This is an abbreviated version of the PowerPoint presentation  that accompanied the CDC's  Sept 16, 2008 COCA Conference C...
Changing Epidemiology   and Prevention of  Clostridium difficile   Carolyn Gould, MD, MS Division of Healthcare Quality Pr...
Prerequisites for CDI  <ul><li>Advanced age </li></ul><ul><li>Underlying illness </li></ul>CDI <ul><li>CDI due to recent (...
Changing Epidemiology of CDI <ul><li>Increasing incidence and severity </li></ul><ul><ul><li>Based on NNIS, national hospi...
Outcomes of CDI in Setting of Endemic Disease Dubberke ER, et al.  Clin Infect Dis.  2008;46:497-504. Dubberke ER, et al. ...
Current Epidemic Strain of  C. difficile <ul><li>BI/NAP1/027, toxinotype III </li></ul><ul><li>Historically uncommon, now ...
How important are asymptomatic carriers in transmission?  Riggs MM et al.  Clin Infect Dis  2007; 45:992–8
Rationale to consider extending isolation beyond duration of diarrhea Bobulsky  GS et al.  Clin Infect Dis  2008; 46:447–50
Environmental control: Effect of hypochlorite in highly endemic ward Mayfield JL.  Clin Infect Dis  2000;31:995–1000
Novel Risk Factors, Washington University Prevention Epicenter (n=36,086)‏ CI=confidence interval; IV=intravenous; OR=odds...
Quinolone Restriction Period Nimber of Defined Daily Doses  2005 2006 2007 Month and Year Impact that Restricting Fluoroqu...
Desperate Measures for Desperate Times: Restricting all Fluoroquinolones to End an Outbreak Kallen, et al. 18th Annual Mee...
<ul><li>Hospitals should conduct surveillance for CDI  </li></ul><ul><ul><li>Track positive laboratory results </li></ul><...
CDI in Previously Low-Risk Populations <ul><li>10 Pregnant women </li></ul><ul><li>23 Generally healthy persons in the com...
Recommendations for Surveillance of  Clostridium difficile  Infection Admission Discharge < 4 weeks 4-12 weeks HO-HCFA  CO...
Clostridium difficile  Infection (CDI) cases N = 1046 Healthcare facility–onset Healthcare facility-associated (HO-HCFA)‏ ...
ToxV (BK/NAP7-8/078) Strains; Historically Rare, Recently More Common <ul><li>Tox V Isolates </li></ul><ul><li>10/6000 </l...
Human CDAD Caused by Strains Similar to Animal Epidemic Strains, 2001–2006 Jhung MA, et al. Second International  Clostrid...
Summary <ul><li>Rates, mortality, and costs associated with CDI continue to increase </li></ul><ul><li>Much of this increa...
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abbreviated C.diff COCA presentation (long)

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Abbreviated version of the CDC's Sept 16 COCA conference call. I am also uploading an even shorter version. Check out the document to see the web address of the original.

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  • abbreviated C.diff COCA presentation (long)

    1. 1. This is an abbreviated version of the PowerPoint presentation that accompanied the CDC's Sept 16, 2008 COCA Conference Call. For the full presentation, visit http://www.emergency.cdc.gov/coca/callinfo.asp (This version should not be used as a basis for making decisions about diagnosis or infection control.)‏
    2. 2. Changing Epidemiology and Prevention of Clostridium difficile Carolyn Gould, MD, MS Division of Healthcare Quality Promotion Clinician Outreach and Communication Activity September 16, 2008 The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention No Conflicts of Interest to Disclose
