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Clostridium difficile Infection

Clostridium difficile Infection. Sherif Ibrahim, MD, MPH WVDHHR, BPH, OEPS Division of Infectious Disease Epidemiology 11/16/2011. Objectives. Review microbiology and epidemiology of Clostridium difficile Review risk factors for transmission Discuss testing methods and diagnosis

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Clostridium difficile Infection

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  1. Clostridium difficile Infection Sherif Ibrahim, MD, MPH WVDHHR, BPH, OEPS Division of Infectious Disease Epidemiology 11/16/2011

  2. Objectives • Review microbiology and epidemiology of Clostridiumdifficile • Review risk factors for transmission • Discuss testing methods and diagnosis • Review surveillance for C. difficile • Discuss preventive strategies

  3. C. difficile : Microbiology • Gram positive spore forming bacillus (rods) • Obligate anaerobe • Part of the GI Flora in • 1-3% of healthy adult • 70% of children < 12 months • Some strains produce toxins A & B • Toxins-producing strains cause C. diff Infection (CDI) • CDI ranges from mild, moderate, to severe and even fatal illness

  4. C. difficile: Background • A common cause of nosocomial antibiotic-associated diarrhea (AAD) • Most common infectious cause of acute diarrheal illness in LTCFs • The only nosocomial organism that is anaerobic and forms spores (survive> 5 months and hard to destroy) • Pathogenesis is mainly due to toxins production • Infective dose is < 10 spores

  5. CDI: Impact

  6. CDI: Impact

  7. C. difficile : Transmission • Fecal – oral route • Contaminated hands of healthcare workers • Contaminated environmental surfaces. • Person to person in hospitals and LTCFs • Reservoir: • Human:colonized or infected persons • Contaminated environment • C. diff spores can survive for up 5 months on environmental surfaces.

  8. CDI: Pathogenesis Step 1- Ingestion of spores transmitted from other patients Step 2- Germination into growing (vegetative) form Step 4 . Toxin B & A production leads to colon damage +/- pseudomembrane Step 3 - Altered lower intestine flora (due to antimicrobial use) allows proliferation of C. difficile in colon

  9. CDI: Pathogenesis

  10. CDI Pathogenesis Colonized no symptoms Antimicrobials C Diff exposure & acquisition Admitted to healthcare facility Infected Symptomatic

  11. CDI: Risk Factors • Exposure to antimicrobials (prior 2-3 months) • Exposure to healthcare (prior 2-3 months) • Infection with toxogenic strains of C. difficile • Old age > 64 years • Underlying illness • Immunosuppression & HIV • Chemotherapy (immunosuppression & antibiotic-like activities) • Tube feeds and GI surgery • Exposure to gastric acid suppression meds ??

  12. Antimicrobials Predisposing to CDI • Among symptomatic patients with CDI: • 96% received antimicrobials within the 14 days before onset • 100% received an antimicrobial within the previous 3 months • 20% of hospitalized patients are colonized with C. diff

  13. Clinical Manifestations • Illness caused by toxin-producing strains of C. difficile ranges from • Asymptomatic carriers = Colonized • Mild or moderate diarrhea • Pseudo membranous colitis that can be fatal • A median time between exposure to onset of CDI symptoms is of 2–3 days • Risk of developing CDI after exposure ranges between 5-10 days to 10 weeks

  14. CDI: Symptoms • Watery diarrhea ( > 3 unformed stools in 24 or fewer consecutive hours) • Loss of appetite • Fever • Nausea • Abdominal pain and cramping

  15. CDI: Testing

  16. Best Strategy for C. difficile Testing • Testing should be performed only on diarrheal stool • Testing asymptomatic patients is not indicated • Testing for cure is not recommended

  17. Best Strategy for C. difficile Testing • For clinical use: two-step testing uses initially EIA detection of GDH for screening followed by cytotoxicity assay or toxigenic culture for confirmation • Gold standard is stool culture followed by toxigenic culture assay • Toxin is very unstable, degrades at room temperature, and undetectable within 2 hours (false negative results)

  18. CDISurveillance: Case Definition • Case definition • Clinical: presence of diarrhea AND • Laboratory: A stool test result positive for toxigenic C. diff or its toxins OR colonoscopic / histopathologic findings demonstrating evidence of pseudomembranes SHEA- ADSA, 2010

  19. CDISurveillance • Surveillance definitions of CDI by time of onset: • Healthcare facility (HCF)-onset, HCF-associated CDI  Onset > 48 hrs of admission • Community-onset, HCF-associated CDI  Onset in the community or within 48 hours of admission and within < 4 weeks of the last discharge • Community-associated CDI  Onset in the community but within more that 12 weeks of last discharge SHEA- ADSA, 2010

  20. Time Line for Surveillance Definitions of CDI Admission Discharge < 4 weeks 4-12 weeks > 12 weeks 2 d HO CO-HCFA Indeterminate CA-CDI * Day 1 Day 4 Time HO: Hospital (Healthcare)-Onset CO-HCFA: Community-Onset , Healthcare Facility-Associated CA: Community-Associated * Depending upon whether patient was discharged within previous 4 weeks Onset defined in NHSN by specimen collection date

  21. CDI Surveillance: Recommendations • At minimum: conduct surveillance for HCF-onset, HCF-associated to • detect outbreaks • monitor patient safety • Rate of HCF-associated CDI (number of cases per 10,000 patient-days • Compare your rates with other facilities • In outbreaks  stratify rates by patient location in order to target control measures

