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Clostridium difficile

April 28, 2016

Objectives • To review key information about Clostidium difficile

including:

• Symptoms

• Epidemiology

• Best practices for testing and care

• To apply these to a LTCH scenario

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C. diff. - What is it?

• A gram positive, anaerobic, spore-forming bacillus

• Widely distributed in environment

• Colonizes 3-5% adults – and 30% or more of newborns

• Commonest cause of infectious diarrhea in hospitalized patients

• C. difficile associated disease ranges from diarrhea to pseudomembranous colitis and toxic megacolon

• The incidence and severity of illness are increasing

• The presence of NAP1 strain does not change IPAC Best Practices

Image sources: Samir at https://commons.wikimedia.org/wiki/File:Pseudomembranous_colitis_1.jpg

and

Gille12 at http://www.lasvegascolonhydrotherapy.com/graphics/Toxic_Images_clip_image005.jpg

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Symptoms

• Diarrhea! – watery, foul (“barnyard”)-smelling

• Fever

• Loss of appetite

• Nausea

• Abdominal pain and/or tenderness

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C. diff. – Who gets it?

• Most at risk are patients/residents/clients with:

• A recent history of antibiotic usage (e.g., Fluoroquinolones, Clindamycin, Penicillins, Cephalosporins)

• Bowel surgery

• Chemotherapy

• Prolonged hospitalization

• The elderly and those with serious underlying illnesses are predisposed to more severe disease

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Image source: Public Health Ontario, 2014

Epidemiology

• An old opponent? Causing healthcare and community associated diarrhea for about 30 years: 1935: Identified as ‘normal flora’ in infants (up to 1 year of age)

Mid-1970’s: Recognised as pathogen in colitis

2000’s: Outbreaks in Quebec - many deaths

Appearance of NAP1 strain and other serious outbreaks

• Causes mild diarrhea to life-threatening disease

• C. difficile produces long-surviving spores that resist destruction (need steam sterilization, strong bleach or accelerated H2O2 to kill)

• Hands and surfaces must be cleaned thoroughly to remove the spores

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Best IPAC Practices

1. Contact Precautions

2. Hand Hygiene

3. Accommodation

4. Environmental Cleaning

5. Education

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Prompt identification & Implementation of Contact Precautions

• The health care professional who first identifies new onset diarrhea should initiate contact precautions immediately - do not wait for laboratory results

• Obtain laboratory specimens right away - do not wait for 24 hours of loose stool

• Single room with toilet preferred • Gloves and gown for room entry • Notify IPAC • Contact precautions remain in place until: • C. difficile is ruled out, or • For confirmed CDI, until at least 48 hours without symptoms • Only IPAC should discontinue precautions

8 Images source: Public Health Ontario, 2014

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Contact Precautions Sign

Contact Precautions

• Post Contact Precautions sign at resident room and bed (if multi-bedded room)

• Have ready access to gloves & gowns - used by all health care staff entering room

• Dedicate patient care equipment or thoroughly clean and disinfect after each use

• No rectal temperatures

• No special handling of trays, linen or waste

• Handle bedpans and commodes carefully

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Laboratory testing for C. difficile

• Detection of cytotoxins A and B

• Stool specimen collection should be done ASAP after onset of watery diarrhea

• Quick turn around time, e.g. within 24 hours, is ideal

• All positive tests should be reported to IPAC immediately

• Do not test formed stools

• Do not “test of cure”

Colonies on blood agar and endospores (Public Health Ontario Laboratories)

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Repeat Tests, Relapse, Recurrences

• If results are negative but symptoms persist, perform a second test

• Do not screen asymptomatic residents

• If symptoms recur within 8 weeks, consider this a relapse and not a new case

• Recurrence is occurs in about 30% of cases

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Hand Hygiene

• All health care facilities should have a hand hygiene program

• PIDAC Best Practices for Hand Hygiene

• Just Clean Your Hands

• Observe meticulous hand hygiene

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Hand Hygiene

• Soap and water is theoretically more effective in removing spores than ABHR

• ABHR does kill 99.9% of organisms, including vegetative C. diff

• Wash hands with soap and water after glove removal if a dedicated hand washing sink is immediately available

