brecher_stephen_-_indiana_leadership_conference.ppt

8/16/2019 BRECHER_STEPHEN_-_Indiana_Leadership_Conference.ppt

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Tres Difficile

Stephen M. Brecher PhDDirector of Microbiology

VA Boston Health Care SystemWest Roxbury, Massachusetts


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The opinions expressed in this

presentation are those of the

presenter and do not necessarilyrepresent the views of the Veterans

Affairs Health-Care Syste


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The Doinant Species

The h!an "ody has

#$#%

h!an cells anda ini! of #$#&

"acterial cells


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'verview

• Case reports

• Historical

perspective• Organism & key

properties

• Changing

epidemiology

•Disease

• Diagnosis

• Treatment

• Infection control


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Case St!dy #

• 60 yo male admitted to hospital for communityacuired pneumonia! treated "ith levoflo#acin anddischarged

• $ days later! seen at another hospital %ecause of'() pound "eight gain over last fe" days *+mya%domen has never %een so %ig,- andhypertension *'./06- 1fe%rile! 23C of 45)! al%umin .5! creatinine 05! no

diarrhea noted 1dmitted! treated for hypertension and ciproflo#acin

given to complete treatment for C178 discharged . dayslater


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Case St!dy # (cont)d*

Day 7resents to 9: . days after discharge

• ;ever *0-! diarrhea! generally feeling ill! noa%dominal pain

• 23C '$54


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Case St!dy # (cont)d*

Day . Transferred to >IC?! anuric!a%dominal pain! distension!developed cardiac complications!

ventilated! renal failure5 7oorprognosis and colectomy ruled outfollo"ing surgical consult

• Oral and rectal vancomycin added

• 23C @ .0


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Historical Perspective

• In the 60s it "as noted that patients on

anti%iotics developed diarrhea&

+staphylococcal colitis,

• Originally thought to %e caused %y S. aureus and treated "ithoral %acitracin

• >tool cultures routinely ordered for S. aureus

• 9arly $0s! a ne" e#planation

+clindamycin colitis,• >evere diarrhea! pseudomem%ranous colitis! and occasional

deaths documented in patients on clindamycin

5 or%ach >5 !"#M 5 8.AE64(65


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+Anti"iotic AssociatedPse!doe"rano!s Colitis D!e to

Toxin-Prod!cin, Bacteria• 3artlett and co("orkers& demonstrated

cytoto#icity in tissue culture and enterocolitis in

hamsters from stool isolates from patients "ith

pseudomem%ranous colitis Isolate "as C. ifficile

• Bacillus ifficilis *no" confirmed as C. ifficile-

"as cultured from healthy neonates *"ith

difficulty! hence the name- in .)'

5 3artlett F! et al5 !"#M 5 $48'4E ).().A5

'5 Hall FC and OGToole 95 Am # Dis Chil 5 .)8AE.0(A0'5


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!i/ Tie

5 2hy did it take so long to associate theorganism C. ifficile "ith the disease

15 Organism "as *is- found in healthy

infants

5 2hy do anti%iotics sometimes cause

diarrhea *unrelated to C. ifficile- 15 Disrupt the intestinal flora "hich plays a

maJor role in digestion of food


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Clostridium difficile

• ram(positive! anaero%ic! spore(forming

%acillus

• Kegetative cells die uickly in an aero%ic

environment

• >pores are a survival form and live for a

very long time in the environment

• ro"s on selective media in ' days and

smells like horse manure *p(cresol-


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0portance of Spores

• :esistant to heat! drying! pressure! andmany disinfectants

• :esistant to all anti%iotics %ecause

anti%iotics only kill or inhi%it activelygro"ing %acteria

• >pores survive "ell in hospital

environment• >pores are not a reproductive form! they

represent a survival strategy


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So!rce of 0nfections

• >pores in hospital! nursing home! or long(term

care environment associated "ith ill patients

arge num%ers of spores on %eds! %ed(rails! chairs!

