Transcript Document 7219730

Clostridium Management in
Long-Term Care
Spring 2011 Joint
Provider/Surveyor Training
Teri Lee Dyke, RN, MSN, CIC
Clostridium difficile Infection (C.
diff, CDI, C. difficile & CDAD)
Two Case Reports *
[Case 1]
•Case 1
*MMWR 2005;54:1201-5
Severe CDAD in populations previously at low risk- four states, 2005
Two Case Reports *
[Case 2]
•Case 1
*MMWR 2005;54:1201-5
Severe CDAD in populations previously at low risk- four states, 2005
Why C. difficile is interesting
• It is a bacterial infection in which antibiotics
cause (or at least contribute to) the disease
• It is one of the only anaerobic organisms that
can be a nosocomial pathogen
• Its mechanism of pathogenesis is almost
completely toxin production; it does not invade
the tissues
• It is the only nosocomial pathogen that forms
endospores that are nearly impossible to kill
• The most effective treatment for the disease
may be to expose the patient to more bacteria
Outline
• Clostridium Difficile
the disease
• Epidemiology
• Infection
Prevention/Mitigation
• Strategies for
Management in LTC
• Resources
C. Difficile the disease
Microbiology
• Description
– Gram positive sporeforming anaerobic
bacteria
• Natural habitat
– GI tract of mammals
• Identification
– Not normally cultured
from stool; difficult to
grow
Clostridium difficile
• Anaerobic spore-forming bacillus
• Clostridium difficile-associated disease or diarrhea
(CDAD)
• Pseudomembranous colitis, toxic megacolon, sepsis,
and death
• Fecal-oral transmission through contaminated
environment and hands of healthcare personnel
• Antimicrobial exposure is major risk factor for
disease
- Acquisition and growth of C. difficile
- Suppression of normal flora of the colon
• Clindamycin, penicillins, and cephalosporins
Healthy
colon
Pseudomembranous
colitis
Background: Pathogenesis of
CDI
1. Ingestion
of spores transmitted
from other patients
via the hands of healthcare
personnel and environment
3. Altered lower intestine flora
(due to antimicrobial use) allows
proliferation of
C. difficile in colon
2. Germination into
growing (vegetative)
form
Sunenshine et al. Cleve Clin J Med. 2006;73:187-97.
4. Toxin A & B Production
leads to colon damage
+/- pseudomembrane
Background: Epidemiology
Risk Factors
•
•
•
•
•
•
•
Antimicrobial exposure
Acquisition of C. difficile
Advanced age
Underlying illness
Immunosuppression
Tube feeds
? Gastric acid suppression
Main modifiable risk
factors
Modes of Transmission
• Fecal-oral
– Food
– Fomite (contaminated object)
• Person-to-person
– Taking care of an ill individual
– Fomite (contaminated object)
• Inpatient healthcare setting
• Previous antibiotic exposure
Symptoms of CDAD
•
•
•
•
•
Watery diarrhea
Loss of appetite
Fever
Nausea
Abdominal pain and cramping
Colonization vs. Infection
• Colonization
– No clinical symptoms
– More common than
disease presence
– Patient will test
positive for Clostridium
difficile and/or its toxin
• Infection
–
–
–
–
–
Watery diarrhea
Abdominal pain
Fever
Nausea/Vomiting
Patient tests positive
for Clostridium difficile
and/or its toxin
Laboratory Testing
• Stool culture
– Most sensitive ( ↑ false-positives)
– Labor intensive
– Results in 48-96 hours
• Antigen detection
– Rapid tests ( < 1 hour)
– Antigen detection by latex agglutination or
immunochromatographicassays
– Must be combined with toxin testing to verify
diagnosis
Laboratory Testing continued..
