The colossal impact of clostridium difficile infection
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CME lecture on Clostridium Difficle Infection
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The colossal impact of clostridium difficile infection
- 1. The Colossal Impact of Clostridium Difficile Infection
- 5. Introduction & Epidemiology Health officials now rank C. diff on par with MRSA as one of the top two infections acquired in hospitals.
- 6. • Decreasing Prevalence of CDI at the NAH since the launch of : * Antimicrobial Stewardship Program, * Switch over to PCR- Lab testing & * Tighter Infection Control measures National average is 7%–26% among adult inpatients in acute care facilities Courtesy: Syed Ali, Laboratory Director Debbie Graham, Infection Control Jillian Baranggay, Quality Improvement
- 7. Case Definition of CDI
- 8. Measurement: Outcome Categorize Cases by location and time of onset† Admission Discharge < 4 weeks 4-12 weeks HO CO-HCFA Indeterminate CA-CDI Time 2 d > 12 weeks * HO: Hospital (Healthcare)-Onset CO-HCFA: Community-Onset , Healthcare Facility-Associated CA: Community -Associated * Depending upon whether patient was discharged within previous 4 weeks, CO-HCFA vs. CA † Onset defined in NHSN LabID Event by specimen collection date Modified from CDAD Surveillance Working Group. Infect Control Hosp Epidemiol 2007;28:140-5. Day 1 Day 4 Standardized Case Definitions for Surveillance
- 9. Sunenshine et al. Cleve Clin J Med. 2006;73:187-97. Pathogenesis of CDI 4. Toxin A & B Production leads to colon damage +/- pseudomembrane 1. Ingestion of spores transmitted from other patients via the hands of healthcare personnel and environment 2. Germination into growing (Vegetative) Form) 3. Altered lower intestine flora (due to antimicrobial use) allows proliferation of C. difficile in colon
- 10. Risk Factors of CDI
- 11. Risk Factors of CDI
- 12. Changing Epidemiology of CDI CA-CDAD (NAP1/BI/027-The Hypervirulent strain) NAP1
- 13. C. diff’ Detectives Track a Murderous Global Microbe
- 14. Routes of Transmission Epidemiology of Colonization and Infection
- 17. Diagnosis What is the Best Testing Strategy to Diagnose CDI
- 18. Diagnosis What is the Best Testing Strategy to Diagnose CDI
- 19. Diagnosis Specimen Collection and Transport
- 20. Diagnosis of CDI
- 21. Diagnosis of CDI
- 23. CT Findings •bowel wall thickening (most common) •CT equivalent to thumbprinting •accordion sign •shaggy mucosal outline •pericolic stranding •peritoneal free fluid •although typically the whole colon is involved, the right colon and transverse colon may be affected in isolation in up to 5% of cases 2 •rectal involvement in the vast majority of cases (90-95%) Management of CDI
- 24. Treatment of CDI Surgical options
- 26. Oral Vancomycin Taper In managing multiple relapsers. It consists of 125 mg four times daily for 14 days, then 125 mg bid. for 7 days, 125 mg once daily for 7 days, 125 mg once every other day for 8 days, and finally 125 mg once every 3 days for 15 days.
- 27. Cost Comparison
- 28. Additional & Adjuvant Therapy • Fidaxomicin • Rifaximin or Rifampin- • Nitazoxanide • Monoclonal antibodies- • Intravenous immune globulin (IVIG)
- 29. Treatment of Recurrent CDI Fecal Microbiota Transplant (FMT)
- 31. Infection Control and Prevention Surveillance & Tracking
- 32. Core Prevention Strategies http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html Dubberke et al. Infect Control Hosp Epidemiol 2008;29:S81-92.
- 33. Prevention Strategies: Supplemental C. difficile can survive on a dry surface for 60 days. Alcohol-based hand sanitizers (Purell)- Do Not kill C.Diff spores
- 34. Infection Control = Antimicrobial Control
- 35. Antimicrobial Stewardship Program NorwegianAmericanHospital Implement Evidence-Based Practices to Prevent Emergence & Improve Management of C. Difficile Infection
- 36. Antibiogram
- 37. 1% 6% 2% 5% 27% 58% 1% Discontinue Redundant Coverage Add Appropriate Cover for Culture Narrow Spectrum of Activity Discontinued with Antibiotic Prescription IV to PO Switch Made Dosing Changed ID Consult Suggested Antimicrobial Stewardship Interventions Performed Antimicrobial Stewardship Intervention Acceptance Rates 94% 6% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Annual Totals Recommended Interventions Performed Recommended Interventions not Performed Courtesy: Charlene Hope., Pharm D, Maali Haleh., Pharm D and P&T Dept.
- 38. Days of Doses Dispensed Continuation of Therapy Courtesy: Charlene Hope., Pharm D, Maali Haleh., Pharm D and P&T Dept.
- 39. Improvement in the Treatment of Clostridium Difficile Infection Issues Identified • Lab • Pharmacy • Physicians Interventions Implemented • Lab • Pharmacy • Physicians
- 42. References http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html http://www.uptodate.com/contents/clostridium-difficile-in-adults-treatment http://jama.jamanetwork.com/article.aspx?articleid=1916296 http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0105454 Special Thanks To: Infection Control, Quality Improvement, Laboratory & Pharmacy departments at NAH
Editor's Notes
- These are the currently recommended surveillance definitions for CDI, illustrated by a time line based on the time of symptom onset. The first white arrow shows the day of admission (Day #1). If the symptom onset occurs > 2 calendar days after the day of admission (i.e., on hospital day #4) the case-patient is categorized as hospital-onset (HO), as shown here in light orange. If the symptom onset occurs less than 4 weeks after discharge from the study facility, the case-patient is categorized as community-onset, healthcare facility-associated or CO-HCFA, as shown in yellow. From 4-12 weeks, the case-patient is categorized as indeterminate, as shown in light blue, and if > 12 weeks, community-associated or CA, as shown in dark orange.
- Acquisition of C. difficile occurs by oral ingestion of spores, which resist the acidity of the stomach and germinate into the vegetative form in the small intestine. Disruption of the commensal flora of the colon, typically through exposure to antimicrobials, allows C. difficile to proliferate and produce toxins that lead to colitis. The primary toxins produced are toxins A and B, two large exotoxins that cause inflammation and mucosal damage. Recent evidence suggests that Toxin B is the major toxin responsible for virulence.
- Tissue culture cytotoxicity assay detects toxin B only. This assay requires technical expertise to perform, is costly, and requires 24-48 hr for a final result.