2013 CLOSTRIDIUM DIFFICILE EDUCATIONAL AND CONSENSUS CONFERENCE

March 11-12, 2013

Overview

Changing Epidemiology More community acquired, role of asymptomatic

carriers New treatments and therapies Antibiotic Stewardship- effectiveness Testing methods Control Strategies

Enhanced precautions, duration of precautions, significance of shedding, asymptomatic colonization source for contamination of environment

Environmental Cleaning Increase in monitoring, new technologies- UV lights,

vaporized hydrogen peroxide Public Reporting- Government Focus

Changing Epidemiology

BI/NAP1/027 strain now found in 30%-40% of CDI cases in North America. Lower cure rate, higher recurrence rate

North American CDI incidence is stable to increasing while EU and UK rates have declined

More community associated infections

Treatment and Prevention

Fidaxomicin is the first new antibiotic CDI treatment in 25 years. Recurrence rate 12.8% vs. 25.3% with vanco

(Cornely et al. Lancet ID 2012; 12: 281-9.)

Primary prevention of CDI is coming: Vaccines (3 vaccines in clinical trials- phase 1

and phase 2) Immunologics (monoclonal antibodies in phase

3) Biotherapies (fecal transplants and non-

toxogenic C. diff colonization – phase 2).

Enhanced Environmental Cleaning Monitoring cleanliness- ATP, fluorescent

gel markers UV Lights

Expensive Depending on room configuration can take

20 minutes to kill C. diff spores Vaporized Hydrogen Peroxide

Expensive Cycling time can be as long as 2-3 hours

Hospital Transmission

Public Reporting- SIR

SIR risk adjusted based on these variables.

Both the diagnostic testing method and prevalence on admission (CA cases) found to help predict number of expected HA CDI cases.

APIC Pace of Progress Survey

January 14-28th, 2013 1,087 APIC members responded- 78%

acute care, 45% >200 beds. Since last CDI survey in 2010:

70% have added more interventions, but only 42% have seen a decline in HA-CDI rates.

42% keep patients in isolation until discharge

77% soap and water hand washing only

APIC Pace of Progress Survey

55% use ATP or fluorescing products to monitor environmental cleaning

67% use bleach for all daily and terminal cleaning of CDI rooms Only 9% use bleach for all rooms at all times 7% use UV lights, 1% use vaporized hydrogen

peroxide

60% have an antibiotic stewardship program

50% have initiated patient education programs

Current CDI prevention measures effective for high CDI incidence Additional research needed in order to drive

incidence much below 4-6 infections per 10,000 pt days.

2013 APIC Guide to Preventing C. diff Outlines a tiered approach to CDI

transmission prevention: routine and heightened.

Moving from the routine tier to the heightened tier does not mean all of the heightened activities need to be added.

Recommended to move to the heightened tier when there is evidence of ongoing transmission of CDI, an increase in CDI rates, and/or a change in the pathogenesis of CDI.

Heightened Tier

Perform daily rounds to identify patients with diarrhea (that may be related to CDI)- isolate immediately.

Consider placing all patients with diarrhea into CP until can rule out CDI.

Consider CDI specific sign- bleach use Strict hand washing (soap and water) only

Increase monitoring of compliance with CP and hand hygiene

Heightened Tier

Continue CP even when diarrhea has resolved- consider extending to discharge.

Use bleach for disinfection of patient’s room and equipment used in room Use bleach daily and at discharge for CDI

patients With continued CDI rates, consider expanding

house wide . Monitor and enforce adherence to cleaning

and disinfection process. Consider use of other technologies: UV

lights, vaporized hydrogen peroxide.

Heightened Tier

Create an Antibiotic Stewardship Program (ASP)

Patient hand hygiene- education and access

Feedback of rates to staff and administration- make everyone aware