c. difficile 2013 - sagelink.ca · • pidac best practice document nov 2007 for management of c....
TRANSCRIPT
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C. Difficile Primer for Primary Care and LTC facilities
Dr Diane Lu and Dr Kieran MooreKFLA Public HealthJanuary 8, 2013
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Disclosure• No funding from pharmaceutical industry• Do not knowingly own shares in Pharmaceutical industry‐Mutual Funds
• The findings and conclusions represent those of the presenter and may not necessarily represent the official position of Public Health Ontario, KFLA Public Health or of the MOH LTC
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Objectives‐Novice to PRO• Understand trends in C. Difficile and become a PRO
• Prevention• Recognition of Cases, Response, Risk assessment in routine practice‐SHEAR
• Optimal Management
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Agent: Gram Positive Spore forming anaerobe...perfringens, botulinum,tetany
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C Diff Seasonality‐IATROGENIC
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NAP 1 toxin production
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Outbreak?
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ELISA• Assessment of the A and B toxins by enzyme‐linked immunosorbent assay (ELISA) for toxin A or B (or both) has a sensitivity of 63–99% and a specificity of 93–100%: At a prevalence of 15%, this leads to a positive predictive value (PPV) of 73% and a negative predictive value (NPV) of 96%.
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PCR• Detects the gene encoding C Difficile toxin B, tcdB(strains producing only toxin A are rare)
• Very sensitive‐>=, 90 percent, high NPV• Very specific, false positive in less than 2%• Turn around time (TAT) less than 24 hours• Need expertise and expensive• Does NOT differentiate carrier state‐CLINICAL correlation required
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Testing
• For all clinical suspicions• Cytotoxin A and or B• PCR may be available‐Public Health Lab• A single negative ELISA test is non‐reliable
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• Who should you not test?
• What should you not test?
• When should you not test?
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CDI testing in Ontario Hospitals
• 38 percent have on site CDI testing• 90 percent have a max TAT of 48 hours• PCR eliminates need for two tests• PCR‐rapid answer, reduced isolation days• PCR needs clinical correlation‐3‐5 percent adult
colonization
• NOW HOST....
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AHE
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Host Risk Factors
• What are these?
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HOST: Risk Factors?‐BEWARE• Increasing age especially > 65 years• History of antibiotic use, particularly fluoroquinolones, cephalosporins and clindamycin
• Use of proton pump inhibitors (PPI) • Prolonged hospitalization• Immunocompromised conditions such as illness, immunosuppressive therapy
• Bowel disease such as IBD and bowel surgery
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Severe CDI
• Who are most at risk?
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Risk factors for severe CDI illness• History of CDI especially if with NAP‐I/B1 strain
• Increasing age• Recent surgery• Immunosuppressive therapy
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CDI
• What are the symptoms?• What are the possible complications?
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Symptoms• New onset diarrhea that is unusual or different for the patient with no identified etiology. It may be watery, mucus or bloody.
• Abdominal pain, cramping or tenderness• Nausea, anorexia, fever• 3 lose stools in 24 hours‐36 percent of causes of diarrhea in Hospital
• Differentiate: Nosocomial: 72 hrs, 4 weeks
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Toxic Megalcolon
• Fever• Abdominal pain• Shock• Abdominal distension or bloating
• Dehydration• Tachycardia• Possible loss of bowel sounds, 5.5 cm or more
• Decompress or surgery
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Treatment• For mild‐moderate (WBC < 15 x 109/L and serum Cr < 1.5 baseline) CDI7:
• Adults: oral metronidazole (Flagyl) 500mg TID or 250mg QID x 10 days
• For severe (WBC > 15 x 109/L and serum Cr ≥1.5 baseline) CDI7:
• Adults: oral vancomycin 125mg QID x 10‐14 days
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Management• Severe CDI may require hospitalization with IV antibiotics
• Serious sequelae of CDI such as pseudo‐membranous colitis or toxic megacolon may also need to be ruled out
• Consider contacting public health if you have 2 or more cases
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Management• Consider treatment of high risk suspicious symptomatic clinical cases with antibiotic pending results and discontinue once confirmed negative on at least 2 separate occasions
• If symptoms persist after completion of antibiotic treatment then samples should be submitted for retesting
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Management• Discontinue use of the implicated/inciting antibiotic
• Discontinue use of any laxatives and/or stool softeners
• Review all other medications until clinically improved including PPI
• Symptomatic treatment including rehydration and potentially hypodermoclysis
• Avoid use of anti‐motility/peristaltic agents
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AHE
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Environment....
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Environment• High touch areas‐bathroom, toilet, commode , bedpan, knobs, phones
• Twice daily cleaning• Hospital grade disinfectant
• Sporocidal: if ongoing transmission‐accelerated H2O2, hypochlorite
• Deep clean post transfer/discharge
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Human Waste Management• Stop use of spray wands• Use bedpan liners• Separate clean from soiled• Assist patients to clean hands• Single stocked rooms‐dedicated equipment, no tape
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Your LTC calls you….
