C. difficile Prevention Partnership Collaborative

1. C. difficile Prevention Partnership Collaborative Clostridium difficile Management in Healthcare Facilities January 19, 2012

2. Clostridium difficile Management in Healthcare Facilities Phenelle Segal, RN CIC Modification of Presentation by Gail Bennett, RN, MSN, CIC

3. Clostridium difficileInfection (CDI) - Objectives Describe the changing epidemiology of Clostridium difficile. State two differences between acute care and long term care in managing patients/residents with C. difficile infection. List three important strategies for preventing transmission of C. difficile within healthcare facilities.

4. Clostridium difficile Infection (CDI) Antibiotic induced diarrhea May cause approximately 30% of all cases of healthcare associated diarrhea Most common cause of acute infectious diarrhea in nursing homes Disease may be a nuisance or cause life threatening pseudomembranous colitis Increasing numbers of cases Cases tripled in US hospitals from 2000 until 2005 Increasing disease severity and mortality

5. 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 Background: Impact 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.

6. Clostridium difficile Colonization vs Infection • Colonization: presence of microorganisms without tissue invasion or damage, therefore no signs or symptoms • Colonization rate of C. difficile • About 10-25% of hospitalized patients • About 4-20% of long term care residents • Antibiotic therapy may disrupt normal colonic flora in colonized patients and C. difficile proliferates, producing toxins and symptomatic disease • Infection: presence of microorganisms with tissue invasion and damage, therefore signs or symptoms

7. Background: EpidemiologyRisk Factors Antimicrobial exposure Acquisition of C. difficile Advanced age Underlying illness Immunosuppression Tube feeds ? Gastric acid suppression Main modifiable risk factors

8. Antibiotics most often associated with Clostridium difficile • Ampicillin • Amoxicillin • Cephalosporins • Clindamycin • Fluoroquinolones

9. Testing for Clostridium difficile • Toxin testing • Quick – same day • Stool culture • Takes 48-96 hours • Testing for C. difficile should be done on unformed (liquid) stool only unless ileus is suspected

10. Treatment Options • Discontinue antibiotics if possible • Fluid and electrolyte replacement • Do not use antimotility agents (e.g. opiates) • Metronidazole (Flagyl) 250 mg QID or 500 mg TID for 10-14 days • Vancomycin 125 mg QID for 7-10 days - used if resident does not respond to or cannot take Flagyl; may be used first if severe disease • New drug: Dificid (Fidaxomicin) – 200 mg bid for 10 days • Experimental fecal transplant (enemas)

11. Recurrent Clostridium difficile infection Rates of recurrence • 20% after 1st episode • 45% after 1st recurrence • 65% after two or more recurrences

12. C. difficile in Acute vs. Non-acute Settings

13. Tiered Approach to Clostridium difficile Infection (CDI) Transmission Prevention • Basic/Core/Routine Approach: C. difficile transmission prevention activities during routine infection prevention and control responses • Enhanced/Supplemental/Heightened Approach: C. difficile transmission prevention activities during heightened infection prevention and control responses • Evidence of • ongoing transmission of C. difficile • an increase in CDI rates and/or • evidence of change in the pathogenesis of CDI (increased morbidity/mortality among CDI patients) despite routine preventive measures • Note: many facilities choose to use the enhanced/supplemental approach all of the time.

14. Infection Prevention Strategies Hand hygiene Contact precautions Identification of cases Environmental disinfection Appropriate use of antibiotics

15. For basic measures, may use alcohol handrubs with C. difficile – OR use soap and water Perform hand hygiene before contact with the patient/resident after removing gloves after contact with the environment Hand Hygiene for Clostridium difficile

16. Hand Hygiene – Soap vs. Alcohol gel • Alcohol not effective in eradicating C. difficile spores • However, one hospital study found that from 2000-2003, despite increasing use of alcohol hand rub, there was no concomitant increase in CDI rates • Discouraging alcohol gel use may undermine overall hand hygiene program with untoward consequences for HAIs in general Boyce et al. Infect Control Hosp Epidemiol 2006;27:479-83.

17. CDC adds: • Because alcohol does not kill Clostridium difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs. • However, early experimental data suggest that, even using soap and water, the removal of C. difficile spores is more challenging than the removal or inactivation of other common pathogens.