curtains! medical instruments! ceiling! etc5• 1symptomatic carriers in those same

environments

o" risk compared to patients "ith active disease

• ;alse negative la% tests *lo" sensitivity-

• ?nkno"n in community %ased infections! %ut food

has %een implicated

5 Fhung L1! et al5 "merg $nfect Dis5 '0048AE0.(0A)5


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1is2 3actors for 0nfection

• Hospitali=ation or long(term care facility

• 1nti%iotics *some more than others-

• Increasing age *@6)! @@40-

• Co(mor%idity• >urgery

• 7roton(pump inhi%itors

•Community(associated cases 7eri(partum Close contact of CDI *C. ifficile infection- case

;ood


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Case St!dy 4

• . yo pregnant female *A "eeks! t"ins- seen at

a local 9: "ith history of

. "eeks intermittent diarrhea

. days cramping and "atery diarrhea >tool M for C. ifficile to#in

:eceived T/> for ?TI . months prior to 9: visit

1dmitted! treated "ith metronida=ole and discharged

:eadmitted ne#t day "ith severe colitis

Treated in hospital for 4 days "ith metronida=ole!

oral vancomycin and cholestyramine! discharged


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Case St!dy 4 (cont)d*

• :eadmitted A days later

Diarrhea and hypotension

>pontaneously a%orted her fetuses

>u%total colectomy! aggressive therapy

Died on .rd day

7ost(mortem sho"ed to#ic megacolon "ith

evidence of pseudomem%ranous colitis

LL2: )AE*A$-8'0('0)5


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5hat Can 5e 6earn 3ro

Case 47• 2e kno" nearly nothing a%out community

%ased CDI

• Testing for C. ifficile is no" %oth an in(

patient and out(patient test

• :isk factors other than colonic im%alance

mediated %y anti%iotics must %e

considered


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1ole of Anti"iotics

• 1ll anti%iotics *including metronida=ole and

vancomycin- are associated "ith CDI

• High(risk group

Clindamycin Cephalosporins/penicillins/%eta(lactams

;luorouinolones

• 1lteration of normal colonic flora thought to favor

gro"th of C. ifficile

1nti%iotics do not kno" they are suppose to kill/inhi%it

only the +%ad guys,


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Patho,enesis

Historical Perspective• Lost CDI "ere mild

Diarrhea "as main symptom

7seudomem%ranous colitis and to#ic

megacolon "ere rare

Discontinuing anti%iotics "orked in many

cases

High response rate to metronida=ole andvancomycin


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0ncidence of CD0

• ?nited >tates

CDI is not a reporta%le disease so e#act

num%er of cases and deaths remain unkno"n

3ased on discharge diagnoses! CDI cases

have tripled over last ) years

• ?nited


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Patho,enesis

• To#igenic strains produce ' large protein

e#oto#ins that are associated "ith virulence

To#ins 1 and 3

Lutants strains that do not make to#ins 1 and 3 arenot virulent

>ome strains make a third to#in kno"n as 3inary

To#in

• 3y itself! not pathogenic• Lay act synergistically "ith to#ins 1 and 3 in severe colitis

• Lore common in animal strains


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1symptomatic

C. ifficile

coloni=ation

Patho,enesis of CD0

C. difficile expos!re

Antiicro"ial

C. ifficile

infectionHospitali=ation

;rom Fohnson >! erding DB5 Clin $nfect Dis. 48'6E0'$(0.68 "ith permission5


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Patho,enesis

Chan,in, 8pideiolo,y• Increasing mor%idity and mortality noted

%eginning in '000

• Out%reaks in ?> & Canada *@'00 deaths-

• 2as this due to poor infection control!

emergence of anti%iotic resistance! or

something else

• 1 ne"! hypervirulent strain "as detected


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8pideic Strain

• >train typed 3I/B17/0'$&!'

• Is highly resistant to fluorouinolones'!A

• 3inary to#in genes are present• 7roduces large uantities of to#ins 1 and 3&!.

