CME lecture on Clostridium Difficle Infection

1. The Colossal Impact of Clostridium Difficile Infection

2. Introduction & Epidemiology

3. Introduction & Epidemiology

5. Introduction & Epidemiology
Health officials now rank C. diff on par with MRSA
as one of the top two infections acquired in hospitals.

6. • Decreasing Prevalence of CDI at the
NAH since the launch of :
* Antimicrobial Stewardship Program,
* Switch over to PCR- Lab testing &
* Tighter Infection Control measures
 National average is 7%–26% among
adult inpatients in acute care facilities
Courtesy:
 Syed Ali,
Laboratory Director
 Debbie Graham,
Infection Control
 Jillian Baranggay,
Quality Improvement

7. Case Definition of CDI

8. Measurement: Outcome
Categorize Cases by location and time
of onset†
Admission Discharge
< 4 weeks 4-12 weeks
HO CO-HCFA Indeterminate CA-CDI
Time
2 d > 12 weeks
*
HO: Hospital (Healthcare)-Onset
CO-HCFA: Community-Onset , Healthcare Facility-Associated
CA: Community -Associated
* Depending upon whether patient was discharged within previous 4 weeks, CO-HCFA vs. CA
† Onset defined in NHSN LabID Event by specimen collection date
Modified from CDAD Surveillance Working Group. Infect Control Hosp Epidemiol 2007;28:140-5.
Day 1 Day 4
Standardized Case Definitions for Surveillance

9. Sunenshine et al. Cleve Clin J Med. 2006;73:187-97.
Pathogenesis of CDI
4. Toxin A & B Production
leads to colon damage
+/- pseudomembrane
1. Ingestion
of spores transmitted
from other patients
via the hands of healthcare
personnel and environment
2. Germination into
growing (Vegetative)
Form)
3. Altered lower intestine flora
(due to antimicrobial use) allows
proliferation of
C. difficile in colon

10. Risk Factors of CDI

11. Risk Factors of CDI

12. Changing Epidemiology of CDI
CA-CDAD (NAP1/BI/027-The Hypervirulent strain)
NAP1

13. C. diff’ Detectives Track a
Murderous Global Microbe

14. Routes of Transmission
Epidemiology of Colonization and Infection

15. Clinical Manifestations

16. Clinical Manifestations

17. Diagnosis
What is the Best Testing Strategy to Diagnose CDI

18. Diagnosis
What is the Best Testing Strategy to Diagnose CDI

19. Diagnosis
Specimen Collection and Transport

20. Diagnosis of CDI

21. Diagnosis of CDI

22. Management of CDI

23. CT Findings
•bowel wall thickening (most common)
•CT equivalent to thumbprinting
•accordion sign
•shaggy mucosal outline
•pericolic stranding
•peritoneal free fluid
•although typically the whole colon is
involved, the right colon and transverse colon
may be affected in isolation in up to 5% of
cases 2
•rectal involvement in the vast majority of
cases (90-95%)
Management of CDI

24. Treatment of CDI
Surgical options

26. Oral Vancomycin Taper
In managing multiple
relapsers.
It consists of 125 mg four times
daily for 14 days,
then 125 mg bid. for 7 days, 125
mg once daily for 7 days, 125
mg once every other day for 8
days, and finally
125 mg once every 3 days for
15 days.

27. Cost Comparison

28. Additional & Adjuvant Therapy
• Fidaxomicin
• Rifaximin or Rifampin-
• Nitazoxanide
• Monoclonal antibodies-
• Intravenous immune globulin (IVIG)

29. Treatment of Recurrent CDI
Fecal Microbiota Transplant (FMT)

30. Use of Probiotics

31. Infection Control and Prevention
Surveillance & Tracking

32. Core Prevention Strategies
http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html
Dubberke et al. Infect Control Hosp Epidemiol 2008;29:S81-92.

33. Prevention Strategies: Supplemental
C. difficile can survive on a dry surface for 60 days.
Alcohol-based hand sanitizers (Purell)- Do Not kill C.Diff spores

34. Infection Control = Antimicrobial Control

35. Antimicrobial Stewardship Program
NorwegianAmericanHospital
Implement Evidence-Based Practices to
Prevent Emergence
&
Improve Management of C. Difficile Infection

36. Antibiogram

37. 1%
6%
2%
5%
27%
58%
1%
Discontinue Redundant Coverage
Add Appropriate Cover for Culture
Narrow Spectrum of Activity
Discontinued with Antibiotic
Prescription
IV to PO Switch Made
Dosing Changed
ID Consult Suggested
Antimicrobial Stewardship
Interventions Performed
Antimicrobial Stewardship
Intervention Acceptance Rates
94%
6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Annual Totals
Recommended
Interventions
Performed
Recommended
Interventions not
Performed
Courtesy: Charlene Hope., Pharm D, Maali Haleh., Pharm D and P&T Dept.

38. Days of Doses Dispensed Continuation of Therapy
Courtesy: Charlene Hope., Pharm D, Maali Haleh., Pharm D and P&T Dept.

39. Improvement in the Treatment of
Clostridium Difficile Infection
Issues Identified
• Lab
• Pharmacy
• Physicians
Interventions Implemented
• Lab
• Pharmacy
• Physicians

42. References
http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html
http://www.uptodate.com/contents/clostridium-difficile-in-adults-treatment
http://jama.jamanetwork.com/article.aspx?articleid=1916296
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0105454
Special Thanks To: Infection Control, Quality Improvement, Laboratory & Pharmacy departments at NAH