2013 CLOSTRIDIUM DIFFICILE EDUCATIONAL AND CONSENSUS CONFERENCE March 11-12, 2013

Overview  Changing Epidemiology  More community acquired, role of asymptomatic carriers  New treatments and therapies  Antibiotic Stewardship- effectiveness  Testing methods  Control Strategies  Enhanced precautions, duration of precautions, significance of shedding, asymptomatic colonization source for contamination of environment  Environmental Cleaning  Increase in monitoring, new technologies- UV lights, vaporized hydrogen peroxide  Public Reporting- Government Focus

Changing Epidemiology  BI/NAP1/027 strain now found in 30%-40% of CDI cases in North America.  Lower cure rate, higher recurrence rate  North American CDI incidence is stable to increasing while EU and UK rates have declined  More community associated infections

Treatment and Prevention  Fidaxomicin is the first new antibiotic CDI treatment in 25 years.  Recurrence rate 12.8% vs. 25.3% with vanco (Cornely et al. Lancet ID 2012; 12: )  Primary prevention of CDI is coming:  Vaccines (3 vaccines in clinical trials- phase 1 and phase 2)  Immunologics (monoclonal antibodies in phase 3)  Biotherapies (fecal transplants and non-toxogenic C. diff colonization – phase 2).

Enhanced Environmental Cleaning  Monitoring cleanliness- ATP, fluorescent gel markers  UV Lights  Expensive  Depending on room configuration can take 20 minutes to kill C. diff spores  Vaporized Hydrogen Peroxide  Expensive  Cycling time can be as long as 2-3 hours

Hospital Transmission

Public Reporting- SIR  SIR risk adjusted based on these variables.  Both the diagnostic testing method and prevalence on admission (CA cases) found to help predict number of expected HA CDI cases.

APIC Pace of Progress Survey  January th, 2013  1,087 APIC members responded- 78% acute care, 45% >200 beds.  Since last CDI survey in 2010:  70% have added more interventions, but only 42% have seen a decline in HA-CDI rates.  42% keep patients in isolation until discharge  77% soap and water hand washing only

APIC Pace of Progress Survey  55% use ATP or fluorescing products to monitor environmental cleaning  67% use bleach for all daily and terminal cleaning of CDI rooms Only 9% use bleach for all rooms at all times 7% use UV lights, 1% use vaporized hydrogen peroxide  60% have an antibiotic stewardship program  50% have initiated patient education programs

Current CDI prevention measures effective for high CDI incidence  Additional research needed in order to drive incidence much below 4-6 infections per 10,000 pt days.

2013 APIC Guide to Preventing C. diff  Outlines a tiered approach to CDI transmission prevention: routine and heightened.  Moving from the routine tier to the heightened tier does not mean all of the heightened activities need to be added.  Recommended to move to the heightened tier when there is evidence of ongoing transmission of CDI, an increase in CDI rates, and/or a change in the pathogenesis of CDI.

Heightened Tier  Perform daily rounds to identify patients with diarrhea (that may be related to CDI)- isolate immediately.  Consider placing all patients with diarrhea into CP until can rule out CDI.  Consider CDI specific sign- bleach use  Strict hand washing (soap and water) only  Increase monitoring of compliance with CP and hand hygiene

Heightened Tier  Continue CP even when diarrhea has resolved- consider extending to discharge.  Use bleach for disinfection of patient’s room and equipment used in room  Use bleach daily and at discharge for CDI patients  With continued CDI rates, consider expanding house wide.  Monitor and enforce adherence to cleaning and disinfection process.  Consider use of other technologies: UV lights, vaporized hydrogen peroxide.

Heightened Tier  Create an Antibiotic Stewardship Program (ASP)  Patient hand hygiene- education and access  Feedback of rates to staff and administration- make everyone aware