Clostridium Management in Long-Term Care

Spring 2011 Joint Provider/Surveyor Training

Teri Lee Dyke, RN, MSN, CIC

Clostridium difficile Infection (C. diff, CDI, C. difficile & CDAD)

Two Case Reports *[Case 1]

*MMWR 2005;54:1201-5Severe CDAD in populations previously at low risk- four states, 2005

•Case 1

Two Case Reports *[Case 2]

*MMWR 2005;54:1201-5Severe CDAD in populations previously at low risk- four states, 2005

•Case 1

Why C. difficile is interesting

• It is a bacterial infection in which antibiotics cause (or at least contribute to) the disease

• It is one of the only anaerobic organisms that can be a nosocomial pathogen

• Its mechanism of pathogenesis is almost completely toxin production; it does not invade the tissues

• It is the only nosocomial pathogen that forms endospores that are nearly impossible to kill

• The most effective treatment for the disease may be to expose the patient to more bacteria

Outline

• Clostridium Difficile the disease

• Epidemiology• Infection

Prevention/Mitigation• Strategies for

Management in LTC• Resources

C. Difficile the disease

Microbiology

• Description– Gram positive spore-

forming anaerobic bacteria

• Natural habitat– GI tract of mammals

• Identification– Not normally cultured

from stool; difficult to grow

Clostridium difficile

• Anaerobic spore-forming bacillus • Clostridium difficile-associated disease or diarrhea

(CDAD) • Pseudomembranous colitis, toxic megacolon, sepsis,

and death• Fecal-oral transmission through contaminated

environment and hands of healthcare personnel• Antimicrobial exposure is major risk factor for

disease - Acquisition and growth of C. difficile- Suppression of normal flora of the colon

• Clindamycin, penicillins, and cephalosporins Pseudo-membranous

colitis

Healthy colon

Sunenshine et al. Cleve Clin J Med. 2006;73:187-97.

Background: Pathogenesis of CDI

4. Toxin A & B Productionleads to colon damage +/- pseudomembrane

1. Ingestionof spores transmitted

from other patients via the hands of healthcare personnel and environment

2. Germination intogrowing (vegetative)

form

3. Altered lower intestine flora (due to antimicrobial use) allows

proliferation of C. difficile in colon

Background: Epidemiology

Risk Factors

• Antimicrobial exposure

• Acquisition of C. difficile

• Advanced age

• Underlying illness

• Immunosuppression

• Tube feeds

• ? Gastric acid suppression

Main modifiable risk factors

Modes of Transmission

• Fecal-oral– Food– Fomite (contaminated object)

• Person-to-person– Taking care of an ill individual– Fomite (contaminated object)

• Inpatient healthcare setting• Previous antibiotic exposure

Symptoms of CDAD

• Watery diarrhea

• Loss of appetite

• Fever

• Nausea

• Abdominal pain and cramping

Colonization vs. Infection

• Colonization– No clinical symptoms– More common than

disease presence– Patient will test

positive for Clostridium difficile and/or its toxin

• Infection– Watery diarrhea– Abdominal pain– Fever– Nausea/Vomiting– Patient tests positive

for Clostridium difficile and/or its toxin

Laboratory Testing

• Stool culture– Most sensitive ( ↑ false-positives)

– Labor intensive

– Results in 48-96 hours

• Antigen detection– Rapid tests ( < 1 hour)

– Antigen detection by latex agglutination or immunochromatographicassays

– Must be combined with toxin testing to verify diagnosis

Laboratory Testing continued..• Toxin testing*

– Enzyme immunoassay detects toxin A, toxin B or both

• Same-day test results

• Less sensitive than tissue culture cytotoxicity assay

– Tissue culture cytotoxicity assay • detect toxin B only

• Requires technical expertise

• Costly

• 24-28 hours results

• Provides specific and sensitive results for c. difficile

* Toxin is very unstable and degrades at room temperature such that toxin may be undetectable within 2 hours. False-negative test results may result from not conducting

immediate testing or not properly refrigerating specimen

Detection of C. difficile in stool

• Culture; too difficult; the organism is fastidious, takes too long

• Cell-associated antigen test; fast, but doesn’t distinguish between toxin-producers and harmless strains

