clinical practice guidelines for clostridium difficile ...€¦ · 3. without “good bacteria”...
TRANSCRIPT
ClinicalPracticeGuidelinesforClostridiumdifficile Infectionin
AdultsandChildren:2017UpdatebytheIDSAandSHEA
Mandee Novack,MD
Co-MedicalDirectorofAntimicrobialStewardship
BaptistHealth
AboutClostridiumdifficile
AboutClostridiumdifficile
1. Normalmicrobiota getsdisturbed(byantibiotics,or
evenpoordiet)
2. GutisexposedtoClostridiumdifficile spores(which
cansurvivestomachacid)
3. Without“goodbacteria”tokeepitincheck,Cdiff
growsandreleasesToxins(Toxin-AandToxin-B)
4. Thosetoxinsdamagethegut,causeinflammation,
diarrhea,andpseudomembranes
NotallClostridiumdifficile havethegenetomaketoxins,
andeventheonesthathavethegenearen’tnecessarily
makingthetoxinallthetime.
Epidemiology• HowareCDIcasesbestdefined?• 1)thepresenceofdiarrhea(orileus,ormegacolon)AND
• 2)apositivelabdiagnostictestorpseudomembranesdemonstratedonendoscopyorhistology
• Anincident caseis{symptoms+labtest}withnoepisodesintheprevious8weeks
• Arecurrentcaseisdefinedas{symptoms+labtest}whentherehasbeenanotherepisodeof{symptoms+labtest}inthelast8weeks
EpidemiologyDefinitions
• CDI=ClostridiumdifficileInfection
• HO=Healthcarefacility-onset
• CO-HCFA=Community-onsethealthcarefacility-associated
• CA=Community-associated
• NHSN=NationalHealthcareSafetyNetwork
• LabID-CDI=LaboratoryIdentifiedCdiffinfection
• SIR=Standardizedinfectionratio
• HAI=Healthcareassociatedinfection
Epidemiology
• HO-CDI casesaredefinedasLabID eventscollected>3daysafteradmission(onorafterday4)
• CO-HCFA CDIcasesaredefinedas{symptoms+labtest}thatoccurwithin28daysafterdischargefromahealthcarefacility
• CA-CDI casesaredefinedas{symptoms+labtest}thatarenotassociatedwithadmission/dischargeinthelast4weeks
HO:HealthcarefacilityonsetCO-HCFA:Community-onsetHealthcarefacilityassociatedCA:Communityassociated
Epidemiology
From2010guidelines
Prevalence,Incidence,Morbidity,Mortality
• 2010rateofLabID-CDIwas7.4per10,000patient-days
• In2011,therewereanestimated453,000cases(147/100,000person)
• Ofthose,64.7%wereconsideredhealthcareassociated:• 37%werehospitalonset
• 36%hadtheironsetinlong-termcarefacilities
• 28%wereCO-HCFA(i.e.withadmissionintheprior12weeks)
• Ofthe35.3%thatwereconsideredcommunity-associated:
• 82%wereassociatedwithoutpatienthealthcareexposure
• Therefore,94%ofallCDIcaseshadarecenthealthcareexposure
Prevalence,Incidence,Morbidity,Mortality
• Cdifficile isthemostcommoncausativepathogeninHAIs
• Afterafirstepisode,10-30%ofpatientsdeveloprecurrence
• Endemicperiods:CDI-attributablemortalityis4.5%- 5.7%
• Epidemicperiods:CDI-attributablemortalityis6.9%- 16.7%
• CDIattributablecost is$3427- $9960perepisode
IncreasedRisk
• Advancedage
• Antibiotics
• PPIs
• Cancer
• Inflammatoryboweldisease
• Solidorgantransplant
• CKDandESRD
• Hematopoieticstemcelltransplant(9xgreatriskthanotherhospitalizedpatients)
Colonization• Asymptomaticcolonizationinadultinpatientsis3%-26%
• (inthegeneralpopulationwithouthealthcareexposure,itis<2%)
• Colonizationà Infectionisprobably3-7days
• Prolongedcolonizationincreasesriskforinfection,butthatriskofprogressiondecreasesovertime(thatis,ifyou’vebeencolonizedfor2weeks,yourriskofprogressionishigherthanifyou’vebeencolonizedfor6weeks).
