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abbreviated C.diff COCA presentation (short)


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This is an abbreviated version of the CDC's Sept 16 COCA conference call. I also uploaded a longer abbreviation. See this document for the web address of the original verison.

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abbreviated C.diff COCA presentation (short)

  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 (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 Unpublished data.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. How important are asymptomatic carriers in transmission? Riggs MM et al. Clin Infect Dis 2007; 45:992–8
  7. 7. Rationale to consider extending isolation beyond duration of diarrhea Bobulsky GS et al. Clin Infect Dis 2008; 46:447–50
  8. 8. Environmental control: Effect of hypochlorite in highly endemic ward Mayfield JL. Clin Infect Dis 2000;31:995–1000
  9. 9. 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
  10. 10. 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.
  11. 11. 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
  12. 12. <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: .
  13. 13. 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
  14. 14. 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>