• Toxin testing*
– Enzyme immunoassay detects toxin A, toxin B or
both
• Same-day test results
• Less sensitive than tissue culture cytotoxicity assay
– Tissue culture cytotoxicity assay
•
•
•
•
•
detect toxin B only
Requires technical expertise
Costly
24-28 hours results
Provides specific and sensitive results for c. difficile
* Toxin is very unstable and degrades at room temperature such that toxin may be
undetectable within 2 hours. False-negative test results may result from not conducting
immediate testing or not properly refrigerating specimen
Detection of C. difficile in stool
• Culture; too difficult;
the organism is
fastidious, takes too
long
• Cell-associated
antigen test; fast, but
doesn’t distinguish
between toxinproducers and
harmless strains
Detection of C. difficile in stool
• Toxin antigen tests; fast,
but less sensitive, can get
toxin A or A+B tests *
• PCR; not commercially
available, not a toxin test
• Cytotoxicity test; the most
sensitive, specific and
cost-effective
• One specimen is enough,
don’t need 3
•Toxin is very unstable and degrades at room temperature such that toxin may be
undetectable within 2 hours. False-negative test results may result from
not conducting immediate testing or not properly refrigerating specimen
New strain C. difficile
• Standard laboratory tests will not
distinguish the new from conventional
strains, although all new strains to date
were positive for Toxins A and B
• Distinguished by clinical presentation
• Can do PCR for the binary toxin and/or for
the deletion in the repressor gene
– Most are also fluoroquinolone-resistant, but that
is not specific for this strain
• Strains can be typed by pulse-field gel
electrophoresis, and the new strain shows
up as a single clone
CDAD Treatment
•
•
•
•
•
•
•
Discontinue the offending antibiotic
– 23% of the patients disease will resolve within 2-3 days
Standard initial treatment of toxin-positive patients
– Metronidazole 500 mg three times per day for 10-14 days
– No resistance, MIC is 0.25-1, stool level is 10
– Clinical response of about 95%, relapse of 5-15%
Alternative
– Vancomycin 125 mg four times per day (relapse 15-30%)
– Bacitracin 25,000 units four times per day
– Cholestyramine 4 grams three times per day for 10 days
For relapse
– Repeat metronidazole plus rifampin 300 mg twice per day for 10 days
– If that fails, go to an alternative
Replace fluid and electrolytes
Avoid anti-peristaltic agents (lomotil, opiates)
Relapse rate 5-15%
American College of Gastroenterology
and SHEA Guidelines
•
•
•
•
•
•
•
Discontinue the offending antibiotic or change it
Replace fluids and electrolytes
Avoid antiperistaltic agents
If those fail, try one course of metronidazole (Flagyl)
Do not treat asymptomatic patients
Retreat relapses once with the same regimen
Avoid vancomycin if possible
Epidemiology
Background: Impact
• Hospital-acquired, hospitalonset: 165,000 cases, $1.3
billion in excess costs, and
9,000 deaths annually
• Hospital-acquired, postdischarge (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.
Background: Impact
Age-Adjusted Death Rate* for
Enterocolitis Due to C. difficile, 1999–2006
2.5
Rate
2.0
Male
Female
White
Black
Entire US population
1.5
1.0
0.5
0
1999 2000 2001 2002 2003 2004 2005 2006
Year
*Per 100,000 US standard population
Heron et al. Natl Vital Stat Rep 2009;57(14).
Available at http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf
Challenges
• Emergence of a new epidemic strain
– Toxinotype III or “BI” by REA
• Distinct from “J” strain of 1989-19921
– Binary toxin as a possible virulence factor
• In addition to toxins A and B containing
– 18 bp deletion in tcdC gene
• Could lead to increased toxin production (18-fold for
toxin A, 23-fold for toxin B) observed by Warny et al.2
– Increased resistance to fluoroquinolones
• Appears responsible for increase in cases
• May be responsible for increase in disease severity
1.
2.
Johnson S, et al. N Engl J Med. 1999;341:1645-1651.
Warny M, et al. Lancet. 2005;366:1079-1084.
CDAD Surveillance Data
• Not reportable
• NNIS data up to 1990s
• Started in Northeast, now spread to
Midwest and South
Annual CDAD Rates, Hospitals with
>500 Beds, Intensive Care Unit
Surveillance Component, NNIS
From Archibald LK, et al. J Infect Dis. 2004;189:1585–158.
National Estimates of US Short-Stay Hospital
Discharges with C. difficile as First-Listed
or Any Diagnosis
From McDonald LC, et al. Emerg Infect Dis. 2006;12(3):409-15
Rates of US Short-Stay Hospital Discharges with
C. difficile Listed as Any Diagnosis by Region
From McDonald LC, et al. Emerg Infect Dis. 2006;12(3):409-15
Acute Care Hospitals with
CDAD Outbreaks* Between 2001-2004
2
1
2
1
1
1
*Detected by increases in the number of positive routine clinical laboratory tests
for C. difficile.