Detection of C. difficile in stool

• Toxin antigen tests; fast, but less sensitive, can get toxin A or A+B tests *

• PCR; not commercially available, not a toxin test

• Cytotoxicity test; the most sensitive, specific and cost-effective

• One specimen is enough, don’t need 3

•Toxin is very unstable and degrades at room temperature such that toxin may be undetectable within 2 hours. False-negative test results may result from not conducting immediate testing or not properly refrigerating specimen

New strain C. difficile• Standard laboratory tests will not distinguish the

new from conventional strains, although all new strains to date were positive for Toxins A and B

• Distinguished by clinical presentation• Can do PCR for the binary toxin and/or for the

deletion in the repressor gene– Most are also fluoroquinolone-resistant, but that is

not specific for this strain

• Strains can be typed by pulse-field gel electrophoresis, and the new strain shows up as a single clone

CDAD Treatment• Discontinue the offending antibiotic

– 23% of the patients disease will resolve within 2-3 days• Standard initial treatment of toxin-positive patients

– Metronidazole 500 mg three times per day for 10-14 days– No resistance, MIC is 0.25-1, stool level is 10– Clinical response of about 95%, relapse of 5-15%

• Alternative– Vancomycin 125 mg four times per day (relapse 15-30%)– Bacitracin 25,000 units four times per day– Cholestyramine 4 grams three times per day for 10 days

• For relapse– Repeat metronidazole plus rifampin 300 mg twice per day for 10 days– If that fails, go to an alternative

• Replace fluid and electrolytes• Avoid anti-peristaltic agents (lomotil, opiates)• Relapse rate 5-15%

American College of Gastroenterology and SHEA Guidelines

• Discontinue the offending antibiotic or change it • Replace fluids and electrolytes• Avoid antiperistaltic agents• If those fail, try one course of metronidazole (Flagyl)• Do not treat asymptomatic patients• Retreat relapses once with the same regimen• Avoid vancomycin if possible

Epidemiology

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.

Heron et al. Natl Vital Stat Rep 2009;57(14). Available at http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf

Background: ImpactAge-Adjusted Death Rate* for

Enterocolitis Due to C. difficile, 1999–2006

*Per 100,000 US standard population

0

0.5

1.0

1.5

2.0

2.5

1999 2003

Rat

e

2000 20042001 20052002 2006Year

MaleFemaleWhiteBlackEntire US population

Challenges • Emergence of a new epidemic strain

– Toxinotype III or “BI” by REA• Distinct from “J” strain of 1989-19921

– Binary toxin as a possible virulence factor• In addition to toxins A and B containing

– 18 bp deletion in tcdC gene• Could lead to increased toxin production (18-fold for

toxin A, 23-fold for toxin B) observed by Warny et al.2

– Increased resistance to fluoroquinolones• Appears responsible for increase in cases• May be responsible for increase in disease severity

1. Johnson S, et al. N Engl J Med. 1999;341:1645-1651.2. Warny M, et al. Lancet. 2005;366:1079-1084.

CDAD Surveillance Data

• Not reportable

• NNIS data up to 1990s

• Started in Northeast, now spread to Midwest and South

From Archibald LK, et al. J Infect Dis. 2004;189:1585–158.

Annual CDAD Rates, Hospitals with >500 Beds, Intensive Care Unit Surveillance Component, NNIS

From McDonald LC, et al. Emerg Infect Dis. 2006;12(3):409-15

National Estimates of US Short-Stay Hospital Discharges with C. difficile as First-Listed

or Any Diagnosis

From McDonald LC, et al. Emerg Infect Dis. 2006;12(3):409-15

Rates of US Short-Stay Hospital Discharges with C. difficile Listed as Any Diagnosis by Region

Acute Care Hospitals with CDAD Outbreaks* Between 2001-2004

*Detected by increases in the number of positive routine clinical laboratory tests for C. difficile.

