Control of C Difficile: What Works, What Doesnt? Sylvia Pegg, RN, - PowerPoint PPT Presentation

Control of C Difficile: What Works, What Doesn’t? Sylvia Pegg, RN, BSN, CIC Senior Infection Preventionist

Acknowledgements : Dr. Werner Bischoff Health System Epidemiologist Wake Forest Baptist Health

North Carolina Healthcare-Associated Infections Report 2014

Interventions to control transmission of Clostridium difficile • 11/2013 Unit notification of newly identified C diff cases • Nurse driven protocol-proactive Enteric Isolation and test ordering for suspected C diff patients • Use of signs on alcohol hand sanitizers-please wash with soap and water for Enteric isolation patients • Developed cleaning tip sheet for Environmental Services. • Bleach cleaning of units with high prevalence of C diff.

Interventions to control transmission of Clostridium difficile Dedicated equipment for all patients: BP cuff, • stethoscope, glucometers when possible Visitor education using CDC C diff education • sheet. Education of staff focused on: • Raised awareness through in-time C. diff • notification and unit status report of C. diff situation to bedside staff, managers, and leadership; Proper hand hygiene with soap and water; • Appropriate patient isolation •

C. diff Cleaning • Always practice hand hygiene before donning gloves • Always practice hand hygiene with soap and water after removing gloves • Always use bleach to clean equipment used between patients and at discharge • Refer to Equipment Cleaning Guidelines for Nursing cleaning responsibilities • Safety Coach assists with compliance guidance

C. diff Bundle • Proactive isolation: use Enteric precautions at the first sign of diarrhea (observed or reported) • Community-onset C. diff requires collection of stool sample within 3 calendar days of admission • Use “No Alcohol Gel” signs on all Purell dispensers in the patient’s room • Assess and limit supplies to minimum in patient room; use dedicated/disposable equipment • Document No Stool and patient reports of loose stool in comments in WakeOne; complete date of last bowel movement • Communicate shift to shift using Shared Handoff in WakeOne including PRN staff, new staff, travelers, float pool, residents, etc. • Use and keep updated “Days Since Last HO C. diff ” signs in staff areas

No ALCOHOL GEL Use SOAP & WATER for 20 seconds to wash your hands! Patients confirmed with C. difficile during admission will remain on Special Enteric Precautions until discharge.

Housewide: Order Panel - Required Screening Questions

Interventions to control transmission of Clostridium difficile • 2014 development of BPA with screening prompts on admission for symptoms of C difficile.

C. diff Testing Changes • Effective Monday, April 4, 2016 routine nucleic acid amplification test (NAAT) testing of stool for Clostridium difficile infection (CDI) was discontinued. • Liquid stools from patients with greater than 3 stools per day with risk factors, clinical symptoms and signs of CDI are tested with a stepwise testing algorithm (STA) (two-component glutamate dehydrogenase (GDH) antigen/toxin A and B assays) as outlined below: For patients with a moderate to high pretest likelihood for CDI, C.diff EIA testing can be ordered • through WakeOne as C Difficile EIA. C.diff test interpretation will be included with the test result as communicated in WakeOne. • Order CDI EIA testing within 72 hours of admission for assessment of community or other hospital • origin of infection. Do NOT retest patients previously tested positive. • Gastroenterology will be able to order C.diff PCR testing in their outpatient clinic for colonization • and infection assessment, particularly when fecal transplant is being considered. For C.diff EIA tests interpreted as indeterminate, approval from CAUSE, or for pediatric patients — • Peds ID, will be needed for further PCR testing. Do NOT test infants (< 1 y/o) for C.diff, as even if the test is positive, they do not develop • symptoms but are merely colonized with C.diff. Any testing for this age group will require approval from Peds ID.

EIA Algorithm Introduction

Methods • Setting: 885 bed academic Medical Center • Design: pre-/post design (12 months each) • Objective: Assess the effect of the STA • Outcome measures: • Enterocolitis due to C.diff (CDE) • NHSN C.diff LabID events • CDI complications (colon surgeries, acute kidney failure, megacolon) • Mortality • Antimicrobial prescription patterns • Cluster occurrences • Testing, treatment, and isolation costs • Data sources: ICD-9/10 diagnosis codes, infection prevention data, laboratory data

Results • Impact on C.diff Detection Before Intervention After Intervention Events/10,000 pat. Events/10,000 pat. OR (95% CI) p-value days days 0.35 C.diff Enterocolitis 30.83 10.74 <0.0001 (0.33, 0.36) ICD 9/10 codes HO NHSN C.diff 0.22 13.62 2.96 <0.0001 LabID event (0.17, 0.28) CO NHSN C.diff 0.26 12.20 3.12 <0.0001 LabID event (0.20, 0.33) CO-HCFA NHSN 0.25 6.32 1.56 <0.0001 C.diff LabID event (0.17, 0.35)

Results • Impact on C.diff Complications Before Intervention After Intervention Events/10,000 pat. Events/10,000 pat. OR (95% CI) p-value days days 0.99 Colon Surgery Total 59.47 58.66 0.72 (0.92, 1.06) 0.39 Colon Surgery C.diff 11.04 4.30 <0.0001 (0.31, 0.49) 0.35 Megacolon Total 10.4 3.67 <0.0001 (0.28, 0.45) 0.29 Megacolon C.diff 7.13 2.07 <0.0001 (0.21, 0.40) Acute Kidney 1.05 1,529 1,608 <0.0001 Failure Total (1.04, 1.07) Acute Kidney 0.45 111.5 49.8 <0.0001 Failure C.diff (0.42, 0.48)

Results • Impact on ABX Usage Before Intervention After Intervention Events/10,000 pat. OR (95% Events/10,000 pat. days p-value days CI) Metronidazole Oral 0.68 56.29 38.34 <0.0001 Total Usage (0.63, 0.74) Metronidazole Oral 0.30 4.08 1.22 <0.0001 C.diff Usage (0.20, 0.45) Vancomycin Oral 0.42 28.19 11.98 <0.0001 Total Usage (0.37, 0.48) Vancomycin Oral 0.39 7.48 2.95 <0.0001 C.diff Usage (0.30, 0.52)

Results • Impact on Mortality Before Intervention After Intervention Events/Monthly Events/Monthly OR (95% Inpatient Discharges p-value Inpatient Discharges (%) CI) (%) 0.95 Mortality Total 2.73 2.60 0.24 (0.88, 1.03) 0.38 Mortality C.diff 0.151 0.057 <0.0001 (0.24, 0.60) Mortality with 0.94 0.95 0.90 0.42 Complications* (0.82, 1.08) Mortality C.diff and 0.41 0.072 0.030 0.0069 Complications* (0.22, 0.78) *Complications: colon surgery, megacolon, acute kidney failure

Results • Testing, Infection Prevention, and Costs • PCR/EIA testing frequency/pat. days: • 2.03% vs 1.66%; OR 0.82 (0.78, 0.85); p< 0.0001 • Infection Prevention: • Need for isolation reduced (748 patients vs 181 patients; -76%; p<0.0001) • No clusters/outbreaks detected pre/post intervention • Annual Cost Savings: >$175,000

Conclusions • Switch to an STA did not affect the diagnosis, treatment, or control of clinically relevant CDI in our institution. • Benefits included avoidance of unnecessary antibiotic treatment, reduction in isolation, achieving publicly reported objectives, and costs savings. • Selection of clinically relevant tests can help to improve hospitalization and treatment of patients and should be considered as part of diagnostic stewardship.