cdiff presentation

S T E P H A N I E F U R L A N

CDIFF

WHAT ARE WE LOOKING AT?

• CDIFF is contagious, painful, and can be deadly!• What’s going on in the hospital regarding CDIFF

rates and trends?• How are we doing?• More HAI? More CAI?

• Who’s the most at risk?• What are the risk factors?• Which part of the hospitals have the most CDIFF

rates?

RISK FACTORS FOR DEVELOPING CDIFF

• Advanced Age (65 and older)• More likely to have a compromised immune system • Higher duration of stay in the hospital

“The daily increase in the risk of C. difficile acquisition during hospitalization suggests that duration of hospitalization is a proxy for the duration, if not the degree, of exposure to the organism from other patients with CDI.” (Wilcox, 2013)

• Acid reducing drugs (proton pump inhibitors, histamine 2 blockers)• Less acid in the stomach= greater possibility of bacteria reaching intestine/colon

and causing infection• Antibiotic use • Antibiotic use disrupts the normal microflora within the GI Tract!

• CDC (2013) reports that 96% of patients within hospitals who had become symptomatic for CDIFF had received antibiotics within 14 days before onset of diarrhea• ***ALL CDIFF patients had received antibiotics within 3 months• Some Antibiotics are more likely to inhibit the growth of CDIFF

Zosyn, Clindamycin, Rocephin, Levaquin• Especially skilled at killing bacteria in the gut (high powered

penicillins, tazobactam, etc)

RISK FACTORS FOR DEVELOPING CDIFF CONT’D

• Double Occupancy rooms- having a roommate who is asymptomatic for C-DIFF can be dangerous• CDC (2013)- 50% or more of hospital patients colonized by CDIFF are

symptomless carriers• Cancer chemotherapy is immunosuppressant therapy and causes a

weakened immune system• Same for immunosuppressant drugs (ie. Steroids)

• Autoimmune Disorders • Immunosuppressant diseases (ie , HIV, AIDS, Crohns, Addison’s) weaken

immune system, more susceptible to bacteria, viruses, etc.• GI procedures- disrupts microflora of gut, “stresses out” immune system

(Wilcox, 2013)• Post Pyloric-Tube Feedings- Feeding tubes can by-pass stomach

(stomach acid), and lead to the intestine. Bacteria can travel easily to their destination• Especially at risk if patient is being treated with antibiotics

RISK FACTORS CONT’D

• Previous ED visit and or Hospital Admission less than 30 days: • You are surrounded by sick people, others in ED might be

asymptomatic for CDIFF

NOSOCOMIAL INFECTIONS:

• Total Cases: 91 (December 2013- October 2014)• HAI: 43 cases (47.8 %)• Community Acquired: 48 cases (52.7%)

FREQUENCY DISTRIBUTION OF SEX

• Total: 43 cases• Females: 24 (55.8%)• Males: 19 (44.2%)

AGE

• Range 31-95 years of age • Mode: 67 (4 cases)• Mean: 65.70 years of age• Age of CDIFF HAI 65 and older: 60.5% (26 cases)• 62 and younger: 39.5 (17 cases)

GRAPH: POSITIVE DAYS AFTER ADMISSION

POSITIVE FOR CDIFF AFTER ADMISSION

• Total Cases: 43• 1) 3-5 days- 16.3% • Frequency- 7

• 2) 6 days to 1 week- 18.6% • Frequency 8

• ******3) 8 days to 2 weeks 30.2% • Frequency-13

• 4) 15 days to 3 weeks 18.6%• ` Frequency 8

• 5) 22 days to 4 weeks 11.6 %• Frequency 5

• 6)More than 4 weeks 4.7%• Frequency 2

GRAPH: HIGH RISK ANTIBIOTICS

ANTIBIOTIC +HIGH RISK ANTIBIOTIC TREATMENT DURING ADMISSION AND LAST 3 MONTHS

Antibiotic treatment during last 3 months and during

admission• Cases 43:

