Kansas HEN 2.0 Collaborative Meeting November 18, 2015 Reducing - PDF document

Kansas HEN 2.0 Collaborative Meeting November 18, 2015 Reducing Clostridium Difficile and Improving Antimicrobial Stewardship WHAT’S THE POOP…MMM...SCOOP?! Cheryl Ruble, MS, RN CNS Improvement Advisor, Cynosure Health 1 2014 Silver Award Recipient Objectives Discuss the changing epidemiology of Clostridium Difficile Infection (CDI) in the US Discuss current strategies to prevent CDI Describe two specific strategies to reduce transmission of C. difficile in the healthcare setting Discuss tracking CDI, data collection & submission 2014 Silver Award Recipient 3 2014 Silver Award Recipient 1

Kansas HEN 2.0 Collaborative Meeting November 18, 2015 C Diff and Antibiotic Stewardship 2014 Silver Award Recipient Background • 2 ‐ 5% of healthy adults have C. difficile colonization of the colon • 20 ‐ 40% of hospitalized adults are colonized with C. difficile 2014 Silver Award Recipient C. Difficile Infection (CDI) • Range from mild to severe • Incidence and severity have increased with dissemination of BI/NAP1 isolates – Historically uncommon – epidemic since 2000 – Increased virulence • Increased toxin A and B production • Polymorphisms in binding domain of toxin B • Increased sporulation – Increased resistance to fluoroquinolones • Higher MICs compared to historic strains and current non ‐ BI/NAP1 strains – Early diagnosis and treatment are required to reduce morbidity/mortality McDonald et al. N Engl J Med. 2005;353:2433 ‐ 41; Warny et al. Lancet. 2005;366:1079 ‐ 84 Stabler et al. J Med Micro. 2008;57:771–5; Akerlund et al. J Clin Microbiol. 2008;46:1530–3 2014 Silver Award Recipient 2

Kansas HEN 2.0 Collaborative Meeting November 18, 2015 Cost of CDI in US • 336,000 hospitalizations annually • Aggregate hospital costs exceed $8.2 billion annually • Patients with principal CDI diagnosis remain hospitalized for 6.9 days at a cost of $10,100/stay – Patients with secondary CDI diagnosis remain hospitalized for 16.0 days at a cost of $31,500/stay. • CDI disproportionately affects the elderly – CMS pays for 68% of CDI hospital stays Lucado J, Gould C, Elixhauser A. Clostridium difficile infections (CDI) in hospital stays, 2009. HCUP Statistical Brief124. January 2012. Rockville, MD: Agency for Healthcare Research and Quality. http://www.hcup ‐ us.ahrq.gov/reports/statbriefs/sb124.pdf. Accessed December 27, 2011. 2014 Silver Award Recipient C. difficile Hospital Epidemiology • Use of antibiotics is frequent • Environmental contamination by C. difficile is common – Spores are difficult to eradicate • Personnel carry C. difficile on their hands • Asymptomatic patients carry C. difficile 2014 Silver Award Recipient Rise in CDI in hospitalized US patients • Retrospective analysis of 2.2 million adult patients discharged from US hospitals from 2001 ‐ 2010 • ICD ‐ 9 ‐ CM code for CDI • CDI was associated with significant resource use • 66% of patients were admitted emergently • >50% had a concomitant infectious diagnosis Reveles KR, Lee GC, Boyd NK, Frei CR. The rise in Clostridium difficile infection incidence among hospitalized adults in the United States: 2001 ‐ 2010. AJIC 42 (2014);1028 ‐ 12 2014 Silver Award Recipient 3

Kansas HEN 2.0 Collaborative Meeting November 18, 2015 Clostridium difficile infection • Incidence of CDI in hospitalized adults in US nearly doubled from 2001 ‐ 2010 • 4.5 CDI discharges /1,000 discharges in 2001 • 8.2 CDI discharges/1,000 discharges in 2010 • Death occurs in approximately 9% of hospitalized patients with CDI • Mean cost per hospital stay is $24,400 Reveles KR, Lee GC, Boyd NK, Frei CR. The rise in Clostridium difficile infection incidence among hospitalized adults in the United States: 2001 ‐ 2010. AJIC 42 (2014);1028 ‐ 12 2014 Silver Award Recipient Who/what may transmit C. diff in Hospital? 1. Symptomatic patients 2. Asymptomatic patients 3. Healthcare workers 4. Environment 2014 Silver Award Recipient CDI Risk Factors • Antimicrobial exposure • Acquisition of C. difficile • Advanced age • Underlying illness • Immunosuppression • Tube feeds • ? Gastric acid suppression 2014 Silver Award Recipient 4

Kansas HEN 2.0 Collaborative Meeting November 18, 2015 Patient related factors • Advancing age • >65 significantly higher risk • Immunity changes • Antibiotic exposure • Other medications e.g. gastric ‐ acid suppressants • Comorbid illness • Frequent hospitalizations 2014 Silver Award Recipient Silver tsunami • In 2000, persons >65 represent 13% of the US population • By 2030, this population will grow to be 19% of the US population 2014 Silver Award Recipient Antimicrobial use Most important risk factor Clindamycin, fluoroquinolones and cephalosporins 2014 Silver Award Recipient 5