Data from McDonald LC, et al. N Engl J Med. 2005;353:2433-2441.

2

12

1

1

1

States with the Epidemic Strain of C. difficile Confirmed by CDC and Hines VA labs (N=27),

Updated 4/3/2007

DC

PRAK

HI

Michigan Data

• Death certificates with C. difficile– Underlying cause– Any mention

Death Certificates in Michigan Clostridium Difficile

1999-2005

0

50

100

150

200

250

300

1999 2000 2001 2002 2003 2004 2005

underlying cause of death any mention of C. difficileany mention of C. difficile

Michigan

Deaths with Enterocolitis caused by C. difficile listed as Underlying Cause

020406080

100120140160180

<40 40-49 50-59 60-69 70-79 80-89 90andup

Total

Age

No

. o

f C

as

es

1999

2000

2001

2002

2003

2004

2005

Source: 2005 death file, data records and health data development section MDCH

Michigan

Death Certificates with Any Mention of Enterocolitis caused by C. difficile

020406080

100120

1999 2000 2001 2002 2003 2004 2005

No

. of

case

s

<40

40-49

50-59

60-69

70-79

80-89

90 and up

Source: 2005 death file, data records and health data development section MDCH

• Boston, 1998¹– Low attributable mortality– Average 3,600 excess cost per case– Average of 3.6 extra hospital days

• Pittsburgh, 20002

– Life-threatening disease from 1.6% to 3.2%– 2000-2001: 26 colectomies and 18 deaths

• Quebec, 2004– 30-day attributable mortality 6.9%– 12-month attributable mortality 16.7%– Average of 10.7 extra hospital days

Increasing Severity and Costs of CDAD

1. Dallal RM, et al. Ann Surg. 2002;235:363-372.2. Muto C, et al. Infect Control HospEpid. 20053. Pepin J, et al. CMAJ. 2005

Changing epidemiology

• Old model of disease; the patient carried the organism into the hospital with them, antibiotics during hospitalization induce toxin production and disease– This hypothesis was tested by culture of

hospitalized patients on admission and then weekly

– The model proved false

Changing epidemiology• New model for C. difficile disease; the organism is not

usually endogenous, antibiotics during hospitalization predispose the patient to colonization, the organism is then acquired in the hospital and causes disease; a nosocomial infection

• In fact, one study showed that colonization with C. difficile prior to hospitalization was protective against C. difficile disease after hospitalization

• Neonates often carry the organism but lack the receptors for the toxin, do not get disease

Epidemiology

• Asymptomatic colonization– Community surveys show that 1-3% of the population

normally carries the organism asymptomatically– Among hospitalized patients, 20% carry it

• CDAD was associated with elderly and long LOS inpatients and nursing homes– Now increasing in non-patients as a community-

acquired disease, in children and young adults, with little antibiotic pre-exposure

• CDAD was associated with use of clindamycin and cephalosporins

Epidemiology; inciting agents and risk factors

• Almost all antibiotics and many antineoplastic agents have caused disease– Most commonly cited: beta-lactams,

clindamycin, fluoroquinolones– Less commonly cited; Timentin,

tetracyclines, SXT, aminoglycosides

• Risk factors:– Advanced age, underlying illness,

immunologic susceptibility (IgG, not cellular)

Recent studies

• Pepin, et al. 2005. Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea; a cohort study during an epidemic in Quebec (CID 41:1254-1260)– Since 2002, 30 hospitals, 7000 cases, rate of

