Clostridium DifficileThe prescriber’s role in prevention & treatment

Linda Nazarko MSc, PgDip, PgCert, BSc(Hons), RN, NIP, OBE, FRCN

Consultant Nurse West London Mental Health TrustNurse Prescribing; LSBU 18th October 2016

Aims and objectives To enable you to:

Be aware what Clostridium Difficile is

Be aware of who is at risk

What the risk factors are

How to reduce risks

How to recognise and respond

How to minimise risks

Be aware of the importance of infection control

What is Clostridium Difficile? Gram positive spore

forming anaerobic bacteria.

Lives in soil Discovered 1935 in

faeces of newborns Became a problem when

broad spectrum antibiotics introduced late 1960s early 1970s

Clostridium Difficile Older person 10 times more likely to be

killed by C.Diff than a car 50,392 ,older people infected in 2007 In 2004 934 deaths – mostly older

people Death rate doubled 2007/2008 In 2008 8,324 deaths Killed four times as many as MRSA

Risk factorsAge – over 65

Current or recent antibiotic therapy

Poor physical health

Admission to intensive care unit

Recent surgery

Use of antacids or drugs such as ranitidine or omeprazole (these reduce stomach acidity and increase the risk of infection.

Nasogastric or gastrostomy tube in place

Prolonged hospital stay

Use of enemas

Pre-existing bowel disease

Sharing a room with some one with C. difficile

E coli antibiotic Resistance

0

10

20

30

40

50

60

70

Coamoxiclav Ampicillin Cefalexin Cefpodoxime Ciprofloxacin Gentamycin Nitrofurantoin Trimethoprim

Community Hospital

Reducing risk factors Proton pump inhibitors (PPIs) such as

omeprazole or lansoprazole increase risk of developing C. Difficile.

They reduce the acidity in the stomach and small bowel and affect the natural bowel flora in the large bowel (Cunningham et al. 2003: Chitnis et al, 2013).

Ensure PPIs are clinically indicated Review “orphan” medication

Reducing risk factors Prudent antimicrobial prescribing, 50%

Px unecessary Use narrow spectrum not wide (co-

amoxiclav,cephalosporins and quinolones). GP practices monitored only max 10% incentives for meeting targets (NHS England, 2016).

Avoid high risk ABX whenever possible

Reducing risk factors Reduce use invasive medical devices In NHS hospitals 1 million catheterised every

year Reduce use IV cannula When med device isn’t needed take it out Avoid discharge delays Avoid over-occupancy 85% regarded as

safest

Falling rates of C. Difficile infection

If a patient develops diarrhoeaSIMS

Stop Any medication that is making the

diarrhoea worse. Discontinue laxatives Any prescribed proton pump inhibition

(PPI) that can be safety discontinued. Any antibiotics that can be

discontinued In mild cases of C. difficile antibiotic

treatment may not be required.

C. Difficile treatment recommendations(Public Health England, 2013)

Level of severity

Treatment

Mild Patients with mild disease may not require specific C. difficile antibiotic treatment. If treatment is required, oral metronidazole 400=500mg three times a day for 10-14 days is recommended

Moderate Patients with moderate disease should be treated with oral metronidazole 400-500mg three times a day for 10-14 days. Oral vancomycin is not recommended as may lead to the development of further antibiotic resistance

Severe For patients with severe disease should be treated with oral vancomycin (dose: 125 mg four times daily for 10-14 days. Fidaxomicin should be considered for patients with severe disease who are considered at high risk for recurrence, such as older people who need to have other antibiotics and have multiple long term conditions.

Isolate

C. Difficile is spread; by faecal/oral transmission and by spores.

Faecal oral transmission occurs when bacteria from faeces passes into the mouth of another person. Poor hand washing

Contaminated healthcare environment toilet seats, commodes, bedpans, bedside lockers, beds and floors.

Monitor

Monitor

Monitor patient Age and general health affect condition acutely unwell or simply have mild symptoms. Monitor carefully and be alert to any deterioration. Fluid intake and output recorded on a fluid balance chart. Stool frequency, volume and consistency will be

monitored. Maintain observations of temperature, pulse, blood

pressure, respirations and oxygen saturations. Diarrhoea increases the risk of skin becoming sore and

excoriated and skin health should be monitored.