• Yes: 42 (97.7 %)• n/a: 1 (2.3 %)

High Risk Antibiotics during last 3 months and during admission

High risk Antibiotics:• 1: Rocephin

Frequency: 2 (4.7%)• 2: Levaquin

Frequency: 8 (18.6%)• *****3: Zosyn

Frequency: 9 (20.9%)

• 4 ClindamycinFrequency: 1 (2.3%)

*****5. NoneFrequency: 10

(23.3%)*****6. 2 High Risk Antibiotics

Frequency: 9 (20.9%)7. 3 or more high-risk antibiotics

Frequency 4 (9.3%_

Total Cases: 43

PREVIOUS ED + ADMISSION WITHIN 30 DAYS

Emergency Department Visit Within 30 days

• Total cases: 43:• Yes 12 (28%)• No: 31 (72%)

Admission within 30 days

• None: 30 cases (69.8%)

• 1 day stay: 9 cases (20.9%)

• 2 day admission: 1 case (2.3%)

• 3 day admission: 2 cases (4.7%)

• 9 day admission: 1 case (2.3%)

ACID REDUCING DRUGS AND/OR IMMUNOSUPPRESSANTS DURING ADMISSION

AND LAST 3 MONTHS

Acid Reducing Drugs During Admission

and/or last 3 months

• Total Cases: 43• Yes: 41 (95.3%)• No: 2 (4.7%)

• Immunosuppressants During Admission

and/or last 3 months

• Total cases: 43• Yes: 27 cases

(62.8%)• No: 16 cases

(37.2%)

GI PROCEDURES DURING ADMISSION + TUBE FEEDING

GI Procedures

• Total Cases: 43• Yes: 12 cases

(27.9%)• No: 31 cases

(72.1%)

Tube Feedings

Total Cases: 43• Yes: 21 cases

(48.8%)• No: 22 cases

(51.2%)

AUTOIMMUNE DISORDER AND CHEMOTHERAPY WITHIN LAST 3 MONTHS

Autoimmune Disorder

• Total cases: 43 • Yes: 13 (30.2%)• No: 30 (69.8%)

Chemotherapy within last 3

months

• Total Cases: 43• Yes: 5 cases (11.6%)• No: 38 cases

(84.4%)

ADMISSION TO AN ECF WITHIN 1 YEAR

• Total cases: 43• Yes: 6 cases (14%)• No: 37 cases (86%)

DOUBLE OCCUPANCY ROOMS

DOUBLE OCCUPANCY ROOMS + ISOLATION INITIATION

Double Occupancy Rooms

• Total Cases: 43• Yes: 13 cases

(30.2%)• No: 30 cases

(69.8%)

Isolation Initiation

• Total cases: 43• Same day as

positive: 20 cases (46.5%)• Already in single

room 17 cases (39.5%)• n/a: 6 cases (14%)

HXCDI + ID CONSULT

HXCDI

• Total Cases: 43• None: 36 cases

(83.7%)• Yes once before: 6

cases (14.0%)• Yes, more than once:

1 case (2.3%)

ID Consult

• Total Cases: 43• Yes: 16 cases

(37.2%)• No: 27 cases

(62.8%)

AGE STRATIFICATION

  62 and younger 65 and older

Cases 17 (39.5% of 43) 26 (60.5% of 43)

Average days positive after admission 6 days to one week 8 days to 2 weeks

(Yes) HXCDI 18% 15%

(Yes) Antibiotic Treatment 94% 100%

(Yes) High Risk Antibiotics 76% 76%

(Yes)Double Occupancy Rooms 17% 30%

(Yes) Previous ED visit less than 30 days 40% 61%

(Yes) Previous Admission Less than 30 Days  58% 20%

(Yes) Acid Reducing Drugs During Ad+3months 94% 96%

(Yes) Immunosuppressant drugs during ad+3mnts 59% 71%

(Yes) GI Procedures During Admission 23% 30%

(Yes) Autoimmune Disorder 35% 26%

(Yes) Chemotherapy within last 3 months 5% 15%

(Yes) Admission to ECF within 1 year 17% 11%

(Yes) ID Consult  59% 34%

(Yes) Tube Feedings 35% 57%

AREA OF 1ST SYMPTOMS (62 AND YOUNGER)

