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2013 CLOSTRIDIUM DIFFICILE EDUCATIONAL AND CONSENSUS CONFERENCE March 11-12, 2013
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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
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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
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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: 281-9.) 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).
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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
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Hospital Transmission
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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.
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APIC Pace of Progress Survey January 14-28 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
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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
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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.
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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.
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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
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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.
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Heightened Tier Create an Antibiotic Stewardship Program (ASP) Patient hand hygiene- education and access Feedback of rates to staff and administration- make everyone aware
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