Support The person may be weak and unwell. Assist with hygiene and continence Encourage oral fluids Monitor any prescribed IV fluids Treat pain Skin care, barrier creams Combating isolation and offering

supportive care

Clinical features C. difficile Cramping abdominal pain, tenderness in the

lower abdomen Pyrexia Mild to moderate watery diarrhorrea Feeling unwell Loss of appetite Dehydration Dry mouth Tachycardia

Importance prompt treatment

8,324 reasons why we need to treat promptly Toxins released by C. diff set up inflammation Life threatening complications such as colitis,

oedema of bowel, bowel perforation, pseudomembranous colitis can develop.

Diagnosis and treatment Diagnosed by clinical features and stool

sample Treatment may begin before results of

specimen available Stop antibiotics if possible Antibiotic therapy may be needed Normal therapy metronidazole or

vancomycin

Preventing cross infection Spread by spores. Can live on floors, toilet seats, furniture,

equipment for months. Common cleaning agents can spread spores Alcohol gels ineffective Hand washing removes Killed by sodium hypochlorite (bleach) Separate toilet, commode, bedpan for person

with C. Diff.

Preventing C. Difficile Prudent antibiotic use Avoiding cephalosporins and broad

spectrum antibiotics whenever possible Strict hand hygiene Correct cleaning & use chlorine based

disinfectants when C. Difficile occurs Early detection and treatment

Outbreak management Emphasise importance hand washing – alcogels

useless Isolate if not possible cohort nurse Barrier nurse Get more staff, especially domestics! Step up cleaning “using chlorine based disinfectants” Stop visiting –limits infection, reduces pressures Stop admissions – 48 hours after last symptoms Stop outpatient visits

Managing outbreak well Outbreak can happen to the best of us Be open, honest and decent Work with others, if patients are

admitted to another hospital communicate with hospital staff

Communicate with relatives, face to face, email, letters

Take time with people and reassure

Gaps in infection control Poor compliance with hand

washing “Magic” gloves Poor cleaning Poor food handling Sick staff coming to work Lack of isolation and risk

assessment Lack of gloves, aprons,

alcohol gel, bleach in some healthcare settings.

Demystifying infection control

Infection control is simple: Wash your hands Keep things clean Use gloves and aprons when needed Avoid unnecessary antibiotics Keep people well by giving good care

ReferencesChitnis AS, Holzbauer SM, Belflower RM, et al (2013). Epidemiology of Community-Associated Clostridium difficile Infection, 2009 Through 2011. JAMA Intern Med. 2013;173(14):1359-1367. doi:10.1001/jamainternmed.2013.7056

http://archinte.jamanetwork.com/article.aspx?articleid=1697791

Cunningham R, Dale B, Undy B, Gaunt N (2003). Proton pump inhibitors as a risk factor for Clostridium difficile diarrhoea. J Hosp Infect. 54(3):243-5.

http://www.journalofhospitalinfection.com/article/S0195-6701%2803%2900088-4/abstract?utm_campaign=Eyes+on+Evidence+email+campaign&utm_medium=email&utm_source=NewZapp

Deshpande A, Pasupuleti V, Thota P, Pant C, Rolston DD, Sferra TJ, Hernandez AV, Donskey CJ (2013). Community-associated Clostridium difficile infection and antibiotics: a meta-analysis. J Antimicrob Chemother.68(9):1951-1961.

http://jac.oxfordjournals.org/content/68/9/1951.abstract?utm_source=NewZapp&utm_medium=email&utm_campaign=Eyes%20on%20Evidence%20email%20campaign

Public Health England (2013) Summary Points on Clostridium difficile Infection

(CDI). Public Health, England.

http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1278944283388?utm_source=NewZapp&utm_medium=email&utm_campaign=Eyes%20on%20Evidence%20email%20campaign

NICE (2015). Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. NICE guidelines [NG15]. NICE, London http://www.nice.org.uk/guidance/ng15

NHS England (2016). Quality Premium Guidance for 2016/17. NHS England, London

https://www.england.nhs.uk/wp-content/uploads/2016/03/qualty-prem-guid-2016-17.pdf

Thank you for listening

Any questions?

Download onhttps://uk.linkedin.com/in/linda-nazarko-1952a746