification of Cases

Enhanced Strategy: Automatic contact precautions for all

patients/residents with orders for C. difficile labs AND for all patients/residents with a known history of CDI

Consider allowing nurses to initiate the lab order and contact precautions

Consider universal glove usage on units that have a high incidence/rate of CDI

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Infection Prevention Strategies Contact precautions Hand hygiene Identification of casesIdentification of cases Environmental disinfection Appropriate use of antibiotics

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Environmental Survival and Contamination

Vegetative form survives for only 15 minutes on dry surfaces in room air May remain viable up to 6 hours on moist

surfaces Spores are highly resistant to drying, heat, and

chemical and physical agents Can exist for five months on hard surfaces

One study (McFarland et al, 1989) found spores in: 49% of rooms occupied with CDI 29% in rooms of asymptomatic carriers

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Environmental Survival and Contamination (continued)

Heaviest contamination on floors and in bathrooms but ALL surfaces have the ability to be contaminated

Spores have been isolated from the air and aerosol dissemination may, in part, account for widespread environmental contamination

The frequency of positive personnel hand culture has been strongly correlated with the intensity of environmental contamination

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Evidence of the role of environmental transmission

Frequency of C. difficile acquisition has been linked with the level of environmental contamination

Patients admitted to a room previously occupied by a patient with C. difficile have a higher risk for C. difficile acquisition

Improved room disinfection has led to decreased rates of C. difficile infection

Monitor environmental cleaning

Environmental Disinfection: Tiered Approach

Basic:Use EPA approved

germicide for routine disinfection during non-outbreak situations

Ensure staff training and contact time

Disinfect shared items between patients/residents

Enhanced:Use 10% sodium

hypochlorite (bleach) for disinfecting room and equipment (or use EPA registered sporicidal agent)

In outbreak, consider bleach solution for cleaning all rooms

Use bleach wipes as an adjunct to cleaning

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Disinfectants

Commonly used disinfectants are not sporicidal Some may actually encourage sporulation

(the changing of the organism to the spore state)

Sporicidal disinfectants: Chlorine-based disinfectants High-concentration, vaporized hydrogen

peroxide Recently approved EPA registered

disinfectants that kill C. diff spores

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Disinfectants

Chlorine-based disinfectants - disadvantages: Can be corrosive to equipment or surfaces over

time Can cause respiratory or other health problems in

workers using them May cause bleaching/fading Reconstituted product needs to be made fresh daily

APIC states use of chlorine-based disinfectants should be limited to outbreak situations and when high rates of CDI have been documented

In these situations (outbreaks and/or high rates), chlorine-based products have demonstrated benefit when used with other control measures

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Pre-mixed Hypochlorite Solution: Advantages and Disadvantages

Advantages: Commercially available solutions include

detergent base Cleaning as well as disinfection Eliminates dilution errors

Disadvantages of pre-mixed solutions: Solutions expire over time May be hard to store May be more costly

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Bleach and water: mixing your own solution

Cleaning and disinfection is a two-step process (must clean first, then disinfect)

Contact time of ten minutes required for disinfection (Rutala, 2008) Thorough wetting of the surface, allowed to

air dry Note: pre-mixed EPA registered

hypochlorite solutions provide cleaning and disinfection in one step

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Floor decontamination Consider cleaning the C. difficile room

as the last room of the day Alternately, if not using microfiber

mops, change the bucket, solution, and mop head after cleaning the C. difficile room and before cleaning another room

All cleaning equipment and supplies should be decontaminated prior to use on another room

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Germicidal Wipes If wipes are used:

The wipe must wet the surface being disinfected for the correct contact time as noted on label

Use the right wipes for the right type of job The user should:

Know the contact time for the germicide used Know the ability of the wipe to maintain contact

time for the task for it will be used Be involved in selection of the right type of wipes

Staff must be trained to use the wipes appropriately

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Additional thought.. Remember the cubicle curtains when doing

terminal cleaning following C. difficile infection

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Monitoring Environmental Cleaning

Consistency with recommended cleaning and disinfection procedures should be routinely monitored.

Include all surfaces and items near the patient Staff performing cleaning should use checklists

Confirm that each critical area has been cleaned and disinfected

Each item must be checked off as it is completed No need for routine environmental sampling for

Clostridium difficile If there is ongoing transmission:

May indicate non-compliance Thorough cleaning and disinfection of the

environment must be done

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APIC Guide

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Environmental Services Training

Because of the high turnover of staff, educate personnel on proper cleaning technique frequently.