15/10,000 patient days, increase in severe disease– Quinolone use had an odds ratio of 3.44, 2nd

generation cephalosporins 1.89– The drug made a difference; gatifloxacin was worst,

levofloxacin was best

Recent studies

• Loo, et al. 2005. A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. NEJM 353:2442-2449.– Studied 12 Quebec hospitals, 1719 patients, 22.5/1000

admissions– Attributable mortality was 6.9%– Of 157 isolates from 9 hospitals, 129 were identical– All isolates were susceptible to metronidazole and

vancomycin– Aminoglycosides and penicillins were protective (odds

ratio), cephalosporins, fluoroquinolones and clindamycin were associated with disease

Recent studies

• McDonald, et al. 2005. An epidemic, toxin gene-variant strain of Clostridium difficile. NEJM 353:2433-2442– Collected 187 strains from 8 hospitals in Georgia,

Illinois, Maine, New Jersey, Oregon and Pennsylvania in 2003

– Typed by restriction endonuclease typing, PFGE, toxin typing

– Compared with a library of older C. difficile strains– Most of the new strains were identical, and were

different from all strains collected before 2001– The new toxin genes and fluoroquinolone resistance

are new

Infection Prevention Mitigation

Prevention Strategies: Core

• Contact Precautions for duration of diarrhea• Hand hygiene in compliance with CDC/WHO• Cleaning and disinfection of equipment and

environment• Laboratory-based alert system for immediate

notification of positive test results• Educate about CDI: HCP, housekeeping,

administration, patients, families

http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.htmlDubberke et al. Infect Control Hosp Epidemiol 2008;29:S81-92.

Prevention Strategies: Supplemental

• Extend use of Contact Precautions beyond duration of diarrhea (e.g., 48 hours)*

• Presumptive isolation for symptomatic patients pending confirmation of CDI

• Evaluate and optimize testing for CDI• 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

* Not included in CDC/HICPAC 2007 Guideline for Isolation Precautions

Supplemental Prevention Strategies: Consider presumptive isolation for patients

with > 3 unformed stools within 24 hours• Patients with CDI may contaminate environment and

hands of healthcare personnel pending results of diagnostic testing

• CDI responsible for only ~30-40% of hospital-onset diarrhea

• However, CDI more likely among patients with >3 unformed (i.e. taking the shape of a container) stools within 24 hours– Send specimen for testing and presumptively isolate patient

pending results– Positive predictive value of testing will also be optimized if

focused on patients with >3 unformed stools within 24 hours– Exception: patient with possible recurrent CDI (isolate and test

following first unformed stool)

Supplemental Prevention Strategies:

Glove Use Rationale for considering universal glove use

(in addition to Contact Precautions for patients with known CDI) on units with high CDI rates

• Although the magnitude of their contribution is uncertain, asymptomatic carriers have a role in transmission

• Practical screening tests are not available • There may be a role for universal glove use as a

special approach to reducing transmission on units with longer lengths of stay and high endemic CDI rates

• Focus enhanced environmental cleaning strategies and avoid shared medical equipment on such units as well

Supplemental Prevention Strategies:

Environmental Cleaning• Bleach can kill spores, whereas other standard disinfectants cannot

• Limited data suggest cleaning with bleach (1:10 dilution prepared fresh daily) reduces C. difficile transmission

• Two before-after intervention studies demonstrated benefit of bleach cleaning in units with high endemic CDI rates

• Therefore, bleach may be most effective in reducing burden where CDI is highly endemic

Mayfield et al. Clin Infect Dis 2000;31:995-1000.

Wilcox et al. J Hosp Infect 2003;54:109-14.

Supplemental Prevention Strategies:

Environmental CleaningAssess adequacy of cleaning before changing

to new cleaning product such as bleach• Ensure that environmental cleaning is adequate and

high-touch surfaces are not being overlooked• One study using a fluorescent environmental marker to

asses cleaning showed:– only 47% of high-touch surfaces in 3 hospitals were cleaned – sustained improvement in cleaning of all objects, especially in

previously poorly cleaned objects, following educational interventions with the environmental services staff

• The use of environmental markers is a promising method to improve cleaning in hospitals.

