Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship C difficile – What’s New? Linda R.Greene,RN,MPS,CIC,FAPIC linda_greene@urmc.rochester.edu Manager, Infection Prevention UR Highland Hospital Rochester, NY linda_greene@urmc.rochester . edu Objectives Describe the incidence of C difficile in the US Review epidemiology and pathogenesis of C. difficile Discuss recent literature to risk factors and prevention strategies Mission to Care FHA HIIN 1
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Burden of C. difficile in the US Estimated that C. difficile caused approximately 453,000 incident infections and was associated with approximately 29,000 deaths in the United States in 2011 on the basis of data from active population- and laboratory-based surveillance across diverse geographic locations in the United States Only an estimated 24% of cases occurred in hospital settings Mission to Care FHA HIIN 2
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship C difficile Of the estimated community onset cases 82% were estimated to be associated with outpatient health care exposure Acquiring C difficile swallow spore or vegetative form (stomach acid does not kill) small intestine vegetative form large intestine disease happens if normal flora disrupted toxins released inflammation Mission to Care FHA HIIN 3
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Pseudomembranous colitis An inflammatory process that can lead to formation of pseudo membranes; a mixture of inflammatory cells, fibrin, bacteria and cellular components, which exude from the bowel mucosa. Normal flora Ingested interrupted Pseudomembrane C Difficile Small Intestine toxins Spores Germinate monocytes Neutrophils C difficile reproduces in the intestinal crypts, releasing toxins A and B, causing Toxin A attracts neutrophils and severe inflammation. monocytes, and toxin B degrades Mucous and cellular the colonic epithelial cells, both debrisare expelled, leading to colitis, pseudomembrane leading to the formation of formation, and watery diarrhea pseudomembranes Mission to Care FHA HIIN 4
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Toxic megacolon Toxic megacolon is characterized by extreme inflammation and distention of the colon. Common symptoms are pain, distention of the abdomen, fever, rapid heart rate, and dehydration. This is a life-threatening complication that requires immediate medical treatment. Mission to Care FHA HIIN 5
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Transmission C diff is shed in feces The transmission is fecal -> oral C. diff spores can live for months on contaminated surfaces. Prevention Judicious use of antibiotics Mission to Care FHA HIIN 6
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Risk Factors Conclusions: • The risk of HA-CDI remains greatest for cephalosporins and clindamycin, and their importance as inciting agents should not be minimized. • The importance of fluoroquinolones should not be overemphasized, particularly if fluoroquinolone-resistant epidemic strains of C. difficile are absent. Mission to Care FHA HIIN 7
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Other Risk Factors C difficile occurrence could increase with moderate to high opioid administration ( delayed passage of intestinal contents allows closer contact with the mucosa and increases chance of infection) Corticosteroid use – 1.5 to 3 fold increase Other Risk Factors Chemotherapy hypothesized mechanisms 1. Alteration in intestinal flora 2. Previous infection with c dif prior to therapy 3. Increased use of antibiotics 4. Increased colonic mucosa damage 5. Reduction in repair capabilities of mucosal epithelium Mission to Care FHA HIIN 8
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Background/Aims: Researchers reviewed PPI use compared to H2RA for stress ulcer prophylaxis • Proton pump inhibitors (PPIs) reduce the production of acid by blocking the enzyme in the wall of the stomach that produces acid. Acid is necessary for the formation of most ulcers . Trade name Nexium • H2 antagonists ( H2RA ) competitively inhibits histamine at the H2 receptors and leads to a reduction in secretion of gastric acid. Trade names Zantac, Pepcid etc. Continued Methods: Identified 12 studies that reported the hospital-acquired CDI occurrence following H2RA and PPI use for the prevention and treatment of stress gastric ulcers Findings : Results: A total of 74,132 patients from 12 observational studies were analyzed. Compared to H2RAs, PPIs increased the risk of CDI by 38.6% Conclusions: The use of PPIs for both the prevention and treatment of stress ulcers was associated with a 38.6% increased risk of hospital-acquired CDI occurrence compared to H2RA use. Mission to Care FHA HIIN 9
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Test Useful for epidemiologic studies • Molecular tests are increasingly used to diagnose C difficile infection (CDI), • Many molecular test-positive patients lack toxins that historically defined disease, • Sometimes unclear if patients need treatment Mission to Care FHA HIIN 10
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Study Prospective observational cohort study Single academic medical center 1416 hospitalized adults tested for C difficile toxins 72 hours or longer after admission between December 1, 2010, and October 20, 2012 Test included both toxin and PCR Conclusion Among hospitalized adults with suspected CDI, virtually all CDI-related complications and deaths occurred in patients with positive toxin immunoassay Patients with a positive molecular test result and a negative toxin immunoassay test result had outcomes that were comparable to patients without C difficile by either method Over reliance on molecular tests may result in over diagnosis, over treatment and increased cost Mission to Care FHA HIIN 11
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Review C difficile toxin- If tests for C. difficile and C. difficile toxin are positive, it is likely that the person's diarrhea and related symptoms are due to the presence of toxin- producing C. difficile GDH -This test detects an antigen that is produced in high amounts by C. difficile , both toxin and non-toxin producing strains. It is considered to be very sensitive, but it is not very specific for toxin-producing C. difficile . This test indicates if C. difficile is present but the bacteria May not be producing toxins. Mission to Care FHA HIIN 12
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Study Continued Twenty-one percent (293 of 1416) of hospitalized adults tested for C difficile were positive by PCR 44.7% (131 of 293) had toxins detected by the clinical toxin test Baseline Tox −/PCR+ patients had lower C difficile bacterial load and less antibiotic exposure, fecal inflammation, and diarrhea than Tox+/PCR+ patients ( P < .001 for all Findings Patients with a positive PCR but negative toxin EIA had a significantly lower 14-day all-cause mortality (11%) than patients with a positive PCR and positive toxin EIA test P = 0.01 A positive toxin EIA test was a significant independent predictor of death odds ratio (OR): 4.7 P = 0.01 and prolonged diarrhea (OR: 8.6 P < 0.001), but a positive PCR (given positive GDH EIA) was not. Mission to Care FHA HIIN 13
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Conclusions TOXIN- PCR + : Questionable Results What is the take home message here? Implications for clinical practice: Testing Guidelines Do not over test Future Directions Mission to Care FHA HIIN 14
Chasing Zero Infections - Connecting the Dots to Thursday, May 25, 2017 Reduce Patient Harm: Hot Topics in Infection Prevention and Stewardship Control Transmission 2 Strategies were independently weighted as being independent statistically Significant interventions 1. Hand Hygiene 2. Pre-emptive isolation when patients have diarrhea and suspected C. difficile Mission to Care FHA HIIN 15
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