• Has a tcC gene deletion&

5 2arny L! et al5 %ancet 5 '00)8.66E0$(04A5

'5 Hu%ert 3! et al5 Clin $nfect Dis5 '00$8AAE'.4('AA5

.5 CDC ;act >heet5 Fuly '00)5A5 LcDonald C! et al5 ! "ngl # Me 5 '00)8.).E'A..('AA5

1dapted from LcDonald C! et al5 ! "ngl # Me. '00)8.).E'A..('AA8 "ith

permission5


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0n Vitro Prod!ction of Toxinsin 8pideic Strain

;rom 2arny L! et al5%ancet 5 '00)8.66E0$(

04A! "ith permission5


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9ot So 3ast

• ' recent papers uestioned "hether thisstrain is more virulent

B17( strain "as detected around ')P of

time in their hospital *3ID in 3oston- %ut "asnot associated "ith increased severity of

disease *non(epidemic setting-&

4 and . %p deletion containing strains "ere

not associated "ith increased severity of CDIat the Layo Clinic'

• 1ge @6) and prior BH stay implicated5 Cloud! F5 et al5 '005 Cl astro and Hept5 $E464(4$.

'5 Kerdoorn! 35 75 et al5 Diag Licro and ID5 0506/J5diagmicro%io5'00504)


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Sho!ld :o! Treat the Patient

or Treat the Strain7• :outine diagnostics la%oratory tests do not

provide strain type

• :outine tests not al"ays relia%le

• 1l"ays treat the patient %ased symptoms!

history! risk factors and markers of severe

disease


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Syptos of CD0

• 1symptomatic coloni=ation

• Diarrhea

mild→ moderate→ severe

• 1%dominal pain and distension

• ;ever

• 7seudomem%ranous colitis

• To#ic megacolon

• 7erforated colon→ sepsis→ death


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Mar2ers of Severe Disease

• eukocytosis 7rominent feature of severe disease :apidly elevating 23C ?p to @00 <

• @0 3L/day

• 1l%umin Q '5)• Creatinine '# %aseline• Hypertension

• 7seudomem%ranous colitis• To#ic megacolon• >evere distension and a%dominal pain


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6a"oratory Dia,nosis of

C. difficile 0nfection (CD0*


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5hich Test Sho!ld 0 ;se7

• Considerations 1ccuracy

Time to detection

7revalence in your population• >creening tests follo"ed %y confirmatory tests• In a lo" prevalence population! a screening test "ith a high

sensitivity is useful *no/fe" false negatives-

Cost

9ase of use• 1t this time! there is no perfect test for the

diagnosis of CDI


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5hat Sho!ld 0 do 3irst7

Lake some rules

• :ule E 1ccept only liuid stools or soft

stools

2hy 1ny 9#ceptions

• :ule 'E imit repeat testing once a patient

is positive

2hy 1ny e#ceptions


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The Specien

• ;resh is %est *test "ithin ' hours-

• iuid or loose! not solid

• If una%le to test "ithin ' hours! refrigerateat ARC for up to . days

• ;ree=e at ($0RC *not ('0RC- if testing "ill

%e delayed• >pecimen uality "ill influence test results

InE Manual Clin Micro. th ed5 '00$8p5 4$5


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6a"oratory Dia,nosis of CD0

6a"oratory6a"oratory

Dia,nosisDia,nosis

8n/ye 0!noassay (80A*8n/ye 0!noassay (80A*


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Conflictin, 1es!lts with 80A

5 >tamper 7D! et al5 # Clin Microbiol. '008A$E.$.(.$45'5 Lusher DL! et al5 # Clin Microbiol. '00$8A)E'$.$('$.5.5 >loan L! et al5 # Clin Microbiol. '0048A6E6('005A5 illigan 7H5 # Clin Microbiol. '0048A6E)'.()')5)5 Ticehurst F:5 # Clin Microbiol. '0068AAEA)(A565 Bice revie" %y 7lanche T! et al5 '0045 """5thelancet5com/infection

