c difficile - the ultimate challenge: controlling the spreadc difficile in the enviornment c....
TRANSCRIPT
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Linda R. Greene, RN, MPS, CIC Manager of Infection Prevention Highland Hospital Rochester, NY
University of Rochester Medical Center [email protected]
C Difficile - The Ultimate Challenge: Controlling the Spread
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The Big Picture C difficile lab ID reported through NHSN Proposed for Value Based Purchasing FY 2017
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The Year 2009
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A vital Energetic woman Friend, Mother and Grandmother
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So what do we need to do? Engage
Educate
Execute
Evaluate
The Evidence based Model for Improvement
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Strategies for Engagement
Multidisciplinary Team
Senior Leadership Putting names and faces to cases
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Education
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C difficile Now rivals MRSA as the most common organism found in
hospitals Incidence outside the hospital may be more common
than previously thought Associated with increased length of stay, morbidity and
mortality
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Impact of C. difficile infection (CDI)
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
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.
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Pathogenesis Alteration of the intestinal flora by antibiotics leads to C. difficile proliferation in the colon
C. difficile is acquired by ingestion of spores from the hospital environment or hands of healthcare personnel
C. difficile diarrhea
Advanced age Multiple comorbidies No antibody to Toxin A/B
No diarrhea
Antibody to Toxin A/B
Colonization
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Ingested Normal flora interrupted
Small Intestine Spores Germinate
Pseudomembrane C Difficile
toxins
monocytes
Neutrophils
Toxin A attracts neutrophils and monocytes, and toxin B degrades the colonic epithelial cells, both leading to colitis, pseudomembrane formation, and watery diarrhea
C difficile reproduces in the intestinal crypts, releasing toxins A and B, causing severe inflammation. Mucous and cellular debrisare expelled, leading to the formation of pseudomembranes
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Wolf P, Kasyan A N, Engl J - Med 2005;353:2491
Pseudomembrenous Colitis
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“I just touched the bed rail…” 100-1,000 bacteria transferred by: Pulling patients up in
bed Taking a blood
pressure or pulse Touching a patient’s
hand Rolling patients over
in bed
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O² sat monitor Stethoscope
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Keyboard & Mouse Med Keyboard
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C Difficile in the enviornment C. difficile forms an endospore or a dormant state with
increased resistance when conditions in the human or animal body or the environment become unfavorable for it to survive in its vegetative (actively growing) state.
In the endospore stage, C. difficile spores will not be destroyed on environmental surfaces by disinfectants
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Transmission- Fecal – Oral Route
o Mainly by direct contact with the hands of HCWs
o Autoinoculation (oral ingestion) o Shed in feces o Indirect contact (inanimate objects such as
commodes, etc) o Environmental contamination – spores can
survive for months in the environment
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What’s Wrong With This Picture
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Another One
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What are the symptoms of Cdiff? watery diarrhea fever loss of appetite nausea abdominal pain/tenderness
(Be wary of lack of stools)
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CDI Prevention Strategies: Core Contact Precautions for duration of diarrhea Hand hygiene in compliance with CDC/WHO Cleaning and disinfection of equipment and
environment Laboratory-based alert system for immediate
notification of positive test results Educate about CDI: HCP, housekeeping,
administration, patients, families http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html
Dubberke et al. Infect Control Hosp Epidemiol 2008;29:S81-92. SEE ALSO: Cohen SP, et al. SHEA/IDSA Clinical Practice Guideline, ICHE May 2010
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Bundle Monitoring Tool
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The Compendium
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Outbreak or Hyper-endemic Setting only
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Hyper-endemic levels
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Other Issues Lab ID is a marker. May also pick up colonization
What are your criteria for sending a specimen
Any Inappropriate testing?
Testing methods PCR 2 STEP Toxin- A and B antigen
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Renewed Respect for Role of the Environment: Who’s Been in the Room Before or With You?
Huang SS (2006); Drees M (2008); Zhou Q (2008); Moore C (2008);Hamel M (2010) All documented increased risk of
acquisition of VRE, MRSA, &/or CDI when admitted to room where prior occupant had one of these or if in multi-occupancy room
So what’s the answer?
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No Doesn’t
Look clean yet
They need to get a life
Keep Going
What’s The Answer?
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NYC- Dr. Brian Koll
Administrative Clinical Physician and Nursing
Champions
Sharing Best Practices
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Infection Prevention Coach Training Program
Teach Teamwork Monitor and enforce
practices Problem-solve Share and spread best
practices Participation in hospital
forums
Environment of Care
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Reducing CDI Measuring and assessing
effectiveness
Feedback
Sustainability
Dissemination and Spread
Web based and electronic communication
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Infection Prevention Bundles
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C. difficile Infection Prevention Bundle Hand hygiene (washing with soap and water for C.
difficile) Contact precautions Sign placement PPE readily available / used Dedicated rectal thermometers Patient placement
private room vs. cohorting vs. shared Bathrooms
dedicated vs. shared vs. commode Transport precautions Environmental cleaning
hypochlorite-based disinfectant daily and terminal cleaning procedures
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Environmental Checklist
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New Technologies
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Other Measures Prevent other Infections UTI’S – use of florquinoles highly associated with C Difficile
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The Bottom Line It’s like eating an elephant – 1 bite at a time