Linda R. Greene, RN, MPS, CIC Manager of Infection Prevention Highland Hospital Rochester, NY

University of Rochester Medical Center linda_greene@urmc.rochester.edu

C Difficile - The Ultimate Challenge: Controlling the Spread

The Big Picture C difficile lab ID reported through NHSN Proposed for Value Based Purchasing FY 2017

The Year 2009

A vital Energetic woman Friend, Mother and Grandmother

So what do we need to do? Engage

Educate

Execute

Evaluate

The Evidence based Model for Improvement

Strategies for Engagement

Multidisciplinary Team

Senior Leadership Putting names and faces to cases

Education

C difficile Now rivals MRSA as the most common organism found in

hospitals Incidence outside the hospital may be more common

than previously thought Associated with increased length of stay, morbidity and

mortality

Impact of C. difficile infection (CDI)

Hospital-acquired, hospital-onset: 165,000 cases, $1.3 billion in excess costs, and 9,000 deaths annually

Hospital-acquired, post-discharge

(up to 4 weeks): 50,000 cases, $0.3 billion in excess costs, and 3,000 deaths annually

Nursing home-onset: 263,000

cases, $2.2 billion in excess costs, and 16,500 deaths annually

Campbell et al. Infect Control Hosp Epidemiol. 2009:30:523-33. Dubberke et al. Emerg Infect Dis. 2008;14:1031-8.

Dubberke et al. Clin Infect Dis. 2008;46:497-504. Elixhauser et al. HCUP Statistical Brief #50. 2008.

Pathogenesis Alteration of the intestinal flora by antibiotics leads to C. difficile proliferation in the colon

C. difficile is acquired by ingestion of spores from the hospital environment or hands of healthcare personnel

C. difficile diarrhea

Advanced age Multiple comorbidies No antibody to Toxin A/B

No diarrhea

Antibody to Toxin A/B

Colonization

Ingested Normal flora interrupted

Small Intestine Spores Germinate

Pseudomembrane C Difficile

toxins

monocytes

Neutrophils

Toxin A attracts neutrophils and monocytes, and toxin B degrades the colonic epithelial cells, both leading to colitis, pseudomembrane formation, and watery diarrhea

C difficile reproduces in the intestinal crypts, releasing toxins A and B, causing severe inflammation. Mucous and cellular debrisare expelled, leading to the formation of pseudomembranes

Wolf P, Kasyan A N, Engl J - Med 2005;353:2491

Pseudomembrenous Colitis

“I just touched the bed rail…” 100-1,000 bacteria transferred by: Pulling patients up in

bed Taking a blood

pressure or pulse Touching a patient’s

hand Rolling patients over

in bed

O² sat monitor Stethoscope

Keyboard & Mouse Med Keyboard

C Difficile in the enviornment C. difficile forms an endospore or a dormant state with

increased resistance when conditions in the human or animal body or the environment become unfavorable for it to survive in its vegetative (actively growing) state.

In the endospore stage, C. difficile spores will not be destroyed on environmental surfaces by disinfectants

Transmission- Fecal – Oral Route

o Mainly by direct contact with the hands of HCWs

o Autoinoculation (oral ingestion) o Shed in feces o Indirect contact (inanimate objects such as

commodes, etc) o Environmental contamination – spores can

survive for months in the environment

What’s Wrong With This Picture

Another One

What are the symptoms of Cdiff? watery diarrhea fever loss of appetite nausea abdominal pain/tenderness

(Be wary of lack of stools)

CDI Prevention Strategies: Core Contact Precautions for duration of diarrhea Hand hygiene in compliance with CDC/WHO Cleaning and disinfection of equipment and

environment Laboratory-based alert system for immediate

notification of positive test results Educate about CDI: HCP, housekeeping,

administration, patients, families http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html

Dubberke et al. Infect Control Hosp Epidemiol 2008;29:S81-92. SEE ALSO: Cohen SP, et al. SHEA/IDSA Clinical Practice Guideline, ICHE May 2010

Bundle Monitoring Tool

The Compendium

Outbreak or Hyper-endemic Setting only

Hyper-endemic levels

Other Issues Lab ID is a marker. May also pick up colonization

What are your criteria for sending a specimen

Any Inappropriate testing?

Testing methods PCR 2 STEP Toxin- A and B antigen

Renewed Respect for Role of the Environment: Who’s Been in the Room Before or With You?

Huang SS (2006); Drees M (2008); Zhou Q (2008); Moore C (2008);Hamel M (2010) All documented increased risk of

acquisition of VRE, MRSA, &/or CDI when admitted to room where prior occupant had one of these or if in multi-occupancy room

So what’s the answer?

No Doesn’t

Look clean yet

They need to get a life

Keep Going

What’s The Answer?

NYC- Dr. Brian Koll

Administrative Clinical Physician and Nursing

Champions

Sharing Best Practices

Infection Prevention Coach Training Program

Teach Teamwork Monitor and enforce

practices Problem-solve Share and spread best

practices Participation in hospital

forums

Environment of Care

Reducing CDI Measuring and assessing

effectiveness

Feedback

Sustainability

Dissemination and Spread

Web based and electronic communication

Infection Prevention Bundles

C. difficile Infection Prevention Bundle Hand hygiene (washing with soap and water for C.

difficile) Contact precautions Sign placement PPE readily available / used Dedicated rectal thermometers Patient placement

private room vs. cohorting vs. shared Bathrooms

dedicated vs. shared vs. commode Transport precautions Environmental cleaning

hypochlorite-based disinfectant daily and terminal cleaning procedures

Environmental Checklist

New Technologies

Other Measures Prevent other Infections UTI’S – use of florquinoles highly associated with C Difficile

The Bottom Line It’s like eating an elephant – 1 bite at a time