1ecently P!"lished 80A Papers(#-=*

Paraeter 1an,e

Sensitivity %4 > [email protected] ?4 > #$$

PPV =.& > ?=

9PV @@ > #$$


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80A Testin,

Advanta,es

• :apid

• Ine#pensive

• :elatively easy

• Bo costly euipment

• 3atch or single test

formats

Disadvanta,es

• reat variations in

pu%lished sensitivity

and specificity• Technologist error

• Contamination


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Most 1ecent St!dies

• Cdiff uik Chek Complete *DH and 9I1

on one test card-&

3oth M M

3oth ( (

.5'P discrepant! re(test5 ?se 7C:

• 7C: had very high >!>! 77K and B7K'

• 7C: resolved lo" false positive 9I1.5 uinn! C5 D5 '005 F Clin Licro%iol5 A4E 60.(60)

'5 Bovak(2eekley! >5 et al5 '005 F5 Clin Licro%iol5doiE05'4/FCL5040(0

.5 3recher! >5 et al5 '005 IC11C 1%stract D(A''


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Molec!lar-Based Assays

• 7olymerase Chain :eaction *7C:-• . ;D1 1pproved test kits

• ' of them are less e#pensive %ut more la%or

intensive• is easy enough to do that even I can do it! %ut is

e#pensive

• I recently s"itched from an 9I1 to the

e#pensive 7C: The cost of a misdiagnosed patient is too great!

especially for our Keterans


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Treatent

f


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Treatent of

Mild to Moderate Disease• >top anti%iotic*s- if medically reasona%le

• Letronida=ole Oral or IK! )00 mg TID for 0(A days is

standard therapy )'0P failure rate

'0P relapse rate

Can use a full 'nd

course for failure/relapse%ut %eyond ' courses! s"itch to vancomycin

;ailures not due to metronida=ole resistance


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0nitial Treatent 'ptions for CD0

• Historical response *6P- and relapse rates *'0P-

similar %et"een metronida=ole and vancomycin&

• Lore recently! efficacy of metronida=ole for severe

disease called into uestion'(A

• :ecent prospective trials report vancomycin to %e

superior to metronida=ole in severe CDI)($

1. Aslam S, et al. Lancet Infect Dis. 2005;5:549-557.

2. Fernandez A, et al. J Clin Gastroenterol. 2004;38:414-418.

3. Gerding !. Clin Infect Dis. 2005;40:1598-1"00.

4. #$s%er #, et al. Clin Infect Dis. 2005;40:158"-1590.

5. &a%$e '(, a)ids*n #. +%e 17t% # #eeting, #ar/% 31 t* Aril 4, 2007; #$ni/%, German.

Astra/t 1732215.

". ar FA, et al. Clin Infect Dis 2007;45:302-307.

7. &*$ie +, et al. +%e 47t% Ann$al AA #eeting, Set. 17-20, 2007; %i/ag*, &. Astra/t -425-a.


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0nitial Treatent 'ptions for CD0

Letronida=ole

')0 mg ID or

)00 mg TID

• Lay %e administered 7O or IK

• Development of resistance rare

• Historical first(line agent

Kancomycin

') mg ID

• 9ffective in enteral *oral or rectal- form only

• Typically reserved for severe disease! thosefailing to respond to metronida=ole! orcases in "hich metronida=ole iscontraindicated

6intra)en*$sl; *rall.

Feet . Am J Gastroenterol. 1997;92:739-750.

Gerding !, et al. Infect Control Hosp Epidemiol. 1995;1":459-477.

Ameri/an S*/iet *


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Metronida/ole vs Vancoycin

• ar et al& classified patients as mild or

severe CDI

• In mild disease! vancomycin "as slightly

%etter than metronida=ole *4P vs 0P-

Bot statistically significant

• In severe disease! vancomycin "as

significantly %etter than metronida=ole

*$P cure vs $6P cure-

5 ar ;1! et al5 C$D5 '00$8A)E .0'(.0$5


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Clinical S!ccess "y Disease

Severity Tolevaer Phase 000 1es!lts

Lild CDI .) 3L/day23C U)!000/mm.

Lild a%dominal pain due to CDI

Loderate CDI 6 3L/day23C )!00 to '0!000/mm.