Ensure that education is provided in the personnel’s native language.

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Infection Control Strategies

Contact precautions Hand hygieneHand hygiene Identification of casesIdentification of cases Environmental disinfection Appropriate use of antibiotics

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Antimicrobial Stewardship: definition

Antimicrobial (or antibiotic) stewardship programs are interventions designed to ensure that hospitalized patients receive the right antibiotic, at the right dose, at the right time, and for the right duration (CDC definition)

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Prescriber educationStandardized antimicrobial order

formsFormulary restrictionsPrior approval to start/continue

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Pharmacy substitution or switch Multidisciplinary drug utilization

evaluation (DUE)Provider/unit performance feedback Computerized decision support/on-

line ordering

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CDC Fast Facts

Antibiotic overuse contributes to the growing problems of Clostridium difficile infection and antibiotic resistance in healthcare facilities.

Improving antibiotic use through stewardship interventions and programs improves patient outcomes, reduces antimicrobial resistance, and saves money.

Interventions to improve antibiotic use can be implemented in any healthcare setting—from the smallest to the largest.

Improving antibiotic use is a medication-safety and patient-safety issue.

http://www.cdc.gov/getsmart/healthcare/inpatient-stewardship.html

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Antibiotic Review for Long Term Care Facilities

F441: Because of increases in MDROs, review of the use of antibiotics is a vital aspect of the infection prevention and control program.

An area of increased surveyor focus - an area where you need to assess if you are meeting the surveyor guidance

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42 CFR §483.25(l), F329, Unnecessary Drugs Determine if the facility has reviewed with

the prescriber the rationale for placing the resident on an antibiotic to which the organism seems to be resistant or when the resident remains on antibiotic therapy without adequate monitoring or appropriate indications, or for an excessive duration

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What most likely exists currently in your program: Comparison of prescribed antibiotics with available

susceptibility reports (charge nurse and infection preventionist)

Review of antibiotics prescribed to specific residents during regular medication review by consulting pharmacist

What may be needed: Antibiotic stewardship program in the facility (CDC

recommendation – 2006 MDRO guideline) Broader overview of antibiotic use in your facility with

reporting to quality assurance/infection control committee

Right drug - Right dosage - Right monitoring - Feedback of data to MDs

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Monitoring of practices is crucial! We must observe to see that our policies and

recommended processes are being done and done correctly

Educate staff or use other appropriate measures when you see non-compliance She doesn’t know She doesn’t care It won’t work

Enforce that all staff must follow the rules for contact precautions and hand hygiene

Conversation and Questions

Thinking about your cleaning processes:

What do you think is working well?

Where could you use help? Questions?

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References Clinical Practice Guidelines for

Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)

http://azdhs.gov/phs/oids/epi/disease/cdif/documents/Clinical%20Practice%20Guidelines%20for%20C%20Diff%20Infection%20%202010%20update%20by%20SHEA-IDSA.pdf

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References APIC Guide to the Elimination of

Clostridium difficile Infections in Healthcare Settings. http://www.apic.org/Content/NavigationMenu/PracticeGuidance/APICEliminationGuides/C.diff_Elimination_guide_logo.pdf

SHEA: Clostridium difficile in Long Term Care Facilities for the Elderly http://www.shea-online.org/Assets/files/position_papers/SHEA_Cdiff.pdf

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References (continued)

Spotlight on Clostridium difficile Infection: An Educational Resource for Pharmacists

David P. Nicolau , PharmD, FCCP, FIDSAhttps://secure.pharmacytimes.com/lessons/200902-02.asp

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CDI Toolkit – CDC

Clostridium difficile (CDI) Infections Toolkit (pdf)   http://www.cdc.gov/hai/organisms/cdiff/cdiff_infect.html

CDI Toolkit  available in PowerPoint format

on the CDC website Clostridium Difficile Infection (CDI) Baseline

Prevention Practices Assessment Tool For States Establishing HAI Prevention Collaboratives Using ARRA Funds Using Recovery Act Funds 

http://www.cdc.gov/HAI/recoveryact/stateResources/toolkits.html

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Protect patients…protect healthcare personnel…promote quality healthcare!

Thank you! gailbennett@icpassociates.com

PreventionIS PRIMARY!

If you haven’t yet…Register for Regional Meetings

Lowell General Hospital—January 24 Baystate Medical Center—January 25 Jordan Hospital—January 26 UMASS Memorial Medical Center—January 31 Register at:

https://www.regonline.com/cdifficilepreventioncollaborativeregionalworkshops