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![Page 1: cdiff presentation](https://reader035.fdocuments.net/reader035/viewer/2022062420/55c56e90bb61eb05538b45ff/html5/thumbnails/1.jpg)
S T E P H A N I E F U R L A N
CDIFF
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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?
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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)
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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
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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
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NOSOCOMIAL INFECTIONS:
• Total Cases: 91 (December 2013- October 2014)• HAI: 43 cases (47.8 %)• Community Acquired: 48 cases (52.7%)
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FREQUENCY DISTRIBUTION OF SEX
• Total: 43 cases• Females: 24 (55.8%)• Males: 19 (44.2%)
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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)
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GRAPH: POSITIVE DAYS AFTER ADMISSION
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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
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GRAPH: HIGH RISK ANTIBIOTICS
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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
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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%)
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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%)
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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%)
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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%)
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ADMISSION TO AN ECF WITHIN 1 YEAR
• Total cases: 43• Yes: 6 cases (14%)• No: 37 cases (86%)
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DOUBLE OCCUPANCY ROOMS
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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%)
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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%)
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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%
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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!
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REFERENCES
• Wilcox, M. (2013). New Clinical Practice Guidelines For Clostridium Difficile Infection. Infectious Diseases in Clinical Practice, 329-331.