18. For enhanced measures, do not use alcohol handrubs with the CDI patient/resident – use soap and water Washing away the spores may be the optimal way to perform hand hygiene when transmission of C. difficile is occurring Many facilities choose to use the enhanced strategy all of the time Hand Hygiene for Clostridium difficile (continued)

19. Infection Prevention Strategies Hand hygiene Contact precautions Identification of cases Environmental disinfection Appropriate use of antibiotics

20. Contact Precautions Designed to reduce the risk of transmission of microorganisms by direct or indirect contact Direct contact skin-to-skin contact physical transfer (turning patients/residents, bathing patients, other patient/resident care activities) Indirect contact Contaminated objects Equipment Linens High touch surfaces

21. Patient or Resident placement Private room preferred 2nd option: Cohorting with other patient/resident with C. difficile 3rd option: In LTCFs, consider infectiousness and resident-specific risk factors to determine rooming with a low risk roommate and socializing outside the room Consider: Clean Contained Cooperative Cognitive Patient care equipment dedicated to single patient/resident if possible. If not, disinfect equipment prior to leaving the room. Contact Precautions

22. Tiered Approach for Contact Precautions: Basic • Contact Precautions - gloves and gowns to enter room or cubicle • Do not re-use gowns • Supplies outside the room

23. Tiered Approach for Contact Precautions: Basic (continued) • In semi-private room, keep cubicle curtain drawn to limit movement between cubicles and as a reminder of precautions

24. Contact Precautions: Basic (Continued) • Use dedicated equipment; if not feasible – decontaminate prior to use on another patient/resident • Maintain adequate supplies for contact precautions • Do not isolate asymptomatic carriers

25. Contact Precautions: Basic (Continued) • May discontinue precautions when diarrhea ceases (may consider 48 hours without loose stool) • Do not do a toxin “for cure” once diarrhea has stopped • Lab should not accept stool for toxin if the stool is formed

26. From the Horse’s Mouth: CDC’s Web Site After treatment, repeat C. difficile testing is not recommended if the patient’s symptoms have resolved, as patients may remain colonized. http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html

27. Tiered Approach for Contact Precautions: Enhanced May consider alternative signage to ensure staff awareness Evaluate current system for patient/resident placement Consider contact precautions for all patients/residents that develop diarrhea until CDI is ruled out Increase monitoring of isolation precautions and hand hygiene Extend use of contact precautions even when diarrhea stops 27

28. Why contact precautions for C. difficile?? Environmental contamination

29. The Inanimate Environment Can Facilitate Transmission Xrepresents VRE culture positive sites ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

30. Signage for Precautions

31. Infection Prevention Strategies Hand hygiene Contact precautions Identification of cases Environmental disinfection Appropriate use of antibiotics

32. Identification of Cases Colonization or asymptomatic fecal carriage of C. difficile • May be common in healthcare facilities • Do we care? C. difficile infection • Acute diarrhea

33. CDI Collaborative Definition • A case of C. difficile is defined as a case with the symptom of diarrhea without other known etiology • The stool sample will yield a positive result for laboratory assay for C. difficile toxin A and/or B • For this collaborative, CDI is limited to lab confirmed cases • Will track healthcare associated CDI

34. CDI Collaborative Definition of Healthcare Associated • This collaborative will track laboratory confirmed cases of Health Care Facility C. difficile. • A laboratory confirmed case of C. difficile is defined as a patient with diarrhea characterized by unformed stool, without other known etiology, and associated with a positive laboratory assay for C. difficile toxin A and/or B on the stool. • Count each case of CDI only once • Recurrent CDI: Episode of CDI that occurs eight weeks or less after the onset of a previous episode, provided the symptoms from the prior episode resolved.

35. Definition (continued) HAI-CDI (INDEX FACILITY) • A patient classified as having a case of healthcare facility associated C. difficileattributable to YOUR facility is defined as a patient who develops diarrhea on or after the 4th day of admission. • OR • A patient classified as having any symptoms that develop on or before the 4th day after your discharge to another healthcare facility. • OR • A patient discharged to home with lab confirmed C.diff.within 28 days from the day of discharge and no intervening admissions. (Day of discharge counts as day 1) Also counts if C.diff is identified on readmission to your facility within that 28 day period.

