cdiff presentation
TRANSCRIPT
S T E P H A N I E F U R L A N
CDIFF
WHAT ARE WE LOOKING AT?
• CDIFF is contagious, painful, and can be deadly!• What’s going on in the hospital regarding CDIFF
rates and trends?• How are we doing?• More HAI? More CAI?
• Who’s the most at risk?• What are the risk factors?• Which part of the hospitals have the most CDIFF
rates?
RISK FACTORS FOR DEVELOPING CDIFF
• Advanced Age (65 and older)• More likely to have a compromised immune system • Higher duration of stay in the hospital
“The daily increase in the risk of C. difficile acquisition during hospitalization suggests that duration of hospitalization is a proxy for the duration, if not the degree, of exposure to the organism from other patients with CDI.” (Wilcox, 2013)
• Acid reducing drugs (proton pump inhibitors, histamine 2 blockers)• Less acid in the stomach= greater possibility of bacteria reaching intestine/colon
and causing infection• Antibiotic use • Antibiotic use disrupts the normal microflora within the GI Tract!
• CDC (2013) reports that 96% of patients within hospitals who had become symptomatic for CDIFF had received antibiotics within 14 days before onset of diarrhea• ***ALL CDIFF patients had received antibiotics within 3 months• Some Antibiotics are more likely to inhibit the growth of CDIFF
Zosyn, Clindamycin, Rocephin, Levaquin• Especially skilled at killing bacteria in the gut (high powered
penicillins, tazobactam, etc)
RISK FACTORS FOR DEVELOPING CDIFF CONT’D
• Double Occupancy rooms- having a roommate who is asymptomatic for C-DIFF can be dangerous• CDC (2013)- 50% or more of hospital patients colonized by CDIFF are
symptomless carriers• Cancer chemotherapy is immunosuppressant therapy and causes a
weakened immune system• Same for immunosuppressant drugs (ie. Steroids)
• Autoimmune Disorders • Immunosuppressant diseases (ie , HIV, AIDS, Crohns, Addison’s) weaken
immune system, more susceptible to bacteria, viruses, etc.• GI procedures- disrupts microflora of gut, “stresses out” immune system
(Wilcox, 2013)• Post Pyloric-Tube Feedings- Feeding tubes can by-pass stomach
(stomach acid), and lead to the intestine. Bacteria can travel easily to their destination• Especially at risk if patient is being treated with antibiotics
RISK FACTORS CONT’D
• Previous ED visit and or Hospital Admission less than 30 days: • You are surrounded by sick people, others in ED might be
asymptomatic for CDIFF
NOSOCOMIAL INFECTIONS:
• Total Cases: 91 (December 2013- October 2014)• HAI: 43 cases (47.8 %)• Community Acquired: 48 cases (52.7%)
FREQUENCY DISTRIBUTION OF SEX
• Total: 43 cases• Females: 24 (55.8%)• Males: 19 (44.2%)
AGE