Carling et al. Clin Infect Dis 2006;42:385-8.

Summary of Prevention Measures

• Contact Precautions for duration of illness

• Hand hygiene in compliance with CDC/WHO

• Cleaning and disinfection of equipment and environment

• Laboratory-based alert system

• CDI surveillance• Education

• Prolonged duration of Contact Precautions*

• Presumptive isolation • Evaluate and optimize

testing• Soap and water for HH

upon exiting CDI room• Universal glove use on

units with high CDI rates*• Bleach for environmental

disinfection• Antimicrobial stewardship

program

Core Measures Supplemental Measures

* Not included in CDC/HICPAC 2007 Guideline for Isolation Precautions

Measurement: Process Measures

• Core Measures:– Measure compliance with CDC/WHO

recommendations for hand hygiene and Contact Precautions

– Assess adherence to protocols and adequacy of environmental cleaning

• Supplemental Measures:– Intensify assessment of compliance with process

measures– Track use of antibiotics associated with CDI in a

facility

HAND HYGIENE MONITORING TOOLPatient Care Unit/Dept.:___________________________ Day of Week: ________ Date: Initials of Monitor: Time: ________AM/PM to __AM/PM Healthcare Worker (HCW) Type: Key: 1 = Physician 8 = Physical Medicine Staff HW = Hand Wash2A = House Officer 9 = Environmental Services Worker HA = Alcohol Hand Antiseptic2B= Medical Student 10 = Patient Transporter Y = Yes2C= PA 11 = Radiology Tech. N= No3 = Physician Support Staff 12 = Respiratory Therapist N/A = Not Applicable 4 = Nursing/Nursing Support 13 = Dietitian D = Bed closest to door5 = Continuing Care/Social Worker 14 = Traypasser W = Bed closest to window 6 = Pastoral Care 15 = Other

7 = IV Team

BED LOCATION () D W

D W

D W

D W

D W

D W

D W

D W

D W

D W

CONTACT PRECAUTIONS: Y, N, N/A

HEALTH CARE WORKER TYPE ()

OPPORTUNITY REQUIRING HANDHYGIENE INTERVENTION

Before Patient Contact

After Contact With Patient’s Skin

After Contact With Patient’s Gown/Linen

Strategies for LTC

2007 Isolation Precautions *

• Multidisciplinary HICPAC group

• Standard Precautions• Transmission-based

Precautions• Respiratory Hygiene

added• Safe injection practices

added• Term “nosocomial”

replaced by “healthcare-associated” infection

* http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf

2007 HICPAC Isolation Precautions*

• Administrative measures• MDRO education• Judicious use of antimicrobials• Surveillance• Infection Precautions• Environmental measures

*http://www.cdc.gov/ncidod/dhqp/gl_isolation.html

Standard Precautions• Previously called Universal Precautions

• Assumes blood and body fluid of ANY patient could be infectious

• Recommends PPE and other infection control practices to prevent transmission in any healthcare setting

• Decisions about PPE use determined by type of clinical interaction with patient

• Standard precautions INCLUDES Hand Hygiene

PPE for Standard Precautions (1)

• Gloves – Use when touching blood, body fluids, secretions, excretions, contaminated items; for touching mucus membranes and nonintact skin (remove before leaving the area)

• Gowns – Use during procedures and patient care activities when contact of clothing/ exposed skin with blood/body fluids, secretions, or excretions is anticipated

PPE for Standard Precautions (2)

• Mask and goggles or a face shield – Use during patient care activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions

PPE for Expanded Precautions

Expanded Precautions include Contact Precautions

Droplet Precautions

Airborne Infection Isolation

Modes of Transmission of Infectious Diseases:

– Contact: • Direct = germ transferred directly from patient to

caregiver; e.g. scabies • Indirect = transfer of germs via intermediate object or

person; e.g. caregiver picks up germs from contaminated surface and transfers to the patient