  22. Changing EpidemiologyCurrent epidemic strain of C. difficile BI/NAP1/027, toxinotype III Historically uncommon – epidemic since 2000 More resistant to fluoroquinolones Produces extra toxin called binary toxin More virulent Increased toxin A and B production Change in binding domain of toxin B increase adherence to the gut wall Increased sporulation  increase survival Causes more cases and more severe disease even at low risk populations

  23. Age-Adjusted Death Rate* for Enterocolitis due to C. difficile, 1999–2006 2.5 Male Female 2.0 White Black Entire US population 1.5 Rate 1.0 0.5 0 1999 2000 2001 2002 2003 2004 2005 2006 Year *Per 100,000 US standard population Heron et al. Natl Vital Stat Rep 2009;57(14). Available at http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf

  24. Mortality due to C. difficile Infection per 100,000 population, Massachusetts

  25. A 31 YO 14 weeks pregnant with twins went to a local ED complaining of 3 weeks of intermittent diarrhea, then 3 days of cramping and watery, black stools 4-5 times/day • Stools specimens tested positive for C. difficile toxin and she was admitted, treated metronidazole and discharged • History of trimethoprim-sulfamethoxazole exposure for a urinary tract infection about 3 months before admission • Readmitted the next day for 18 days with severe colitis and was treated with metronidazole, cholestyramine, and oral vancomycin, improved and discharged home • 4 days later she was readmitted with diarrhea and hypotension, had a spontaneous abortion • Despite aggressive treatment including a subtotal colectomy, intubation, and inotropic medication, the patient died on the third hospital day. • Histopathologic examination of the colon demonstrated megacolon with evidence of pseudomembranous colitis.

  26. CDI Pathogenesis Colonized no symptoms Antimicrobial stewardship Antimicrobials C Diff exposure & acquisition Optimizing Environmental cleaning and Hand Hygiene Admitted to healthcare facility Infected Symptomatic

  27. Antimicrobial stewardship • Regardless of setting, ~ 50% antibiotic use is “inappropriate” • The best CDI preventative measure • Decrease in number of patients at risk (susceptible) • Decrease in number of patients with CDI (reservoirs)

  28. Antimicrobial stewardship • Recommendations: • Minimize the frequency and duration of antimicrobial therapy • Decrease the number of antimicrobial agents prescribed, • Targeted antimicrobials should be based on the local epidemiology and the C. difficile strains • Restrict the use of cephalosporin and clindamycin • Audit and feedback targeting broad-spectrum antibiotics

  29. Prevention Strategies Core • High level of scientific evidence • Demonstrated feasibility Supplementary • Some scientific evidence • Variable level of feasibility

  30. Prevention Strategies: Core • Contact Precautions for duration of diarrhea • Hand hygiene (HH) in compliance with CDC/WHO • Cleaning and disinfection of equipment and environment • Laboratory-based alert system for immediate notification of positive test results • Educate HCP, housekeeping, admin staff, patients, families, visitors, about CDI Tip: Routine identification of colonized patients for infection control purposes is not recommended and treatment of such identified patients is not effective

  31. Prevention Strategies: Supplemental • Extend contact precautions beyond duration of diarrhea (48 hours) • Presumptive isolation for symptomatic patients • Implement soap and water for hand hygiene before exiting room of a patient with CDI • Implement universal glove use on units with high CDI rates • Use sodium hypochlorite (bleach) - containing agents for environmental cleaning • Implement an antimicrobial stewardship program

  32. Preventive Strategies: Contact Precautions • Core • Gloves/gowns on room entry • Private room (preferred) or cohort with dedicated commodes • Dedicated equipment • Maintain for duration of diarrhea • Measure compliance Supplemental • Extend use of contact precautions beyond duration of diarrhea • Presumptive isolation • Universal glove use on units with high CDI rates • Intensify assessment of compliance

  33. Preventive Strategies: Hand Hygiene Conclusion: Spores may be difficult to eradicate even with HH absolute adherence with glove use Core HH based on CDC or WHO guidelines Soap and water preferentially in outbreak or endemic settings Measure compliance Supplemental Soap and water for HH before exiting room of a patient with CDI Intensify assessment of compliance

  34. Environmental Contamination

  35. Preventive Strategies: Environmental Cleaning Core • Cleaning and disinfection of equipment and environment • Consider sodium hypochlorite in outbreak or endemic settings • Routinely assess adherence to protocols and adequacy of cleaning Supplemental • Reassess adequacy of room cleaning and address issues • Use sodium hypochlorite (bleach) – containing agents

  36. Preventive Strategies: Environmental Cleaning • Identify and remove environmental sources of C. diff • Routine environmental screening for C. diff is not recommended • Ensure that environmental cleaning is adequate and high-touch surfaces are not being overlooked • IF possible, use the environmental markers to assess cleaning after education

  37. Preventive Strategies: Summary • Surveillance • Microbiologic identification • Contact precautions • Hand hygiene • Environmental cleaning • Antimicrobial stewardship • Education  HCWs, patients, visitors, families • Administrative support

  38. Resources SHEA/IDSA Compendium of Recommendations Prevention of Clostridium difficile Infection (CDI) Massachusetts CDI Prevention Collaborative Carolyn Gould, MD MSCR L. Cliff McDonald, MD SHEA HAI training program, May 2011

  39. Questions

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