1. Building on Patient Safety Clostridium difficile practice opportunities Mary Ellen Scales RN MSN CIC Baystate Medical Center

2. Objectives At the conclusion of this session the participant will be able to :  Plan Clostridium difficile infection prevention strategies for their healthcare setting

3. Clostridium difficile practice opportunities Prevention strategies: 1. Identifying patients suspect or confirmed with CDI 2. Preventing transmission 3. Preventing recurrence Included in this presentation: Survey results, references, resources and opportunities to influence your practice

4. 1.Identification of Patients What are the main clinical symptoms of C. difficile-associated disease? Clinical signs/symptoms include:  watery diarrhea  fever  loss of appetite  nausea  abdominal pain/tenderness http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html#6

5. Definition of diarrhea http://www.thefreedictionary.com/diarrhea  Excessive and frequent evacuation of watery feces Diarrhea is defined by the World Health Organization as having 3 or more loose or liquid stools per day (or as having more stools than is normal for that person).

6. Date Time ColourType No Blood Mucus AmountCommentsInitials

7. 1.Identification of Patients Patients who are at increased risk for C. difficile-associated disease, Risk Factors:  antibiotic exposure  gastrointestinal surgery/manipulation  long length of stay in healthcare settings  a serious underlying illness  immunocompromising conditions  advanced age http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html#6

8. 1.Identification of Patients Microbiological testing Stool culture for C. difficile This is the most sensitive test available, but the one most often associated with false-positive results due to presence of non- toxigenic strains. Antigen detection for C. difficile These are rapid tests (<1 hr) that detect the presence of C. difficile antigen. They must be combined with toxin testing to verify diagnosis. Toxin testing for C. difficile Enzyme immunoassay detects toxin A, toxin B, or both A and B Tissue culture cytotoxicity assay detects toxin B only. * C. difficile toxin is very unstable. The toxin degrades at room temperature and may be undetectable within 2 hours after collection of a stool specimen. False-negative results occur when specimens are not promptly tested or kept refrigerated until testing can be done. http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html#6

9. Low magnification micrograph of colonic pseudomembranes in Clostridium difficile colitis, less precisely also known as pseudomembraneous colitis. The presence of pseudomembranes is not synonymous with Clostridium difficile colitis; pseudomembranes may arise due to other infectious organisms and/or bowel ischemia http://en.wikipedia.org/wiki/File:Colonic_pseudomembranes_low_mag.jpg Additional criteria for Clostridium difficile: Pseudomembranous colitis is seen during endoscopic examination or surgery; and Pseudomembranous colitis is seen during histopathological examination. MacDonald,L.C, et al ICHE February 2007, VOL. 28, NO. 2 Pseudomembraneous colitis

10. Microbiological testing Survey results: check all that apply

11. Microbiological testing Survey results: 24 respondents

12. Microbiological testing Survey results: if yes, check all that apply

13. Surveillance: develop a case definition for your institution or follow established surveillance criteria Patient criteria  Signs and symptoms  Admission/Discharge/ Transfer data  Microbiological testing Prior history of CDI Time frames regarding health care episodes for relevancy

14. Practice opportunities Signs and Symptoms:  Bristol Stool chart Laboratory testing:  Microbiological and Histopathological testing guidelines for your institution Surveillance definitions  NHSN module  NHSN/CDC*  Facility designed algorithm ( see BMC example in handouts) * McDonald, L.C. et al. Recommendations for Surveillance of Clostridium difficile- Associated Disease. Infection Control and Hospital Epidemiology; Feb 2007, Vol.28, No.2.

15. 2. Prevent transmission Hand Hygiene Patient Placement Transmission prevention Cleaning and disinfection of equipment and environment

16. Hand Hygiene APIC 1 : Perform hand hygiene upon removal of gown and gloves and exiting the patient’s room Use alcohol hand rubs for hand hygiene during routine infection prevention and control responses to C. difficile Hand washing is the preferred method when hands are visibly soiled Assess hand hygiene compliance to address obstacles to performance Patient /Visitor Education IDSA 2 : In outbreak or increased CDI rate, instruct visitors and healthcare workers to wash hands with antimicrobial soap and water after caring for or contacting patients with CDI 1.APIC Guide to the Elimination of Clostridium difficile in Healthcare settings 2008 2.SHEA-IDSA Cohen, S. H. et al, Guideline Infection Control land Hospital Epidemiology May 2010 Vol 31, No. 5

19. Patient Placement APIC 1 : Place patients with CDI on Contact precautions in private rooms when available. Preference for private rooms should be given to patients with fecal incontinence. If a private room is not available, cohort patients with CDI, however not with patients with other organisms of significance (MRSA,VRE, Acinetobacter) Put on a gown and gloves to enter the patient’s room IDSA 2 : Patients with CDI to be placed in a private room on contact precautions. If single room is not available, cohort patients, providing a dedicated commode for each patient. Maintain contact precautions for the duration of diarrhea. Healthcare workers and visitors must use gloves and gowns on entry to a room of a patients with CDI. 1.APIC Guide to the Elimination of Clostridium difficile in Healthcare settings 2008 2.SHEA-IDSA Cohen, S. H. et al, Guideline Infection Control land Hospital Epidemiology May 2010 Vol 31, No. 5

24. Example of isolation rounds tool in packet How many patients in each category and opportunity add categories How many patients with barrier supplies missing Patient details

25. APIC 1 : Use dedicated equipment (blood pressure cuff, thermometer, stethoscope) Use EPA –approved germicide for routine disinfection during non-outbreak situations Ensure personnel allow appropriate contact time and are appropriately trained. Address specific items in daily cleaning in patient’s room Disinfect all shared items between patients Monitor adherence to cleaning and disinfection processes IDSA 2 : Identify and remove all potential environmental sources of C. difficile, including rectal thermometers, replace with disposables. With increased rates of CDI, use chlorine containing cleaning agents or other sporicidal agents to address environmental contamination. Routine environmental screening for C difficile is not recommended 1.APIC Guide to the Elimination of Clostridium difficile in Healthcare settings 2008 2.SHEA-IDSA Cohen, S. H. et al, Guideline Infection Control land Hospital Epidemiology May 2010 Vol 31, No. 5 Cleaning and Disinfection of Equipment and the Environment

31. Practice opportunities Hand hygiene  Soap and water  AHR Patient placement  Precautions  Cohorting  Barrier attire availability Cleaning and Disinfection of Equipment and Environment  Practice  Products  Process

32. 3. Prevent recurrence Antimicrobial stewardship Home Care

33. APIC 1 : Implement a program that supports the judicious use of antimicrobial agents Program should incorporate a process that monitors and evaluates antimicrobial use and provides feedback to medical staff and facility leadership IDSA 2 : Minimize the frequency and duration of antimicrobial therapy and number of antimicrobial agents prescribed to reduce CDI risk Implement an antimicrobial stewardship program. Antimicrobials should be based on the local epidemiology and C difficle strains present, but restricting the use of cephalosporin and clindamycin ( except for surgical prophylaxis) may be particularly useful. 1.APIC Guide to the Elimination of Clostridium difficile in Healthcare settings 2008 2.SHEA-IDSA Cohen, S. H. et al, Guideline Infection Control land Hospital Epidemiology May 2010 Vol 31, No. 5 Antimicrobial Stewardship

35. Practice opportunities for the team Antimicrobial stewardship program  Antimicrobial ordering, restriction, monitoring Home care  Education  Hygiene  Barrier attire

36. Objectives At the conclusion of this session the participant will be able to :  Plan Clostridium difficile infection prevention strategies for their healthcare setting