• Range 31-95 years of age • Mode: 67 (4 cases)• Mean: 65.70 years of age• Age of CDIFF HAI 65 and older: 60.5% (26 cases)• 62 and younger: 39.5 (17 cases)
GRAPH: POSITIVE DAYS AFTER ADMISSION
POSITIVE FOR CDIFF AFTER ADMISSION
• Total Cases: 43• 1) 3-5 days- 16.3% • Frequency- 7
• 2) 6 days to 1 week- 18.6% • Frequency 8
• ******3) 8 days to 2 weeks 30.2% • Frequency-13
• 4) 15 days to 3 weeks 18.6%• ` Frequency 8
• 5) 22 days to 4 weeks 11.6 %• Frequency 5
• 6)More than 4 weeks 4.7%• Frequency 2
GRAPH: HIGH RISK ANTIBIOTICS
ANTIBIOTIC +HIGH RISK ANTIBIOTIC TREATMENT DURING ADMISSION AND LAST 3 MONTHS
Antibiotic treatment during last 3 months and during
admission• Cases 43:
• Yes: 42 (97.7 %)• n/a: 1 (2.3 %)
High Risk Antibiotics during last 3 months and during admission
High risk Antibiotics:• 1: Rocephin
Frequency: 2 (4.7%)• 2: Levaquin
Frequency: 8 (18.6%)• *****3: Zosyn
Frequency: 9 (20.9%)
• 4 ClindamycinFrequency: 1 (2.3%)
*****5. NoneFrequency: 10
(23.3%)*****6. 2 High Risk Antibiotics
Frequency: 9 (20.9%)7. 3 or more high-risk antibiotics
Frequency 4 (9.3%_
Total Cases: 43
PREVIOUS ED + ADMISSION WITHIN 30 DAYS
Emergency Department Visit Within 30 days
• Total cases: 43:• Yes 12 (28%)• No: 31 (72%)
Admission within 30 days
• None: 30 cases (69.8%)
• 1 day stay: 9 cases (20.9%)
• 2 day admission: 1 case (2.3%)
• 3 day admission: 2 cases (4.7%)
• 9 day admission: 1 case (2.3%)
ACID REDUCING DRUGS AND/OR IMMUNOSUPPRESSANTS DURING ADMISSION
AND LAST 3 MONTHS
Acid Reducing Drugs During Admission
and/or last 3 months
• Total Cases: 43• Yes: 41 (95.3%)• No: 2 (4.7%)
• Immunosuppressants During Admission
and/or last 3 months
• Total cases: 43• Yes: 27 cases
(62.8%)• No: 16 cases
(37.2%)
GI PROCEDURES DURING ADMISSION + TUBE FEEDING
GI Procedures
• Total Cases: 43• Yes: 12 cases
(27.9%)• No: 31 cases
(72.1%)
Tube Feedings
Total Cases: 43• Yes: 21 cases
(48.8%)• No: 22 cases
(51.2%)
AUTOIMMUNE DISORDER AND CHEMOTHERAPY WITHIN LAST 3 MONTHS
Autoimmune Disorder
• Total cases: 43 • Yes: 13 (30.2%)• No: 30 (69.8%)
Chemotherapy within last 3
months
• Total Cases: 43• Yes: 5 cases (11.6%)• No: 38 cases
(84.4%)
ADMISSION TO AN ECF WITHIN 1 YEAR
• Total cases: 43• Yes: 6 cases (14%)• No: 37 cases (86%)
DOUBLE OCCUPANCY ROOMS
DOUBLE OCCUPANCY ROOMS + ISOLATION INITIATION
Double Occupancy Rooms
• Total Cases: 43• Yes: 13 cases
(30.2%)• No: 30 cases
(69.8%)
Isolation Initiation
• Total cases: 43• Same day as
positive: 20 cases (46.5%)• Already in single
room 17 cases (39.5%)• n/a: 6 cases (14%)
HXCDI + ID CONSULT
HXCDI
• Total Cases: 43• None: 36 cases
(83.7%)• Yes once before: 6
cases (14.0%)• Yes, more than once:
1 case (2.3%)
ID Consult
• Total Cases: 43• Yes: 16 cases
(37.2%)• No: 27 cases
(62.8%)
AGE STRATIFICATION
62 and younger 65 and older