– Droplet: germ in droplets (> 5µ) produced from person with infection when they cough or sneeze; droplets only travel 3 feet; example: influenza

– Airborne: germ in droplet nuclei (< 5µ) that become airborne and can travel long distance and be inhaled deep into lung; example: TB

– Additional Modes: Common source vehicle = e.g. contaminated food item; Vectorborne = transmitted by insect; example: West Nile virus

Use of PPE for Expanded Precautions

Contact Precautions – Gown and gloves for contact with patient or environment of care (e.g., medical equipment, environmental surfaces)

In some instances these are required for entering patient’s environment

Droplet Precautions – Surgical masks within 3 feet of patient

Airborne Infection Isolation – Particulate respirator*

*Negative pressure isolation room also required

Visitors please check with nursesbefore entering room

STOPSTOPSTOPSTOP

Healthcare workers must do the following:

Gloves and gowns required for all direct patient contacts Mask required for direct resident contact Door may remain open Other instructions _______________

When leaving room: Remove all PPE (personal protective equipment)

Perform hand hygieneAlways follow Standard Precautions PLUS

Questions? Contact ___________________ ext.______

S A M P L E

Hand Hygiene

• Required for Standard and Expanded Precautions

• Perform…

Immediately after removing PPE

Between patient contacts

• Wash hands thoroughly with soap and water or use alcohol-based hand rub

Opportunities for

Hand Hygiene

Infection Control Precautions

• Hand Hygiene• Hand washing continued…

– Before and after contact with food, products for food preparation and before eating

– Following any contact with pets during animal assisted therapy or visitation and after contact with any pet care item

• Hand sanitizer– Before any direct patient contact

– After contact with resident’s skin

– After contact with body fluids, mucous membranes, and non-intact skin or dressing, provided hands are not visibly soiled

– After contact with inanimate objects in the care environment

Infection Control Precautions

• Hand Hygiene• Discourage use of artificial nails• Educate patient family and volunteers• Observe compliance

Infection Control Precautions

• Hand Hygiene– Written policy– Hand washing facilities, alcohol-based hand

sanitizer available– When to use each

• Hand washing– Anytime hands are visibly soiled– After toileting

Poor Adherence

• Time• Access• Understanding

CDC:HICPAC Management of Multi-drug-Resistant Organisms

• Routine measures• Enhanced measures

•Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006

MDRO Control Measures• Administrative support • Education • Judicious use of antimicrobial agents • MDRO surveillance

– Surveillance for MDROs isolated from routine clinical cultures • Antibiograms • MDRO Incidence Based on Clinical Culture Results • MDRO Infection Rates • Molecular typing of MDRO isolates

– Surveillance for MDROs by Detecting Asymptomatic Colonization • Infection Control Precautions

– Standard Precautions – Contact Precautions – Cohorting and other MDRO control strategies – Duration of Contact Precautions – Barriers used for contact with patients infected or colonized with MDROs – Impact of Contact Precautions on patient care and well-being

• Environmental measures • Decolonization

MDRO Infection Precautions

• Prioritize patient placement to single bed room and use of isolation, Expanded Precautions with given criteria, discontinue isolation when criteria met

• Observe compliance to Standard Precautions, report back to HCW

• Observe compliance to Hand Hygiene, visibly soiled, before and after patient contact, before performance of aseptic procedure, and after removing gloves

MDRO Environmental Measures

• Practices for cleaning /disinfecting are standardized for all areas -routine, isolation

• Standardized training– monitoring compliance• Environmental cleaning should focus on frequently

touched surfaces with contaminated hands• Sequence of cleaning: cleanest areas to dirtiest• Minimize dust accumulation• Use appropriate agent- following mftr rec.