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On call :Telephone Call….• 200 bed LTC care facility• Rate had been 0.5 to 2.0 per 1000 patient days over the
last year• They now state they have seen a significant rise from
baseline to... 3
• Next steps?
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They are up to their…..in c diff...outbreak management priorities?
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Outbreak Management
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Management• Implementation of site‐specific infection control protocol for CDI including identification, isolation and contact precautions
• Use of gloves when providing care to residents with CDI
• After glove removal, hand hygiene with preferably soap and water in the presence of a dedicated hand wash sink
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SHEAR Approach• Surveillance‐case definition, thresholds, lab notification
• Hand Hygiene‐rates, contact precautions>48hr• Environmental cleaning‐checklists, sporocidal, audit, ICRT report
• Education‐staff, patients, families, signage• Antibiotic Stewardship‐program, audit• Risk Factors‐Epi triad of Agent , Host, Environment
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patientsafetyontario.net compare
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KEY Resource
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Outbreak declared???• Ensure that the rationale for declaring the outbreak is documented.
• Once an outbreak is declared, the health unit will provide the LTC with an outbreak number and will enter preliminary data into iPHISwithin one business day of outbreak notification.
• Is this a true “outbreak”?
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Treatment…antibiotic for antibiotic associated illness!
• Stop inciting antibiotic• Rehydrate• Avoid anti‐motility and peristaltic agents• Metronidazole 250 mg q 6 h, or 500 mg q 8 h for TEN DAYS minimum
• Vancomycin if allergy or non response to metronidazole or if severely ill
• Follow protocols…Kelly NEJM Oct 2008
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Population Prevention
• Immunization:• Influenza immunization for everyone!• Especially those over 65 years of age, Staff and VISITORS to LTCF
• Pneumococcal Polysaccharide Vaccine:• All residents of nursing homes for the aged and chronic care
facilities
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Why we need to improve in‐patient antibiotic use?
• Antibiotics are misused in hospitals/LTCs• Antibiotic misuse adversely impacts patients and society
• Improving antibiotic use improves patient outcomes and saves money
• Improving antibiotic use is a public health imperative
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Antibiotics are misused in hospitals• “It has been recognized for several decades that up to 50%
of antimicrobial use is inappropriate”– Given when they are not needed– Continued when they are no longer necessary– Given at the wrong dose– Broad spectrum agents are used to treat very susceptible
bacteria– The wrong antibiotic is given to treat an infection
IDSA/SHEA Guidelines for Antimicrobial Stewardship Programshttp://www.journals.uchicago.edu/doi/pdf/10.1086/510393
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Antibiotic misuse adversely impacts patients ‐ CDI
• Antibiotic exposure is the single most important risk factor for the development of Clostridium difficile associated disease (CDAD)– Up to 85% of patients with CDAD have antibiotic exposure in the 28 days before infection1
1. Chang HT et al. Infect Control Hosp Epidemiol 2007; 28:926–931.
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Risk Management‐Active and Passive Immunity
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Targeted antibiotic consumption and nosocomial CDI
Valiquette, et al. Clin Infect Dis 2007;45:S112.
CHUS; Quebec, 2003-2006
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SHEAR Approach• Surveillance‐case definition, thresholds, lab notification
• Hand Hygiene‐rates, contact precautions>48hr• Environmental cleaning‐checklists, sporocidal, audit, ICRT report
• Education‐staff, patients, families, signage• Antibiotic Stewardship‐program, audit• Risk Factors‐Epi triad of Agent , Host, Environment
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Thanks
• Adam Van Dijk, KFLA Epidemiologist• Amanda Knapp, KFLA PHI ICP• Kingston General Hospital‐Dr. Gerald Evans
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References• PIDAC Best Practice Document Nov 2007 for Management of C. Diff in all health
care settings• Ontario Anti‐Infective Guidelines for Community Acquired Infections 2012
www.mumshealth.com• Control of C. Difficile Outbreaks in Hospitals‐Guide for Hospital and Health Unit
Staff, Dec 2009 MOH LTC• BCCDC Investigation of C Diff associated disease outbreak at Nanaimo General
Regional Hospital August 2008• Impact of a Reduction in the Use of High Risk Antibiotics on the Course of an
Epidemic of Cl. Difficile‐Associated Disease caused by the Hypervirulent NAP1/027 Strain, Valiquette et al, CID 2007 :45
• CDC C Difficile infections Tool kit: Gould and McDonald, December 2009• C Difficile‐More Difficult than Ever, NEJM, 0ct 30th 2008, 359:18 Kelly et al.• A Review of the Epidemiology of Cl. Difficile in Se LHIN and Ontario‐Agnes Tong,
PHO