36. Definition (continued) HAI-CDI (OTHER FACILITY) • A patient classified as having a case of healthcare facility associated C. difficileattributable to another health care facility is defined as a patient who develops diarrhea before the 4th day of admission • after transfer from another health care facility OR: • within 28 days of discharge from another health care facility

37. 48 hours - example • Admission = day 1 – Monday • Day 2- Tuesday • Day 3- Wednesday • Day 4- Thursday at 12:01 a.m. is the cutoff. After Thursday at 12:01, it counts for your facility. Prior to that time, it is considered “community acquired” which includes any location other than your facility. • Exception – home care – 28 days

38. Facility Healthcare Associated CDI Rate • # of HA CDI cases divided by patient/resident days X 10,000 = ___ HA CDI per 10,000 patient/resident days Example: • 3 cases HA CDI divided by 3,585 patient/resident days = .0008368 X 10,000 =8.368 or 8.4 cases of HA CDI per 10,000 patient/resident days

40. Identification of Cases Basic Strategy: With cases of diarrhea, consider C. difficile Take a detailed history for risk factors Norovirus, dietary changes, medications, and other things may also be causes of diarrhea Notify physician Watch for dehydration

41. Identification of Cases Enhanced Strategy: Automatic contact precautions for all patients/residents with orders for C. difficile labs AND for all patients/residents with a known history of CDI Consider allowing nurses to initiate the lab order and contact precautions Consider universal glove usage on units that have a high incidence/rate of CDI

42. Infection Prevention Strategies • Contact precautions • Hand hygiene • Identification of cases • Environmental disinfection • Appropriate use of antibiotics

43. Environmental Survival and Contamination • Vegetative form survives for only 15 minutes on dry surfaces in room air • May remain viable up to 6 hours on moist surfaces • Spores are highly resistant to drying, heat, and chemical and physical agents • Can exist for five months on hard surfaces • One study (McFarland et al, 1989) found spores in: • 49% of rooms occupied with CDI • 29% in rooms of asymptomatic carriers

44. Environmental Survival and Contamination (continued) • Heaviest contamination on floors and in bathrooms but ALL surfaces have the ability to be contaminated • Spores have been isolated from the air and aerosol dissemination may, in part, account for widespread environmental contamination • The frequency of positive personnel hand culture has been strongly correlated with the intensity of environmental contamination

45. Evidence of the role of environmental transmission • Frequency of C. difficile acquisition has been linked with the level of environmental contamination • Patients admitted to a room previously occupied by a patient with C. difficile have a higher risk for C. difficile acquisition • Improved room disinfection has led to decreased rates of C. difficile infection • Monitor environmental cleaning

46. Basic: Use EPA approved germicide for routine disinfection during non-outbreak situations Ensure staff training and contact time Disinfect shared items between patients/residents Enhanced: Use 10% sodium hypochlorite (bleach) for disinfecting room and equipment (or use EPA registered sporicidal agent) In outbreak, consider bleach solution for cleaning all rooms Use bleach wipes as an adjunct to cleaning Environmental Disinfection: Tiered Approach

47. Disinfectants • Commonly used disinfectants are not sporicidal • Some may actually encourage sporulation (the changing of the organism to the spore state) • Sporicidal disinfectants: • Chlorine-based disinfectants • High-concentration, vaporized hydrogen peroxide • Recently approved EPA registered disinfectants that kill C. diff spores

48. Disinfectants • Chlorine-based disinfectants - disadvantages: • Can be corrosive to equipment or surfaces over time • Can cause respiratory or other health problems in workers using them • May cause bleaching/fading • Reconstituted product needs to be made fresh daily • APIC states use of chlorine-based disinfectants should be limited to outbreak situations and when high rates of CDI have been documented • In these situations (outbreaks and/or high rates), chlorine-based products have demonstrated benefit when used with other control measures

49. Pre-mixed Hypochlorite Solution: Advantages and Disadvantages • Advantages: • Commercially available solutions include detergent base • Cleaning as well as disinfection • Eliminates dilution errors • Disadvantages of pre-mixed solutions: • Solutions expire over time • May be hard to store • May be more costly

50. Bleach and water: mixing your own solution • Cleaning and disinfection is a two-step process (must clean first, then disinfect) • Contact time of ten minutes required for disinfection (Rutala, 2008) • Thorough wetting of the surface, allowed to air dry • Note: pre-mixed EPA registered hypochlorite solutions provide cleaning and disinfection in one step