Loderate a%dominal pain due to CDI

>evere CDI V 0 3L/day23C V'0!00/mm.8>evere a%dominal pain due to CDI

Defining CDI Disease Severity

&*$ie +, et al. +%e 47t% Ann$al AA #eeting, Set. 17-20, 2007; %i/ag*, &. Astra/t -425-a.

An *ne * t%e 3 deining /%ara/teristi/s assigns a atient t* t%e m*re se)ere /ateg*r.

M t id l V i


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Metronida/ole vs Vancoycin

vs Tolevaer

• 7atients stratified as mild! moderate! or severe

• Original goal of study "as to evaluate tolevamer

as a treatment for CDI

Dr!, Mild Moderate Severe

Tolevamer ) A6 .$

Letronida=ole $ $6 6)

Kancomycin 4) 40 4)

&*$ie et al. AA Astra/t=-425-9 2007


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C. difficile 0nfection Case %

• $(year(old "oman "ith multiple medical pro%lems admitted to

hospital for treatment of community(acuired pneumonia

• :esponds slo"ly to levoflo#acin $)0 mg daily

• 1fter 6 days Develops diarrhea * loose 3Ls-

23C countE !)00/mm.

• Day $A loose 3Ls! 23C count rises to !)00/mm.

• >tool testing for C. ifficile to#ins 1 and 3 is reuested

• Continued anti%iotic therapy for pneumonia is deemed necessary

• Ho" "ould you manage her care

15 1"ait stool test results and monitor her progress

35 9mpirically start metronida=ole 7O

C5 9mpirically start metronida=ole IK

D5 9mpirically start vancomycin 7O


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C. difficile 0nfection Case %

• $(year(old "oman "ith multiple medical pro%lems admitted tohospital for treatment of community(acuired pneumonia

• :esponds slo"ly to levoflo#acin $)0 mg daily

• 1fter 6 days Develops diarrhea * loose 3Ls-

23C countE !)00/mm.

• Day $A loose 3Ls! 23C count rises to !)00/mm.

• >tool testing for C. ifficile to#ins 1&3 is reuested

• Continued anti%iotic therapy for pneumonia is deemed necessary

• Ho" "ould you manage her care

15 1"ait stool test results and monitor her progress

35 9mpirically start metronida=ole 7O

C5 9mpirically start metronida=ole IK

D5 9mpirically start vancomycin 7O


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Treatent of Severe Disease

• ;ollo" definition of severe disease

@0 3L/day! high 23C! lo" al%umin

• This is a life(threatening infection

• >urgical consultation recommended as

patient may reuire a colectomy

•Oral vancomycin drug of choice Dose varies %ased on severity

Can add metronida=ole *oral or IK-


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Mana,eent of Severe CD0

• 9arly recognition is critical Initiate therapy as soon as diagnosis is suspected

• Lanage as for mild CDI plusE Oral vancomycin *') mg ID for 0 to A days- as initial

treatment• If patient is una%le to tolerate oral medication! consider

intracolonic vancomycin instillation *%y enema- 05) g vancomycin *IK formulation- in 05 to 05) of normal

saline via rectal *or ;oley- catheter

Clamp for 60 minutes

:epeat every A' hours

Gerding !, et al. Infect Control Hosp Epidemiol. 1995;1":459-477.

ar FA, et al. Clin Infect Dis. 2007;45:302-307.

&*$ie +, et al. +%e 47t% Ann$al AA #eeting, Set. 17-20, 2007; %i/ag*, &. Astra/t -425-a.

Aisarnt%anara A, et al. Clin Infect Dis. 2002;35:"90-"9".


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• 7otential role of intravenous immunoglo%ulin *IKI-&(6

1ntito#in 1 Ig predicts clinical outcome of CDI

>erum anti%odies to to#ins 1 and 3 are prevalent in

healthy populations

• :ecent studies in severe disease)!6

2ell tolerated in small num%ers of patients

Conflicting data regarding outcome improvement*mortality and need for colectomy-

• Often administered "hen surgery is considered imminent

1. Sal/ed* (, et al. Gut 1997;41:3""-370.

2. 'eales &.Gut. 2002;51:45".