• ColonizationwithanontoxigenicstrainconfersprotectionagainstCDI
Diagnosis
• Whototest:• Patientswithunexplainednew-onsetdiarrhea,with≥3unformedstoolsin24hours
• Examplesof“explaineddiarrhea”• Inflammatoryboweldisease
• Enteraltubefeeding
• Intensivechemotherapyforcancer
• Laxatives
“However,someoftheseconditionsandinterventionsassociatedwithdiarrheaintheirownright,suchasIBD
andenteraltubefeeding,havebeenshowntohaveincreasedriskofCDIwhencomparedwithamatched
cohort.So,inpracticeitisdifficulttoexcludethepossibilityofCDIonclinicalgroundsalone”
Improvinglaboratorytestrelevance
• Donotroutinelyteststoolwithin48hoursafteralaxative
• Laboratorycanrejectspecimensthatarenotliquid
• Includecriteriafortesting(#ofunformedstoolsin24hours,orincludeotherclinicalriskfactors/signs/symptomsofCDI)
AboutCdiff testing
AboutCdiff testing
AboutCdiff testing
AboutCdiff testing
AboutCdiff testing
Diagnostictesting• 2017Update
• Onlytestunformedstools
• Donottestasymptomaticpatients,anddonottestfor
cure
• (Newguidelinesmentionstoolculturedeepinthe
“summaryofevidence”,notintherecommendations)
• (NewguidelinesendwithNAATtestingratherthan
cellcytotoxicityassayortoxigenicculture)
• PCRtakesamuchmoreprominentrole
• Repeattestingisstilldiscouraged
Diagnostictesting
• VII.Whatisthebest-performingmethod(ie,inusepositiveandnegativepredictivevalue)fordetectingpatientsatincreasedriskforclinicallysignificantC. difficileinfectionincommonlysubmittedstoolspecimens?
• Useastooltoxintestaspartofamultistepalgorithm(ie,glutamatedehydrogenase[GDH]plustoxin;GDHplustoxin,arbitratedbyNAAT;orNAATplustoxin)ratherthanaNAATaloneforallspecimensreceivedintheclinicallaboratorywhentherearenopreagreedinstitutionalcriteriaforpatientstoolsubmission
Diagnostictesting
• VIII.WhatisthemostsensitivemethodofdiagnosisofCDIinstoolspecimensfrompatientslikelytohaveCDIbasedonclinicalsymptoms?Recommendation
• UseaNAATaloneoramultistepalgorithmfortesting(ie,GDHplustoxin;GDHplustoxin,arbitratedbyNAAT;orNAATplustoxin)ratherthanatoxintestalonewhentherearepre-agreedinstitutionalcriteriaforpatientstoolsubmission
WhentotestforCdiff…
Ifyes…
Ifno(butyou’refibbing)…
WhentotestforCdiff
Ifthey’vehadfewerthan3waterystools,it’snottimetotestyet…
Aboutrepeattesting…
• Ifusing2-stagealgorithmorstand-aloneNAAT,asingletestshasanegativepredictivevalueof>99%
• DONOTREPEATTESTINGWITHIN7DAYS
• Testingforrecurrence(followingsuccessfultreatmentanddiarrhea)shouldincludetoxindetection(sincePCRcanremainpositiveforalongtimeafterCDI)
• Empirictreatmentforrecurrenceisdiscouraged(andmaybeharmfultomicrobiomerestoration)
ButIagree,realCdiffisrealbad
InfectionControl
• Privateroomsanddedicatedtoilets• Prioritizeprivateroomsforpatientswithincontinence
• Gownandgloves
• IsolatewhenCDIissuspected“iftestresultscannotbeobtainedonthesameday”
• Continueisolationforatleast48hoursafterdiarrheahasresolved• KeepitgoinguntildischargeifCDIratesremainhigh
• Cdiffissuppressedtoundetectablelevelsinstoolsamplesbythetimediarrhearesolves,inmostpatients,butskin/environmentalcontaminationremainshigh
Routesoftransmission
• Handsofhealthcarepersonnel
• Environmentalcontamination
• High-riskfomites(electronicrectalthermometers,bedpans,commodes)
• Asymptomaticallycolonizedpatients
• Formostcases,theexactrouteoftransmissionisneverdetermined
Infectioncontrol- Handhygiene
• “Inroutineorendemicsettings,performhandhygienebeforeandaftercontactofapatientwithCDIandafterremovinggloveswitheithersoapandwateroranalcohol-basedhandhygieneproduct”
• InCDIoutbreaksorhyperendemic settings,usesoapandwaterpreferentiallyoveralcohol-basedproducts
• Ifthereisdirectcontactwithfeces,washwithsoapandwater.
