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

• 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 Cleaning

• 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

• C. diff Bundle

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

• 2014 development of BPA with screening prompts on

admission for symptoms of C difficile.

Interventions to control transmission of Clostridium difficile

• 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
• rigin 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.

• C. diff Testing Changes

EIA Algorithm Introduction

• 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

Methods

• Impact on C.diff Detection

Results

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

• Impact on C.diff Complications

Results

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

• Impact on ABX Usage

Results

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

• Impact on Mortality

Results

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

*Complications: colon surgery, megacolon, acute kidney failure

• 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

Results

• 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.

Conclusions