C. difficile Update Kim Vermedal, RN, MSN, CIC APIC January 25, 2019

The Gut Microbiome & Disease Prevention Microbiome is a collection of 39 trillion microbes in our GI tract (predominantly the colon) Healthy microbiome protects the body from disease Preclude emergence of pathogens/MDRO’s Prevent changes to the microbial metabolome Preserve healthy gut function

Testing Multistep testing required One step testing-half of positives are not CDI 25% of CDI resolves on its own Do not test asymptomatic patients

Algorithm

Pediatric Testing High prevalence of asymptomatic carriage Never routinely recommended for neonates or infants < 12 months of age with diarrhea Should not be performed in children with diarrhea 1-2 years of age unless other infectious or non-infectious causes have been excluded

Antibiotic Stewardship IDSA Guidelines for decreased length of antibiotic therapies UK eliminated the most toxic subtype of C. difficile with stewardship (Fluorquinolones and Cephalosporin's) 41% increase in abx prescriptions in the outpatient setting by NP’s/PA’s. 15% decrease ordering by physicians

Community Acquired On the increase Usually less severe infection How is it spread in those patients without healthcare contact? 82% with outpatient exposure It's on surfaces 39.7% on shoe bottoms in one community study

Fecal Transplants Can prevent reoccurrence Many failures related to incorrect initial testing Trials in process to use for initial acute phase diagnosis In the near future-capsules

The Future is Close Vaccines in clinical trials New antibiotics with narrow spectrum focus 40 new antibiotics in development-only 1 in phase three trial stage Other compounds to maintain microbiome Extended tapers of Vancomycin-QOD FMT as primary treatment for CDI

SARMC Criteria for Testing Patient must have: ≥3 watery stools in the past 24 hrs (sample conforms to specimen container) Formed stool samples will be rejected. In rare suspicion of ileus/toxic megacolon 2ndary to C diff, consider rectal swab. AND At least 1 of the following: o Abdominal pain/discomfort (cramping, bloating) o Antibiotic therapy within last 3 months o Gastric acid suppression (proton pump inhibitor or H2 blocker) o GI surgery within last month o Resident of SNF, age >65 o Chemotherapy within last month o Hospitalization within last 2 months o C diff infection within last 90 days (unless tested within last 7 days or tested positive within last 30 days)

Criteria None of the following are applicable: Laxatives, Bowel prep or other current medications that are known to cause diarrhea within last 3 days TPN infusion Tube feedings Other infectious or parasitic sources of diarrhea are unlikely Acute resolution of bowel obstruction Expected post-operative diarrhea (post-operative day 0-2)--if unsure, clarify with provider Ileostomy or short bowel syndrome

Testing Algorithm Antigen/toxin testing first PCR if indicated Remember never order for test of cure

Removal for Isolation Has completed at least seven days of therapy Has formed stool Is capable of performing personal and hand hygiene with soap and water.

Questions?