    3. 3. Prerequisites for CDI <ul><li>Advanced age </li></ul><ul><li>Underlying illness </li></ul>CDI <ul><li>CDI due to recent (re)acquisition of C. difficile </li></ul><ul><ul><li>Incubation period unknown </li></ul></ul><ul><ul><li><7 days to several weeks? </li></ul></ul><ul><li>Antimicrobial exposure may or may not precede acquisition </li></ul><ul><ul><li>The two appear to be in proximity </li></ul></ul>Antimicrobial therapy Disturbed colonic microflora Acquisition of toxigenic C. difficile Toxin A & Toxin B production
    4. 4. Changing Epidemiology of CDI <ul><li>Increasing incidence and severity </li></ul><ul><ul><li>Based on NNIS, national hospital discharge data, reports from healthcare systems, death certificate data </li></ul></ul><ul><li>Recent outbreaks of severe disease caused by epidemic strain of C. difficile with increased virulence, antibiotic resistance </li></ul><ul><li>Although elderly are still most greatly affected, more disease reported in “low-risk” persons </li></ul><ul><ul><li>Healthy persons in community, peripartum women </li></ul></ul>
    5. 5. Outcomes of CDI in Setting of Endemic Disease Dubberke ER, et al. Clin Infect Dis. 2008;46:497-504. Dubberke ER, et al. 17th Annual Meeting of The Society for Healthcare Epidemiology of America (SHEA), April 14-17, 2007; Baltimore, MD. Unpublished data. <ul><li>Excess costs </li></ul><ul><ul><li>$2,380 to $3,240 per index hospitalization </li></ul></ul><ul><ul><li>$3,797 to $7,179 inpatient costs over 180 days of follow-up </li></ul></ul><ul><li>Other outcomes </li></ul><ul><ul><li>2.8 days attributable excess length of stay </li></ul></ul><ul><ul><li>19.3% attributable readmission (180 days)‏ </li></ul></ul><ul><ul><li>5.7% attributable mortality (180 days)‏ </li></ul></ul><ul><ul><li>More likely discharged to long-term care </li></ul></ul>
    6. 6. Current Epidemic Strain of C. difficile <ul><li>BI/NAP1/027, toxinotype III </li></ul><ul><li>Historically uncommon, now epidemic </li></ul><ul><li>Current strain more resistant to fluoroquinolones </li></ul><ul><li>Carries extra toxin known as binary toxin </li></ul><ul><li>Polymorphism in toxins A and B regulatory gene ( tcdC ) and increased toxin production in vitro </li></ul>
    7. 7. How important are asymptomatic carriers in transmission? Riggs MM et al. Clin Infect Dis 2007; 45:992–8
    8. 8. Rationale to consider extending isolation beyond duration of diarrhea Bobulsky GS et al. Clin Infect Dis 2008; 46:447–50
    9. 9. Environmental control: Effect of hypochlorite in highly endemic ward Mayfield JL. Clin Infect Dis 2000;31:995–1000
    10. 10. Novel Risk Factors, Washington University Prevention Epicenter (n=36,086)‏ CI=confidence interval; IV=intravenous; OR=odds ratio. Dubberke ER, et al. Clin Infect Dis. 2007;45:1543-1549. 0.5 (0.3–0.6)‏ Metronidazole 1.9 (1.3–2.7)‏ IV vancomycin, >7 days 2.5 (1.8–3.5)‏ Fluoroquinolones, >7 days 1.6 (1.3–2.1)‏ Proton pump inhibitors 2.0 (1.6–2.5)‏ Histamine-2 blockers Medications 4.0 (2.9–5.6)‏ >1.4 2.9 (2.1–4.2)‏ 0.3–1.4 Reference <0.03 C. difficile -associated disease pressure OR (95% CI)‏ Risk Factor by Multivariable Analysis
    11. 11. Quinolone Restriction Period Nimber of Defined Daily Doses 2005 2006 2007 Month and Year Impact that Restricting Fluoroquinolones can Have on Reducing Unnecessary Antimicrobial Use 0 500 1000 1500 2000 2500 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Aminoglycosides Cephalosporins (1st gen.)‏ Cephalosporins (2nd gen.)‏ Cephalosporins (3rd and 4th gen.)‏ Quinolones Vancomycin Piperacillin/Tazobactam Ampicillin/Sulbactam Azithromycin Carbapenems Aztreonam Clindamycin Kallen, et al. 18th Annual Meeting of The Society for Healthcare Epidemiology of America (SHEA), April 6, 2008; Orlando, FL.