Cases 17 (39.5% of 43) 26 (60.5% of 43)
Average days positive after admission 6 days to one week 8 days to 2 weeks
(Yes) HXCDI 18% 15%
(Yes) Antibiotic Treatment 94% 100%
(Yes) High Risk Antibiotics 76% 76%
(Yes)Double Occupancy Rooms 17% 30%
(Yes) Previous ED visit less than 30 days 40% 61%
(Yes) Previous Admission Less than 30 Days 58% 20%
(Yes) Acid Reducing Drugs During Ad+3months 94% 96%
(Yes) Immunosuppressant drugs during ad+3mnts 59% 71%
(Yes) GI Procedures During Admission 23% 30%
(Yes) Autoimmune Disorder 35% 26%
(Yes) Chemotherapy within last 3 months 5% 15%
(Yes) Admission to ECF within 1 year 17% 11%
(Yes) ID Consult 59% 34%
(Yes) Tube Feedings 35% 57%
AREA OF 1ST SYMPTOMS (62 AND YOUNGER)
• Top areas• for 62 and younger:• AP5: 5 cases• 4NSSU: 3 cases• IMCU: 2 cases• EW7 2 cases
AP5 4NSSU IMCU 4SO EW4 EW7 4E AP3 5SO0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Area where symptoms first re-ported (less than or equal to age
62)
Location within hospital
Fre
quency
AREA OF 1ST SYMPTOMS (65 AND OLDER)
• Top areas for65 and older • AP5: 5 cases• EW7: 4 cases• IMCU: 3 cases• AP4: 3 cases• 5SO: 3 cases• AP3W: 2 cases
AP5 ICU IMCU AP4 AP3W EW7 5S0 5N 4NSSU0
1
2
3
4
5
6
Area where symptoms first reported (greater than or
equal to age 65)
Location within hospital
Fre
quency
AVG. CDIFF PREV. + PATIENT DAYS HOSPITAL WIDE
months 7 to 9 2013
months 10 to 12 2013
months 1 to 3 2014
months 4 to 6 2014
months 7 to 9 2014
0
0.4
0.8 0.773
0.2490.389 0.501
0.348
Avg. Hospital-wide Prev rates of CDIFF from 7/2013 to 9/2014
months (in quarters)Avg p
rev.
rate
per
100 a
dm
ins
months 7 to 9 2013
months 10 to 12 2013
months 1 to 3 2014
months 4 to 6 2014
months 7 to 9 2014
0
10 10.177
3.267
12.2818.715 10.253
Avg. CDIFF patient days Hospital wide from 7/2013 to 9/2014
months (in quarters)rate
pe
r 1
0,0
00
p
ati
en
t d
ays
Correlation Patient Days to Avg CDIFF Prev: .435
AVG CDIFF PREV + PATIENT DAYS IN 4NSSU
months 7 to 9 2013 months 10 to 12 2013
months 1 to 3 2014 months 4 to 6 2014 months 7 to 9 20140
0.4
0.8
1.2
1.6
0.935
0
1.426
1.012
0
Avg. prev. CDIFF rates in 4NSSU (4N) from 7/2013 to 9/2014
Months (in quarters )
Avg.
Pre
v r
ate
per
100
adm
ins
months 7 to 9 2013
months 10 to 12 2013
months 1 to 3 2014
months 4 to 6 2014
months 7 to 9 2014
02468
1012
0 0
11.123
6.68
0
Avg. CDIFF patient days in 4NSSU (4N) from 7/2013 to 9/2014
months (in quarters)
rate
per
10,0
00
pati
ent
days
Correlation Pt days and Avg. Cdiff rate: .805
AVG CDIFF PREV IN ICU
months 7 to 9 2013 months 10 to 12 2013
months 1 to 3 2014 months 4 to 6 2014 months 7 to 9 201402468
3.333
6.066
2.703
0
3.333
Avg. Prev . CDIFF rate in ICU from 7/2013 to 9/2014
Months (in quarters)Avg.
pre
v.