• Otherwise, clean hands with ABHR after glove removal

– use of ABHR has not contributed to spread of CDI

• Do not use resident sink for hand hygiene

• Educate and assist residents in hand hygiene

14 Images source: Public Health Ontario, 2014

Environmental Cleaning

• Advise Environmental Services of cases

• All horizontal surfaces and items within reach must be thoroughly cleaned twice daily with a hospital grade disinfectant

• Consider sporicidal agent, especially for bathrooms

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Image source: Microsoft ClipArt

Environmental Cleaning

• Pay particular attention to high touch items

• Thorough cleaning:

• Clean to dirty

• Do not spray – apply directly – saturate – ensure sufficient contact time

• Change cloths and mops frequently – no ‘double-dipping’

• Use dedicated disposable toilet brushes – may remain in resident’s room until discharge/transfer/recovered

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Images source: Microsoft ClipArt

Environmental Cleaning

• If C. difficile transmission continues, consider hypochlorite (bleach)-based or sporicidal products (e.g., higher concentration accelerated hydrogen peroxide)

• Sporicides: • Sodium hypochlorite (bleach) solution at 5000 parts per million chlorine

(10 minutes contact time)

• Hydrogen peroxide enhanced action formulation at 4.5% concentration (10 minutes contact time)

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Environmental Cleaning

• Discharge/transfer cleaning must be done at resolution of symptoms or when resident is moved (and Contact Precautions maintained until cleaning is complete) • Launder all curtains • Thoroughly clean bathroom • Discard all disposables items and toilet brush

• If resident is transferred from a multi-bed room to another room – the toilet/bathroom in the multi-bed room must be cleaned

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Accommodation

• All residents with suspect or confirmed CDI should be placed in a single room with dedicated toilet facilities

• When single room not available:

• Consult with IPAC professional

• Cohort residents with confirmed CDI

• In multi-bed rooms: ensure resident space has visible Contact Precautions sign, dedicated toileting, and accessible linens, supplies, garbage and laundry bags

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Patient/Resident Transfer

• C. diff. should not preclude transfer within the healthcare system, but . . .

• Receiving department/facility must be able to comply with accommodations and Contact Precautions

• Notify receiving department/facility (and ICP) and transport services (e.g., ambulance) of precautions required before transfer

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Discontinuation of Precautions

• Consult with IPAC

• Contact Precautions may usually be discontinued when patient has at least 48 hours symptom-free

• Retesting for C. difficile cytotoxin is not necessary to discontinue precautions and should not be done

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Treatment Recommendations

• Treatment recommendations outlined in PIDAC best practice document

• The physician may start treatment for CDI before the laboratory results are available

• Should include: • Stop antibiotic(s) if possible

• Rehydration

• Avoid antimotility agents

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Recurrence of Symptoms

• Common – occurs in about 30% of cases

• If diarrhea recurs: • Place patient on Contact Precautions • Re-test for C. difficile • Physician may re-start therapy before test results

available

• With recurrent CDI: consider keeping resident in single room

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Visitors

• Should receive instruction on hand hygiene and personal protective equipment

• If visitor providing care, or significant contact with resident or his/her environment, they should wear gloves and gown

• Printed information sheets are helpful

• Should not use resident’s bathroom or enter other residents’ rooms or bed space

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Education & Empowerment

• All direct care providers should receive education on C. difficile, measures to control spread, and their responsibility

• Reinforce that staff are not at risk with consistent use of Routine Practices and safe work practices, e.g., no eating or drinking in resident care areas

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Program Evaluation

• The facility IPAC program, including C. difficile, should be evaluated regularly

• Make improvements based on new research, information, and standards

• Periodic hand hygiene and environmental cleaning audits should be done. (e.g., Environmental Services in collaboration with IPAC)

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Image source: Public Health Ontario, 2015