– Amount– Dilution– CONTACT TIME

The Inanimate Environment Can Facilitate Transmission

~ 16/151 (10.6%) surfaces sampled where transfer via hands of HCW was documented ~

Duckro AN, et al. Arch Intern Med 2005;165:302-7

X represents VRE culture positive sites

Attention to the Environment• Frequently touched surfaces• Areas contaminated with feces• In an outbreak setting or in highly endemic units

use diluted 5.25-6.15% sodium hypochlorite diluted 1:10 for routine disinfection*

• EPA registered hypochlorite based disinfectant• Cleaning

– Pre-cleaning– Order of cleaning– Dilution, contact time

*Rutala, WA, 2005 http://disinfectionandsterilzation.org

Environmental Measures Con’t

• Laundry Avoid contact with body, clothing– No shaking/aerosolizing bedding Contain soiled laundry in a bin/bag segregate soiled from clean

• Patient care equipment– Cleaned according to mftr rec– Between patients– Dedicated to isolation rooms– Return to stock protocols

Facility

• Verify facility is using bleach – NOT quaternary ammonia

• Increase frequency of housekeeping• Stress importance of all items to disinfect• Observe housekeeping

– Fresh solution– Proper bleach concentration– Order of disinfection

Items to Disinfect• Faucets, toilet seats, sinks, light switches,

counter tops• Doorknobs, hand rails, elevator buttons,

washroom door plates• ANY commonly used item that multiple people

may come in contact with• Order of disinfection matters!

– “Start out and work in”

Surveillance

• Methods- Standardized, Definitions, Denominators– Whole-house limitations– Targeted, point prevalence– Device related– Combination– Based on high risk, high volume problem

areas

Surveillance

• Purpose– Improve quality and outcome of healthcare– Promote public health– Benchmarking

• NHSN- www.cdc.gov/ncidod/hip– NNIS– NaSH– DSN

Surveillance

• Data Collection– What

• System • Process• Outcome

– Identify sources• Lab reports• Unit reports• Pharmacy• observational

Surveillance

• Analysis• Reports

– Infection Control Committee– Quality Committee– Administrator – Medical Director– Director of Nursing– Unit– Front line personnel– Physicians

Surveillance

• Intervention of risk-reduction measure– Documented

• Evaluate effectiveness of intervention

• See Websites– http://www.cdc.gov/ncidod/hip/

http://www.cdc.gov/ncidod/hip/Guide/guide.htm

Patient Care Protocols

• Standardized processes for wound care– Aseptic/clean technique– covered

• Standardized processes for catheter care• Teach the patient/family members about

good hand hygiene– Especially after incontinence care for both care

provider and patient– Before they eat

Control of C. difficile

• In the healthcare facility:– Prompt diagnosis– Isolation precautions,

hand hygiene– Stop unneeded

antibiotics – Good environmental

cleaning• In the community:

– Avoid unnecessary antibiotic use

Future answers?

• Improve infection control • Avoid unnecessary antibiotics• Probiotics to restore the normal microbial

balance• Vaccine to produce protective antibody• Immune globulin for passive immunity• Non-antibiotic therapies like resins

Summary for Prevention in Healthcare

• Isolate patients with C. difficile in a private room, or cohorted• Attention to Hand Hygiene

– Soap and water– ABHR

• PPE• Dedicate equipment• Isolate as long as diarrhea is present• Individualized patient assessment is required• Conduct surveillance for CDI• Judicious use of antibiotics (clindamycin)• Early detection, isolation and treatment

Resources

• http://www.cdc.gov/HAI/pdfs/toolkits/CDItoolkitwhite_clearance_edits.pdf

• www.apic.org

• http://www.cdc.gov/hicpac/pubs.html

• www.who.int/patientsafety/en

• http://www.mi-marr.org/ (Long-Term Care Toolkit)

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

• Frequently asked questions document for healthcare providers

Additional resources

Dubberke et al. Infect Control Hosp Epidemiol 2008;29:S81-92.Abbett SK et al. Infect Control Hosp Epidemiol 2009;30:1062-9.

SHEA/IDSA Compendium of Recommendations CDI Checklist Example

Acknowledgements

• Dr. Richard Van Enk

• Dr Clifford McDonald