rate
per
100
adm
ins
months 7 to 9 2013
months 10 to 12 2013
months 1 to 3 2014
months 4 to 6 2014
months 7 to 9 2014
0
10
20
30
13.363
31.299
19.92
0
14.124
Avg. Cdiff patient days in ICU from 7/2013 to 9/2014
months (in quarters)
rate
per
10,0
00
pati
ent
days
Correlation Pt, days and Avg. Cdiff Rate: .941
AVG CDIFF PREV + PATIENT DAYS IN IMCU (6E)
months 7 to 9 2013 months 10 to 12 2013 months 1 to 3 2014 months 4 to 6 2014 months 7 to 9 20140
1
2
3
43.318 3.591
1.3342.032
1.35
Avg. CDIFF Prev. Rate in IMCU (6e) form 7/2013 to 9/2014
months (in quarters)rate
per
100 a
dm
ins
months 7 to 9 2013
months 10 to 12 2013
months 1 to 3 2014
months 4 to 6 2014
months 7 to 9 2014
05
10152025
16.103
9.523 10.582 11.82
21.825
Avg. CDIFF Patient Days in IMCU (6E) from 7/2013 to 9/2014
months (in quarters)
rate
per
10,0
00
pati
ent
days
Correlation Pt. Days and Avg. Prev. Rate: -.331
AVG. CDIFF PREV. +PATIENT DAYS IN 7E
months 7 to 9 2013 months 10 to 12 2013
months 1 to 3 2014 months 4 to 6 2014 months 7 to 9 20140
2
4
6
2.2071.471
3.6852.047
4.938
Average Prev. CDIFF rate in 7e from 7/2013 to 9/2014
months (in quarters)Avg.
Pre
v.
rate
per
100
adm
ins
months 7 to 9 2013
months 10 to 12 2013
months 1 to 3 2014
months 4 to 6 2014
months 7 to 9 2014
05
1015
0
7.62810.972
05.204
Avg Cdiff patient days in 7e from 7/2013 to 9/2014
months (in quarters)
rate
pe
r 1
0,0
00
p
ati
en
t d
ays
Correlation Pt. Days and Cdiff Prev: .278
AVG CDIFF PREV + PATIENT DAYS IN AP5
months 7 to 9 2013
months 10 to 12 2013
months 1 to 3 2014
months 4 to 6 2014
months 7 to 9 2014
0
1
2
3 2.725
1.384 1.429 1.3180.9445
Average Prev. CDIFF rate in AP5 from 7/2013 to 9/2014
months (in quarters)Avera
ge p
revale
nce
ra
te p
er
100 a
dm
ins
months 7 to 9 2013
months 10 to 12 2013
months 1 to 3 2014
months 4 to 6 2014
months 7 to 9 2014
0102030
21.76312.361 15.371 11.574
0
Avg. CDIFF patient days in AP5 from 7/2013 to 9/2014
months (in quarters)rate
per
10,0
00
pati
ent
days
Correlation Pt. Day and Cdiff Prev: .851
TAKE AWAY:
• More community acquired infections!• 48 CA cases compared to 43 HA
• Antibiotic + High Antibiotic treatment a risk of C-Diff Infection • Zosyn
• 2nd risk factor: Acid Reducing Drugs• Protonix, Pepcid
• Hospital wide patient days+ Avg. CDIFF Prev. is getting lower, but there are still “problem areas”!• 7E, ICU• Patient days and Avg. Cdiff Rates are rising!
• Units that have the most CDIFF rates:• AP5, 7E, 4NSSU
TAKE AWAY: AGE GROUPS
• Findings: Age group 65 and older are more at risk for developing C-DIFF
• 100% antibiotic treatment• More cases in Double Occupancy Rooms (30% compared to 17%)• More cases had Previous Ed Visit Less than 30 days (61% compared
to 41%)• More cases had acid reducing drugs: 96% yes!• Immunosuppressant drugs (71% compared to 59% (62 and younger)• More GI procedures during admission (30% compared to 23%)• Chemotherapy within last 3 months (15% compared to 5%)• Tube feedings
• Age group 65 and older less likely not to have ID consult: 64% of cases did not have ID consult!
• Age group 65 and older is staying longer in the hospital!• Longest stay 1+ month compared to 2 weeks in age group 62 and
younger!
REFERENCES
• Wilcox, M. (2013). New Clinical Practice Guidelines For Clostridium Difficile Infection. Infectious Diseases in Clinical Practice, 329-331.