Kansas HEN 2.0 Collaborative Meeting November 18, 2015 Changing molecular epidemiology • Emergent strain BI/NAP1/027 • Severe outbreaks in Europe, Canada and US • Prolonged toxin production, increased duration of germination and increased sporulation 2014 Silver Award Recipient Clostridium difficile primer • Gram positive, spore forming rod • Obligate anaerobe • Toxin A and Toxin B • Required to cause disease • Clostridium difficile infection (CDI, formerly CDAD) • Most common cause of healthcare ‐ associated diarrhea • Fecal ‐ oral transmission • Is also community ‐ associated 2014 Silver Award Recipient Pathogenesis of CDI 2014 Silver Award Recipient 6

Kansas HEN 2.0 Collaborative Meeting November 18, 2015 Putting a face on CDI 2014 Silver Award Recipient Got Data? • Baseline? – 2010 – 3 rd quarter 2015 • Tracking… 2014 Silver Award Recipient CDI Risk Factors Major modifiable risk factors • Antimicrobial exposure • Acquisition of C. difficile • Advanced age • Underlying illness • Immunosuppression • Tube feeds • ? Gastric acid suppression 2014 Silver Award Recipient 7

Kansas HEN 2.0 Collaborative Meeting November 18, 2015 Major Modifiable Risk Factors 2014 Silver Award Recipient Major Modifiable Risk Factors Antibiotic Exposure Acquisition of C. difficile Antibiotic Stewardship Optimizing Environmental Cleaning and Hand Hygiene 2014 Silver Award Recipient Major Modifiable Risk Factors Acquisition of C. difficile Antibiotic Exposure 2014 Silver Award Recipient 8

Kansas HEN 2.0 Collaborative Meeting November 18, 2015 Tips on prevention of transmission Early Recognition Early Precautions Hand Hygiene Environmental Cleaning 2014 Silver Award Recipient Early Recognition: screening for CDI 2014 Silver Award Recipient Is it Mine or Yours? 2014 Silver Award Recipient 9

Kansas HEN 2.0 Collaborative Meeting November 18, 2015 Lab Tests for CDI • 2014: NHSN requires reporting type of test used at your facility for CDI reporting • PCR=90% sensitive, 96% specific • EIA significantly lower for detection FV Tenover, JCM 48:3719, 2010 28 2014 Silver Award Recipient How to optimize specimen collection Charts Tarts 2014 Silver Award Recipient If it ain’t loose….it’s of no use 2014 Silver Award Recipient 10

Kansas HEN 2.0 Collaborative Meeting November 18, 2015 If the sticks stand, the tests are banned 2014 Silver Award Recipient 32 SHEA ‐ IDSA Guideline: CDI Case Definition • Diarrhea ( ≥ 3 loose stools in 24 hours) • Stool test positive for Clostridium difficile toxin or toxigenic Clostridium difficile OR Colonoscopic evidence of pseudomembranous colitis Cohen SH et al. Clin Infect Dis. 2010;31(5):431 ‐ 455 . 2014 Silver Award Recipient 11

Kansas HEN 2.0 Collaborative Meeting November 18, 2015 SHEA/IDSA Compendium • Perform testing on unformed stool • Do not test asymptomatic patients or for “test of cure” • Stool culture is most sensitive test • Toxigenic culture is the gold standard for CDI testing • EIA is suboptimal for diagnostic testing • GDH followed by cell cytotoxicity or toxigenic culture is a potential option for testing (2 ‐ step procedure) • rtPCR may be the optimal test ‐ more data needed • Repeat testing is of limited value SH Cohen et al, ICHE 31:431 ‐ 55, 2010 34 2014 Silver Award Recipient Tips on prevention of transmission Early Recognition Early Precautions Hand Hygiene Environmental Cleaning 2014 Silver Award Recipient Contact Precautions Core Supplemental Gloves/gowns on room entry Extend use of Contact • • Precautions beyond duration of Private room (preferred) or cohort • diarrhea (hospitalization) with dedicated commodes Presumptive isolation Dedicated equipment • • Universal glove use on units Maintain for duration of diarrhea • • with high CDI rates Measure compliance • Intensify assessment of • compliance 2014 Silver Award Recipient 12

Kansas HEN 2.0 Collaborative Meeting November 18, 2015 Tips on prevention of transmission 2014 Silver Award Recipient Special Contact Precautions 2014 Silver Award Recipient CONTACT PLUS Precautions CONTACT • Floor PLUS “STOP” sign decal Signage • Filled with Yellow gowns, Caddy gloves 2014 Silver Award Recipient 13

Kansas HEN 2.0 Collaborative Meeting November 18, 2015 Safe Zone 2014 Silver Award Recipient Tips on prevention of transmission Early Recognition Early Precautions Hand Hygiene Environmental Cleaning 2014 Silver Award Recipient Hand Hygiene Core Supplemental Hand hygiene based on CDC Soap and water for hand • • or WHO guidelines hygiene before exiting room of a patient with CDI Soap and water preferentially • in outbreak or hyper Intensify assessment of • endemic settings compliance Measure compliance • 2014 Silver Award Recipient 14