Prevention – always better than control

• Early identification of resident, i.e., syndromic surveillance

• Empowering front-line staff to institute Contact Precautions at onset of symptoms

• Daily surveillance reporting to Infection Prevention & Control (IPAC)

• IPAC resources appropriate to the facility

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Case Definition of CDI The case definition of CDI is: • Diarrhea with laboratory confirmation of a positive toxin assay

(A/B) for C. difficile;

OR

• Visualization of pseudomembranes on sigmoidoscopy or colonoscopy;

OR

• Histological/pathological diagnosis of pseudomembranous colitis

OR

• Diagnosis of toxic megacolon

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What is diarrhea?

Diarrhea is defined as:

• Loose/watery bowel movements

(conform to the shape of the container)

AND

• The bowel movements are unusual or different for the resident

AND

• There is no other recognized cause for the diarrhea (for example, laxative use)

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Surveillance Case Definitions

• New nosocomial case of CDI associated with reporting facility:

• A case that meets the case definition for CDI; AND • CDI was not present on admission (i.e., onset of

symptoms >72 hours after admission); OR • the infection was present at time of admission and patient

was admitted to the same facility within the last 4 weeks AND • the case has not had CDI in the past 8 weeks

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Scenario:

• Bob is a 79 year old gentleman who had a fall in his long-term care home (LTCH) that resulted in a fractured hip and a slow recovery requiring prolonged hospitalization

• Soon after readmission to the LTCH, Bob develops pneumonia and is treated with antibiotics

• Two days after antibiotic therapy is started, Bob develops diarrhea, abdominal pain, and fever

31 Image source: Public Health Ontario, 2015

What would you do now?

• Initiate contact precautions and decide to keep him in his room until you determine the cause of his symptoms

• Notify the attending physician

• What would the doctor do?

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Culture Results

• Culture results are NEGATIVE for Salmonella, Shigella, Campylobacter, pathogenic Yersinia and E. coli O157:H7, and O&P also negative

• Note: C. difficile is not covered in the stool culture testing/ outbreak enteric panel

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As time goes on . . .

• Bob continues to have diarrhea and is no longer eating well

• Because Bob has been sick for nine days and no one else is demonstrating symptoms, the physician decides not to test for norovirus

• The possibility of C. diff crosses your mind

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C. diff. – Who gets it?

• Most at risk are patients/residents/clients with:

• A recent history of antibiotic usage (e.g., Fluoroquinolones, Clindamycin, Penicillins, Cephalosporins)

• Bowel surgery

• Chemotherapy

• Prolonged hospitalization

• The elderly and those with serious underlying illnesses are predisposed to more severe disease

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Image source: Public Health Ontario, 2014

C. Diff considerations include:

1. Contact Precautions

2. Hand hygiene

3. PPE

4. Environmental Cleaning: including • Sporicide

• High touch surfaces, double cleaning

• Auditing

5. Education: including Antimicrobial Stewardship

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Key References

• Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Annex C: Testing, Surveillance and Management of Clostridum difficile in all Health Care Settings, May 2013. Available from https://www.publichealthontario.ca/en/eRepository/PIDAC-IPC_Annex_C_Testing_SurveillanceManage_C_difficile_2013.pdf

• Ontario Ministry of Health and Long-Term Care: Appendix B: Provincial Case Definitions for Reportable Diseases Disease: Clostridium difficile Infection (CDI) outbreaks in public hospitals, February 2014. Available from http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/cdi_cd.pdf

• Public Health Agency of Canada C. diff. fact sheet. Available from http://www.phac-aspc.gc.ca/id-mi/cdiff-eng.php

• MSH + UHN ASP. First episode Clostridium difficile infection (CDI) management algorithm. Available from http://www.antimicrobialstewardship.com/sites/default/files/article_files/clostridium_difficile_infection_protocol_march2016.pdf

• Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings. Revised. Toronto, ON: Queen’s Printer for Ontario; May 2012. Available from https://www.publichealthontario.ca/en/eRepository/Best_Practices_Environmental_Cleaning_2012.pdf

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