• Top areas• for 62 and younger:• AP5: 5 cases• 4NSSU: 3 cases• IMCU: 2 cases• EW7 2 cases

AP5 4NSSU IMCU 4SO EW4 EW7 4E AP3 5SO0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Area where symptoms first re-ported (less than or equal to age

62)

Location within hospital

Fre

quency

AREA OF 1ST SYMPTOMS (65 AND OLDER)

• Top areas for65 and older • AP5: 5 cases• EW7: 4 cases• IMCU: 3 cases• AP4: 3 cases• 5SO: 3 cases• AP3W: 2 cases

AP5 ICU IMCU AP4 AP3W EW7 5S0 5N 4NSSU0

1

2

3

4

5

6

Area where symptoms first reported (greater than or

equal to age 65)

Location within hospital

Fre

quency

AVG. CDIFF PREV. + PATIENT DAYS HOSPITAL WIDE

months 7 to 9 2013

months 10 to 12 2013

months 1 to 3 2014

months 4 to 6 2014

months 7 to 9 2014

0

0.4

0.8 0.773

0.2490.389 0.501

0.348

Avg. Hospital-wide Prev rates of CDIFF from 7/2013 to 9/2014

months (in quarters)Avg p

rev.

rate

per

100 a

dm

ins

months 7 to 9 2013

months 10 to 12 2013

months 1 to 3 2014

months 4 to 6 2014

months 7 to 9 2014

0

10 10.177

3.267

12.2818.715 10.253

Avg. CDIFF patient days Hospital wide from 7/2013 to 9/2014

months (in quarters)rate

pe

r 1

0,0

00

p

ati

en

t d

ays

Correlation Patient Days to Avg CDIFF Prev: .435

AVG CDIFF PREV + PATIENT DAYS IN 4NSSU

months 7 to 9 2013 months 10 to 12 2013

months 1 to 3 2014 months 4 to 6 2014 months 7 to 9 20140

0.4

0.8

1.2

1.6

0.935

0

1.426

1.012

0

Avg. prev. CDIFF rates in 4NSSU (4N) from 7/2013 to 9/2014

Months (in quarters )

Avg.

Pre

v r

ate

per

100

adm

ins

months 7 to 9 2013

months 10 to 12 2013

months 1 to 3 2014

months 4 to 6 2014

months 7 to 9 2014

02468

1012

0 0

11.123

6.68

0

Avg. CDIFF patient days in 4NSSU (4N) from 7/2013 to 9/2014

months (in quarters)

rate

per

10,0

00

pati

ent

days

Correlation Pt days and Avg. Cdiff rate: .805

AVG CDIFF PREV IN ICU

months 7 to 9 2013 months 10 to 12 2013

months 1 to 3 2014 months 4 to 6 2014 months 7 to 9 201402468

3.333

6.066

2.703

0

3.333

Avg. Prev . CDIFF rate in ICU from 7/2013 to 9/2014

Months (in quarters)Avg.

pre

v.

rate

per

100

adm

ins

months 7 to 9 2013

months 10 to 12 2013

months 1 to 3 2014

months 4 to 6 2014

months 7 to 9 2014

0

10

20

30

13.363

31.299

19.92

0

14.124

Avg. Cdiff patient days in ICU from 7/2013 to 9/2014

months (in quarters)

rate

per

10,0

00

pati

ent

days

Correlation Pt, days and Avg. Cdiff Rate: .941

AVG CDIFF PREV + PATIENT DAYS IN IMCU (6E)

months 7 to 9 2013 months 10 to 12 2013 months 1 to 3 2014 months 4 to 6 2014 months 7 to 9 20140