Infectioncontrol
• “Encouragepatientstowashhandsandshowertoreducetheburdenofsporesontheskin”
• Usedisposablepatientequipmentwhenpossible,andensurethatreusableequipmentiscleanedanddisinfectedwithsporicidalproducts(thatareequipmentcompatible)
• “TerminalroomcleaningwithsporicidalagentshouldbeconsideredinconjunctionwithothermeasuretopreventCDIduringendemichighratesoroutbreaks,orifthereisevidenceofrepeatedcasesofCDIinthesameroom”• Dataonautomated disinfectionaretoolimitedtomakearecommendationfornow
Infectioncontrol
• Dailysporicidaldisinfection“shouldbeconsidered”duringoutbreaks
• Thereisnorecommendationtoscreen/isolateasymptomaticpatients
AntimicrobialStewardship
AntimicrobialStewardship
• Minimizethefrequencyanddurationofhigh-riskantibiotictherapy,andthenumberofagentsprescribed
• Implementanantibioticstewardshipprogram
• AntibioticstobetargetedshouldbebasedonlocalepidemiologyandstrainsofCdiffinthecommunity.
• Restrictionsoffluouroquinolones,clindamycin,andcephalosporin(exceptforsurgicalantibioticprophylaxis)shouldbeconsidered
Probiotics• “ThereisinsufficientdataatthistimetorecommendadministrationofprobioticsforprimarypreventionofCDIoutsideofclinicaltrials”
Treatment
Oldguidelines(donotmemorize!!!)
Newguidelines
Initialepisode
• Initialepisode,non-severe• Vancomycin125mg4x/dfor10days
• Fidaxomycin 200mgBIDx10days
• Ifthoseareunavailable,metronidazole500mgTIDx10d
• Initialepisode,severe• Vancomycin125mg4x/dfor10days
• Fidaxomycin 200mgBIDx10days
• Initialepisode,fulminant• Vancomycin500mg4x/d,plusrectalinstillation,plusIVmetronidazole
Fulminantdisease
• POVancomycin500mg 4x/d+IVmetronidazole500mgQ8h
• Ifileusispresent,vancomycincanbeadministeredPR(500mg/100mLq6hasaretentionenema)
• “itmaybeappropriatetomonitortroughserumconcentrationtoruleoutdrugaccumulation”whenhighdosesareused
RecurrentCDI
• Firstrecurrence:tapered/pulsedVancomycin,notanother10-daycourse
OR
• Treatafirstrecurrencewith10-dayfidaxomicin
OR
• Ifyou(wrongly)usedflagyl thefirsttimearound,try10daysofPOVanc
Multiplerecurrences
• POVanc tapered+pulsed(weak,lowquality)
• POVancomycinfollowedbyPORifaximin (weak,lowquality)
• POFidaxomicin (weak,lowquality)
• Fecalmicrobiotatransplantation(strong,moderatequality)
Take-HomeMessage
• PreventCdiffbymakingbetterantibioticchoicestobeginwith
• PreventspreadofCdiffwithexcellentInfectionControladherence
• Ourtestisoverlysensitive,soweneedtobepickieraboutwhenweuseit(notforpatientsonlaxatives,orwithlessthan3stoolsin24h)
• Firstlinetreatmenthaschanged(POFlagyl isnolongerrecommended)
Questions?