    12. 12. Desperate Measures for Desperate Times: Restricting all Fluoroquinolones to End an Outbreak Kallen, et al. 18th Annual Meeting of The Society for Healthcare Epidemiology of America (SHEA), April 6, 2008; Orlando, FL. Number of Cases Month and Year Beginning of outbreak period Quinolone restriction New housekeeping company Quinolone restriction partially lifted 2004 2005 2006 2007
    13. 13. <ul><li>Hospitals should conduct surveillance for CDI </li></ul><ul><ul><li>Track positive laboratory results </li></ul></ul><ul><ul><li>Consider measures to track outcomes </li></ul></ul><ul><li>Early diagnosis and treatment important for reducing severe outcomes and reducing transmission </li></ul><ul><li>Strict infection control: CDC Fact Sheet* </li></ul><ul><ul><li>Contact precautions for CDI patients </li></ul></ul><ul><ul><li>An environmental cleaning and disinfection strategy </li></ul></ul><ul><ul><li>Hand-washing with CDI patients in outbreak </li></ul></ul><ul><li>Antimicrobial management </li></ul>Recommendations for Hospitals *See CDC C. difficile Fact Sheets: http://www.cdc.gov/ncidod/dhqp/ .
    14. 14. CDI in Previously Low-Risk Populations <ul><li>10 Pregnant women </li></ul><ul><li>23 Generally healthy persons in the community </li></ul><ul><li>Cases without precedent antimicrobial use </li></ul>Centers for Disease Control and Prevention. MMWR Morbid Mortal Wkly Rep . 2005;54:1201-1205.
    15. 15. Recommendations for Surveillance of Clostridium difficile Infection Admission Discharge < 4 weeks 4-12 weeks HO-HCFA CO-HCFA Indeterminate CA-CDI Time 48 h > 12 weeks * HO: Hospital (Healthcare) onset CO-HA: Community Onset Healthcare-associated CA: Community Associated * Depending upon whether patient was discharged within previous 4 weeks, CO-HA vs. CA CDAD Surveillance Working Group. Infect Control Hosp Epidemiol 2007; 28:140-145
    16. 16. Clostridium difficile Infection (CDI) cases N = 1046 Healthcare facility–onset Healthcare facility-associated (HO-HCFA)‏ N=584 (56%)‏ (Including 142 with onset in another HCF)‏ Community Onset **Excluded: Prisoner: 8 Out of State:20 Bone Marrow Transplant: 17 Hemodialysis:29 Community Onset Healthcare facility-associated (CO-HCFA ) Indeterminate Community Associated (CA) N= 462 (44%)‏ 40 (4%)‏ 94 (9%)‏ 208 (20%)‏ Unknown Excluded** 46 (4%)‏ 74 (7%)‏ Adapted from Kutty PK, et al. Infect Control Hosp Epidemiol. 2007;29:197-202.
    17. 17. ToxV (BK/NAP7-8/078) Strains; Historically Rare, Recently More Common <ul><li>Tox V Isolates </li></ul><ul><li>10/6000 </li></ul><ul><li>10/600 </li></ul><ul><li>6/125 </li></ul>Jhung MA, et al. Second International Clostridium difficile Symposium, June 6-9, 2007; Maribor, Slovenia. Jhung MA et al. Emerg Infect Dis 2008;14:1039-45 <ul><li>Time </li></ul><ul><li>Prior to 2001 </li></ul><ul><li>2001-2005 </li></ul><ul><li>2006 </li></ul>
    18. 18. Human CDAD Caused by Strains Similar to Animal Epidemic Strains, 2001–2006 Jhung MA, et al. Second International Clostridium difficile Symposium, June 6-9, 2007; Maribor, Slovenia. Source Binary toxin Toxino type tcdC deletion Human Human Human Pig Pig Pig Pig Pig Pig Pig Pig Human Human Human Human Hosp Env V V V V V V V V V V V V V V V V + + + + + + + + + + + + + + + + + 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp
    19. 19. Summary <ul><li>Rates, mortality, and costs associated with CDI continue to increase </li></ul><ul><li>Much of this increase may be due to emergence and spread of BI/NAP1/027 </li></ul><ul><li>Hospital rates can be controlled through tiered implementation of existing and enhanced recommendations </li></ul><ul><li>Disease becoming more notable in previously low-risk populations </li></ul><ul><li>Community-associated disease appears associated with variant toxinotypes </li></ul><ul><li>Circumstantial evidence for animal-to-human transmission of toxinotype V strains </li></ul>

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