Clostridium difficile Update OMC Infection Prevention August 2018

C DIFF Across the Nation Rates of C DIFF have tripled since 2000 The burden of C DIFF is nearly 500,000 infections annually associated with up to approximately 30,000 deaths The cost associated with inpatients alone is in excess of $4.8 billion

OMC HO CDiff In 2018 - 5 out of the 7 were inappropriately sent or ordered.

OMC CDIff 2018 volume

July cases 10/13 patients received protonix during hospital stay prior to developing c.diff 7/13 No UV disinfection upon discharge 2/13 Not appropriate for testing (TF; Lax) 2/13 Delay in specimen (diarrhea POA)

Ordering info 5/13 ordered on weekend/holiday Service: Family Medicine 3 ID 3 Internal Medicine 2 Renal 2 Oncology 1 Pulmo 2

Interventions EVS team training off shift to use UV light Daily safety huddle reinforcing disinfection of equipment/environment Prioritize patient list with EVS team Daily review by IP of pending orders

C DIFF is Publically Reported All positive C DIFF PCRs are reported into the CDC’s national electronic surveillance system, NHSN where data is accessed by CMS and others Any positive C DIFF PCR on or after hospital day 4 is considered to be hospital onset regardless of whether or not the patient is known to have had a prior infection Utilizing appropriate clinical testing guidance helps to capture infection versus colonization

C DIFF Prevention Efforts Capture C DIFF that is present on admission by sending the specimen within the first 3 hospital days There is a nursing protocol to assist in capturing these specimens on admission Utilize appropriate clinical testing guidance to decrease the chance of detecting colonization versus true infection The PCR test is VERY sensitive and will identify CDIFF toxin B even after symptoms have resolved PCR doesn’t differentiate if colonized or infected

C DIFF Prevention Efforts Prompt isolation of any patient being ruled out for C DIFF Patients being ruled out for C DIFF require a private room Patients are guilty until proven innocent!! Use of appropriate PPE and dedicated patient care equipment when in the patient’s room Terminal cleaning of the patient’s room along with the use of UV light technology by EVS to disinfect the environment C DIFF spores can survive for months on surfaces left untreated. HAND HYGIENE: With SOAP and WATER upon leaving the patient’s room!! Alcohol is ineffective against spores.

C DIFF Prevention Efforts The lab with automatically cancel the order for C DIFF when… Specimens are not received in the lab within 24 hours of the order being placed Specimens are received within 90 days of a positive PCR result

CDIFF PCR Order Set

New Treatment Guidelines Initial Episode: Vancomycin 125mg PO QID x 10 days Initial Episode FULMINANT: Hypotension or shock, ileus, megacolon Vancomycin 500mg PO/NG TUBE Q6h x 10 day If ileus add the following to the Vancomycin 500mg oral: Metronidazole 500mg IV Q8h x 10 days AND Vancomycin 500mg/NS irrigation rectal Q6h x 10 days, please retain for 60 min First, Second or Subsequent Recurrence: Vancomycin Taper Vancomycin 125mg PO QID x 14 days AND Vancomycin 125mg PO BID x 7 days AND Vancomycin 125mg PO Daily x 7 days AND Vancomycin 125mg PO Q48h x 14 days OR Fidaxomicin 200mg PO BID x 10 days (Restricted to ID and GI)