3. =ne &, et al. En!l J "ed. 2000;342:390-397.

4. =ne &, et al. Lancet. 2001;357:189-193.

5. #/%ers*n S, et al. Dis Colon #ectum. 200";49:"40-"45.

". ($ang , et al. Am J Infect Control 2007;35:131-137.

Management of Severe,

Complicated CDI


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M!ltiple 1ec!rrent CD0

• :ates of recurrent CDI '0P after first episode&

A)P after first recurrence'

6)P after t"o or more recurrences.

• Letronida=ole or vancomycin resistance aftertreatment not reported

• :epeated! prolonged courses of metronida=ole not

recommended *risk for peripheral neuropathy-

• >everal empirical approaches have %een advocated

%ut most have no controlled data

1. Aslam S, et al. Lancet Infect Dis. 2005;5:549-557.

2. #/Farland &6, et al. Am J Gastroenterol. 2002:97:17"9-1775.

3. #/Farland &6, et al. JA"A. 1994;271:1913-1918.


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Treatent of 1ec!rrent CD0

• ;irst recurrence can %e treated in the same "ayas a first episode according to disease severity&

• Letronida=ole should not %e used %eyond first

recurrence or for @A days'

Concerns for hepatoto#icity and

polyneuropathy

• ;urther recurrences can %e treated "ith oral

vancomycin taper and/or pulse dosing'!.

1. Gerding !, et al. Infect Control Hosp Epidemiol. 1995;1":459-477.

2. #/Farland &6, et al. Am J Gastroenterol 2002;97:17"9-1775.

3. +edes/* F(, et al. Am J Gastroenterol . 1985;80:8"7-8"8.


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'ther Treatents

W 7atients "ho produce anti%ody to to#ins 1 and 3 usually do "ell so IKI has %een

tried5

Pro"iotics

1ifaxiin

Chasers

1ifapin

9ita/oxiide

0V0


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;nproven AdE!nctive Therapies

for 1ec!rrent CD07ro%ioticsSaccharomyces boularii

%actobacillus

Lay reduce the likelihood of further recurrences in somepatients "hen added to and continued after treatment "ithmetronida=ole or vancomycin(.

:ifampin 9fficacy in one series *n$- "hen added to vancomycinA

Bita=o#anide :esponse demonstrated in patients *n.)- "ho failedprior metronida=ole therapy) and similar response andrecurrence rates "hen compared "ith metronida=ole forinitial therapy *n0-6

:ifa#imin +chaser, 9ffective "hen used for A days after vancomycin therapy*n4-$

1. #/Farland &6, et al. JA"A. 1994;271:1913-1918.

2. #/Farland &6. J "ed "icro$iol. 2005;54:101-111.

3. S$ra>i/z #, et al. Clin Infect Dis. 2000;31:1012-1017.

4. '$gg ', et al. J Clin Gastroenterol . 1987;9:155-159.

5. #$s%er #, et al. J Antimicro$ Chemother . 2007;59:705-710.

". #$s%er #, et al. Clin Infect Dis. 200";43:421-427.

7. (*%ns*n S, et al. Clin Infect Dis. 2007;44:84"-848.

S h b l dii f CD0 P ti


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Saccharomyces boulardii for CD0 Prevention

5 Lc;arland5 #AMA5 A8'$E.(45

'5 >ura"ic= et al5 Clin $nfect Dis5 '0008.E0'(0$5

P P =0.04=0.04

?#etr*nidaz*le *r )an/*m/in *r 10@14 das plus la/e* *r S. $oulardii 1 g dail 4 >ees.

R

e c u r r e n t C D I

S. boulardii


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1ec!rrent CD0 1ifaxiin Chaser

• 9ight "omen "ith multiple recurrences :ifa#imin A00 mg 3ID for ' "eeks immediately

after completing last course of vancomycin

>even of eight patients had no further diarrhearecurrence

>ingle case of rifa#imin resistance *identified

after therapy- "ith recurrent CDI after a second

course of rifa#min

• 9ffective in interrupting recurrent episodes

%ut resistance may %ecome an issue

(*%ns*n S, et al. Clin Infect Dis. 2007;44:84"-848.