1

2

3

43.318 3.591

1.3342.032

1.35

Avg. CDIFF Prev. Rate in IMCU (6e) form 7/2013 to 9/2014

months (in quarters)rate

per

100 a

dm

ins

months 7 to 9 2013

months 10 to 12 2013

months 1 to 3 2014

months 4 to 6 2014

months 7 to 9 2014

05

10152025

16.103

9.523 10.582 11.82

21.825

Avg. CDIFF Patient Days in IMCU (6E) from 7/2013 to 9/2014

months (in quarters)

rate

per

10,0

00

pati

ent

days

Correlation Pt. Days and Avg. Prev. Rate: -.331

AVG. CDIFF PREV. +PATIENT DAYS IN 7E

months 7 to 9 2013 months 10 to 12 2013

months 1 to 3 2014 months 4 to 6 2014 months 7 to 9 20140

2

4

6

2.2071.471

3.6852.047

4.938

Average Prev. CDIFF rate in 7e from 7/2013 to 9/2014

months (in quarters)Avg.

Pre

v.

rate

per

100

adm

ins

months 7 to 9 2013

months 10 to 12 2013

months 1 to 3 2014

months 4 to 6 2014

months 7 to 9 2014

05

1015

0

7.62810.972

05.204

Avg Cdiff patient days in 7e from 7/2013 to 9/2014

months (in quarters)

rate

pe

r 1

0,0

00

p

ati

en

t d

ays

Correlation Pt. Days and Cdiff Prev: .278

AVG CDIFF PREV + PATIENT DAYS IN AP5

months 7 to 9 2013

months 10 to 12 2013

months 1 to 3 2014

months 4 to 6 2014

months 7 to 9 2014

0

1

2

3 2.725

1.384 1.429 1.3180.9445

Average Prev. CDIFF rate in AP5 from 7/2013 to 9/2014

months (in quarters)Avera

ge p

revale

nce

ra

te p

er

100 a

dm

ins

months 7 to 9 2013

months 10 to 12 2013

months 1 to 3 2014

months 4 to 6 2014

months 7 to 9 2014

0102030

21.76312.361 15.371 11.574

0

Avg. CDIFF patient days in AP5 from 7/2013 to 9/2014

months (in quarters)rate

per

10,0

00

pati

ent

days

Correlation Pt. Day and Cdiff Prev: .851

TAKE AWAY:

• More community acquired infections!• 48 CA cases compared to 43 HA

• Antibiotic + High Antibiotic treatment a risk of C-Diff Infection • Zosyn

• 2nd risk factor: Acid Reducing Drugs• Protonix, Pepcid

• Hospital wide patient days+ Avg. CDIFF Prev. is getting lower, but there are still “problem areas”!• 7E, ICU• Patient days and Avg. Cdiff Rates are rising!

• Units that have the most CDIFF rates:• AP5, 7E, 4NSSU

TAKE AWAY: AGE GROUPS

• Findings: Age group 65 and older are more at risk for developing C-DIFF

• 100% antibiotic treatment• More cases in Double Occupancy Rooms (30% compared to 17%)• More cases had Previous Ed Visit Less than 30 days (61% compared

to 41%)• More cases had acid reducing drugs: 96% yes!• Immunosuppressant drugs (71% compared to 59% (62 and younger)• More GI procedures during admission (30% compared to 23%)• Chemotherapy within last 3 months (15% compared to 5%)• Tube feedings

• Age group 65 and older less likely not to have ID consult: 64% of cases did not have ID consult!

• Age group 65 and older is staying longer in the hospital!• Longest stay 1+ month compared to 2 weeks in age group 62 and

younger!

REFERENCES

• Wilcox, M. (2013). New Clinical Practice Guidelines For Clostridium Difficile Infection. Infectious Diseases in Clinical Practice, 329-331.