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Clostridium difficile
Presented byNate Smith, MD, MPHCarole Yeung, RN CIC
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Outline
• Epidemiology
• Treatment
• Prevention
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What is Clostridium difficile?
• Anaerobic spore-forming bacillus• Present in the soil and environment• Produces two toxins – Toxins A and B• Common cause of antibiotic associated diarrhea
(AAD). 15 – 25 % all episodes of AAD• Health care settings are major reservoirs• 20 – 40% hospital patients colonized• 4 – 20% LTCF residents colonized
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What are C. difficile-associated diseases (CDAD)
• Pseudomembranous colitis (PMC)
• Toxic megacolon
• Perforations of the colon
• Sepsis
• Death (rarely) but increasing!
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CDAD-related deaths - Arkansas
0
10
20
30
40
50
60
DE
AT
HS
1999 2000 2001 2002 2003 2004 2005*
*2005 data incomplete
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Symptoms of CDAD
• Watery diarrhea• Fever• Loss of appetite• Abdominal pain• Nausea and vomiting• Severe cases: increase WBC and/or creatinine • Can occur up to 8 weeks after antimicrobial
therapy
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Which patients are at increased risk for CDAD?
• Antibiotic exposure – clindamycin, penicillins, cephalosporins, floroquinolones
• Gastrointestinal surgery
• Length of stay in healthcare settings
• A serious underlying illness
• Immunocompromising conditions
• Advanced age
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C. difficile colonization
• Patient exhibits no clinical symptoms
• Patient tests positive for C. difficile organism and/or its toxin
• More common than CDAD
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C. difficile disease (CDAD)
• Patient exhibits clinical symptoms
• Patient tests positive for C. difficile organism and/or its toxin
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Laboratory Tests for CDAD
• Stool culture
• Antigen detection
• Toxin testing
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C. difficile Transmission
• C. difficile spores are shed in feces
• Any surface, device or material that becomes contaminated with feces may serve as a reservoir
• Transferred by hands of healthcare personnel
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Treatment
• Discontinue antibiotics if feasible
• Metronidazole orally for 10 days
• Vancomycin orally
• Relapses are common
• Repeat testing NOT recommended
• NO antiperistalic agents
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Infection Control Preventive Methods
• Use antibiotics judiciously
• Early diagnosis
• Contact precautions for patients with CDAD
• Hand hygiene
• Environmental cleaning and disinfection
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Contact Precautions
• Private room or cohort
• Gloves
• Gowns
• Dedicated patient care equipment
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Hand Hygiene
Soap and water for at least 15 seconds:
• Wet hands under running water
• Apply soap
• Good friction rub for 15 seconds
• Rinse hands
• Dry well with paper towel
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Cleaning and Disinfection
• Clean/disinfect environmental surfaces and reusable items
• Hospital disinfectant
• 1:10 bleach
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Discontinuing Precautions
• NO diarrhea. NO precautions!
• Repeat testing NOT recommended
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Transfer of Patients
• Notify receiving facility if patient has a history of C. difficile
• Observe for recurrence
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References
• SHEA Position Paper CDAD, ICHE 1995
• SHEA Position Paper C. difficile in LTCF for the elderly, ICHE 2002
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QUESTIONS?