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• :ationaleE restoration of %acterial homeostasis

• 7reparation of donor specimen

;resh *Q6 hours- N.0 g or N' cm. volume

1dd )0 m 05P normal saline! and homogeni=e "ith%lender

;ilter suspension t"ice "ith paper coffee filter

• Delivered %y nasogastric tu%e follo"ing vancomycin

• :esults of 6 survivors had a single su%seuent recurrence

1ec!rrent CD0 3ecal

Transplantation

Aas (, et al. Clin Infect Dis. 2003;3":580-585.


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0nfection Control

• 2ash hands "ith "arm soap and "ater

Lechanical removal of spores

1lcohol does not kill spores

>tool is pre(treated "ith alcohol "hen gro"ing

C. ifficile

• Contact and %arrier precautions

• 7rivate room

• 1nti%iotic ste"ardship


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8fficacy of Hand Hy,iene Methods for 1eoval

of C. difficile Containation fro Hands

CF = colony forming units

? ierent r*m A


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Alcohol


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0solation and Barrier Preca!tions

• 7atients "ith CDI and incontinence should%e in private rooms or cohorted if privaterooms are not availa%le

• Contact precautions and isolation loves and go"ns reuired for direct contact and

contact "ith environment

Discontinuation of isolation "hen diarrhea resolves• Dedicated euipment "hen possi%le

G$ideline *r s*lati*n re/a$ti*ns, 2007.

Gerding !, et al. Infect Control Hosp Epidemiol . 1995;1":459-477.

Sim*r A, et al. Infect Control Hosp Epidemiol. 2002;23:"9"-703.


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8nvironental Disinfection

• :emoval/thorough cleaning of environmentalsources can decrease incidence

• ?se chlorine(containing agents *at least

)000 ppm availa%le chlorine 0 minutes contact

time- for environmental contamination! especiallyin out%reak areas

• ;ogging

*$tanen S#, Sim*r A. Can "ed Assoc J. 2004;171:51-58.

. Fa/t S%eet, ($l 2005.

#/#$llen =#, et al. Infect Control Hosp Epidemiol . 2007;28:205-207.

#aield (&, et al. Clin Infect Dis. 2000;31:995-1000.

Fa>le E!, et al. Infect Control Hosp Epidemiol . 2007;28:920-925.


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Antiicro"ial ;se 1estrictions

• 7ractice antimicro%ial ste"ardship• Decrease duration of e#posure and num%er

of antimicro%ial agents

• 3est evidence for controlling C. ifficile demonstrated "ith restriction of

cephalosporin or clindamycin

• :ecent reports of fluorouinolone restrictionhelping to control out%reaks

#/!$lt , et al. J Antimicro$ Chemother. 1997;40:707-711.

ear S#, et al. Ann Intern "ed. 1994;120:272-277.

lim* #E, et al. Ann Intern "ed. 1998;128:989-995.

=allen A(, et al. ne/t *ntr*l


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S!ary

• CDI is increasing in incidence! severity and pooroutcomes

• a%oratory diagnosis is challenging

Carefully evaluate "hat "orks %est in your setting• Bo reasona%le e#planation for treatment failures

• Community %ased infections are not "ellunderstood

• Improved therapies are needed• 9#tremely important to accurately detect and

aggressively treat severe disease

: Chroosoe


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Testis Deterinin, 3actor (TD3*

Pre-adolescent fascination with Arachnid

and 1eptilia (M'M-&;*Spittin, (P48*

Sittin, on the Eohn readin, (S0T*

0na"ility to express eotion over the

phone (M8-4*

Selective hearin, loss (H;H7*

Total lac2 of recall for dates (''PS*

itsc&ier, 5., Science, '661 +2)' p. )6


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Than2 yo!

brecher_stephen_-_indiana_leadership_conference.ppt

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