c’est difficile…?
DESCRIPTION
C’est difficile…?. Martin Kiernan Nurse Consultant Southport and Ormskirk NHS Trust Vice President, Infection Prevention Society. Clostridium difficile. 1935 first described by as bacillus difficilis by Hall and O’Toole and classified as a commensal 1977 - PowerPoint PPT PresentationTRANSCRIPT
C’est difficile…?Martin Kiernan
Nurse ConsultantSouthport and Ormskirk NHS Trust
Vice President, Infection Prevention Society
Clostridium difficile
1935first described by as bacillus difficilis by Hall and
O’Toole and classified as a commensal1977
toxin isolated from stool samples produced a cytopathic effect in cell culture
1978C. difficile identified as source for toxin and
cause of psuedomembranous colitis
Microbiology
Gram positive, spore forming rod shaped bacillus
Obligate anaerobeProduces 2 major toxins
toxin A and toxin Bboth contribute to disease
Toxins responsible for manifestation of disease and marker for diagnosis
Annual Cases (England)
The authors of the latest 2009 guidelines considered that ‘it is the failure to implement the guidance described in the 1994 report that has contributed to the recent rise’Noted by the HPA and the HCC in 2006
So why are we where we are?
Financial Burden of C. difficileWilcox, Cunniffe et al, JHI; 1996
Cases stay an average of 21.3 days longerExtra costs
Treatment, Investigations, ‘Hotel costs’
Total identifiable costs over £4,000 per case2006 costs
My Trust - £400KNW SHA - 6,946 cases - £28 millionNHS - 55,681 cases - £222 million
NHS lost nearly 1.2 million bed days
Risk factors for disease
Chang and Nelson (2000)Age > 65 yearsAntibiotic therapy, particularly cephalosporins,
clindamycinUnderlying bowel diseaseProton pump inhibitorsPEG feedsPhysical proximity to symptomatic patient
C.difficile, ABx, PPIs
0
10000
20000
30000
40000
50000
60000
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
CDAD Antibiotic x1000 PPI x 1000
Case control study of Community CdI Wilcox, Mooney et al (2008)
Exposure to Abx in previous 4 weeksesp. multiple agentsHalf had no abx in the previous month
Hospitalisation in previous 6 monthsA third had neither hospitalisation not ABxContact with infants >2 years oldPPI not significantly more common
C. difficile strains
160 ribotypes of C. difficileType 001 most common in UK hospitals,
Community epidemiology differs Type 010 most common
All sensitive to metronidazole and vancomycinso far
Epidemiology of C. difficile is changingType 106
C. difficile 027
Hyper-toxin producer18 base pair deletion ? Red herring
16-20 times more toxin producedToxin produced earlier in the disease processOverwhelming of immune responsePresence of binary toxin
? Red herring
Diagnosis of C.difficile
Clinical diagnosissigmoidoscopy radiology
Toxin isolationcytotoxin assay 92% sensitivity & specificity
expensive and lengthy incubation requiredculture less efficientrapid immunoassay (less expensive, quick)
Smell…
Clinical manifestations of C.difficile
Asymptomatic carriage2% healthy adults16-35% recently treated with antibiotics
important reservoir in medical facilitiesshed organisms, contaminate environment
carriage not reduced by treatment with metronidazole or vancomycin
Clinical manifestations of C.difficile
Antibiotic colitis presents as diarrhoea, lower abdominal painstarts during or shortly after antibiotics commence
(a few days) but may present much later (1-2 months)
systemic symptoms often absentexamination often normal including sigmiodoscopytoxins in stool
Clinical manifestations of C.difficile
Psuedomembranous colitissymptoms more marked, bloody stoolscharacteristic yellow plaques 2-10mm
intervening mucosa mild inflammationplaques may conjoin
rectum and sigmoid most commonmay progress to fulminant colitis
Fulminating Disease
Five AlertsAbdominal distension and tendernessHigh (very high) WCC
( can be 40-50 x109/l)Raised CRP/ drop in HbNon response
To oral metronidazole/vancomycinLow albumin
all these features could denote the presence of Toxic Mega Colon - IMMEDIATE senior review, abdominal Xray and surgical referral
Management of C.difficile
Treatmentresuscitation stop causative antibiotic (if possible)antibioticsrestore normal gut floraSurgery
Mortality from surgery 25-100%Low Serum Albumin a good predictor of certain
death (<25g/L) or a fall by 11g/L at the onset of infection
Saccharomyces boulardii
Produces a protease that inhibits effect of toxins A and B in human colonic mucosacolonisation by 72 hours 107-108 cfucleared when therapy discontinuednot absorbed ExpensiveDifferent preparations have differing activity
Other options?
Brewers yeast Saccharomyces cerevisae less expensive than S.boulardiibut distinct and not equivalent
Faeces from related donorsGiven as enema or via Nasogastric TubeNot very acceptable to staff or patients
Immunoglobulin
Transmission
Faecal-oral routeEnvironment becomes contaminated by sporesHands become contaminated by sporesVulnerable patients acquire spores after contact
with contaminated staff and the environmentAnd then they eat them..
What is Critical?
Prevent environmental contaminationConsider faecal containment if liquid stool
Rapid isolation of the patientSimple things
Pulling back the sheetsCommode cleaningSide room with toiletNo exposed foodCareful with that bedding
C.difficile spores
Environment floors toilets bedpans beddingmopsscales
Health Care professionalshands ringsstethoscopes faecal carriage rare
Am J Epidemiology 1988 127:1289-94
Am J Med 1981;70:906
Just how important IS the environment?
Samore et alpresence on hands correlates with density of
environmental contamination (AmJ Med 1996)0-25%sites + 0% hands +26-50% + 8% hands +>50% + 36% hands +
Fawley (Epid Infect 2001)incidence correlates significantly with level of
environmental contamination
Isolation Wards
They workThey also free up isolation capacity elsewhere
in the organisationThey ensure consistency of care for all
patients, whose primary diagnosis should now be considered to be the infection
They are not permanentThey do allow you to get the situation back under
control and draw breath
Cross-infection risksIs it only the symptomatic patient?
One paper recently published in Clinical Infectious Diseases in October 06 says not
56% of skin tests were positive for C. difficile in the asymptomatic patientSpores present on the skin can be effectively
transmitted to HCW hands and the environmentHands must be washed with soap and water
after dealing with faecal matter for every patient
Efficacy of Alcohol Hand Sanitizers
Provide an overall 3-4 log10 (99.9-99.99%) reduction in most bacterial and viral pathogens with a contact time of 15 seconds
NOT C. difficile sporesNOT Norovirus
Norovirus are reduced by only 1-2 log10
(90-99%) with a 30 second contact time
C. difficile in the over-65sQuarterly Cases - England, 2006-8
C’est tres difficile
Increasing elderly populationAverage age of inpatients up 1.5 years each year
Acute beds falling in numbersCreates a filtered inpatient population
Expectation to treatHave sympathy for the poor house officer
The ‘old man’s friend’ is now his greatest enemy