Data from McDonald LC, et al. N Engl J Med. 2005;353:2433-2441.
States with the Epidemic Strain of C. difficile
Confirmed by CDC and Hines VA labs (N=27),
Updated 4/3/2007
DC
HI
AK
PR
Michigan Data
• Death certificates with C. difficile
– Underlying cause
– Any mention
Death Certificates in Michigan Clostridium Difficile
1999-2005
300
250
200
150
100
50
0
1999
2000
2001
2002
underlying cause of death
2003
2004
2005
anymention
mention of
of C.
C. difficile
difficile
any
Michigan
No. of Cases
Deaths with Enterocolitis caused by C.
difficile listed as Underlying Cause
180
160
140
120
100
80
60
40
20
0
1999
2000
2001
2002
2003
2004
2005
<40
40-49 50-59 60-69 70-79 80-89
Age
90
and
up
Total
Source: 2005 death file, data records and health data development section MDCH
Michigan
No. of cases
Death Certificates with Any Mention of
Enterocolitis caused by C. difficile
120
100
80
60
40
20
0
1999 2000 2001 2002 2003 2004 2005
<40
40-49
50-59
60-69
70-79
80-89
90 and up
Source: 2005 death file, data records and health data development section MDCH
Increasing Severity and Costs of CDAD
• Boston, 1998¹
– Low attributable mortality
– Average 3,600 excess cost per case
– Average of 3.6 extra hospital days
• Pittsburgh, 20002
– Life-threatening disease from 1.6% to 3.2%
– 2000-2001: 26 colectomies and 18 deaths
• Quebec, 2004
– 30-day attributable mortality 6.9%
– 12-month attributable mortality 16.7%
– Average of 10.7 extra hospital days
1.
2.
3.
Dallal RM, et al. Ann Surg. 2002;235:363-372.
Muto C, et al. Infect Control HospEpid. 2005
Pepin J, et al. CMAJ. 2005
Changing epidemiology
• Old model of disease; the patient carried the
organism into the hospital with them, antibiotics
during hospitalization induce toxin production and
disease
– This hypothesis was tested by culture of
hospitalized patients on admission and then
weekly
– The model proved false
Changing epidemiology
• New model for C. difficile disease; the organism is not
usually endogenous, antibiotics during hospitalization
predispose the patient to colonization, the organism is
then acquired in the hospital and causes disease; a
nosocomial infection
• In fact, one study showed that colonization with C.
difficile prior to hospitalization was protective against
C. difficile disease after hospitalization
• Neonates often carry the organism but lack the
receptors for the toxin, do not get disease
Epidemiology
• Asymptomatic colonization
– Community surveys show that 1-3% of the population
normally carries the organism asymptomatically
– Among hospitalized patients, 20% carry it
• CDAD was associated with elderly and long LOS
inpatients and nursing homes
– Now increasing in non-patients as a communityacquired disease, in children and young adults, with
little antibiotic pre-exposure
• CDAD was associated with use of clindamycin
and cephalosporins
Epidemiology; inciting agents and
risk factors
• Almost all antibiotics and many
antineoplastic agents have caused
disease
– Most commonly cited: beta-lactams,
clindamycin, fluoroquinolones
– Less commonly cited; Timentin,
tetracyclines, SXT, aminoglycosides
• Risk factors:
– Advanced age, underlying illness,
immunologic susceptibility (IgG, not
cellular)
Recent studies
• Pepin, et al. 2005. Emergence of
fluoroquinolones as the predominant risk
factor for Clostridium difficile-associated
diarrhea; a cohort study during an epidemic in
Quebec (CID 41:1254-1260)
– Since 2002, 30 hospitals, 7000 cases, rate of
15/10,000 patient days, increase in severe disease
– Quinolone use had an odds ratio of 3.44, 2nd
generation cephalosporins 1.89
– The drug made a difference; gatifloxacin was worst,
levofloxacin was best
Recent studies
• Loo, et al. 2005. A predominantly clonal multiinstitutional outbreak of Clostridium difficileassociated diarrhea with high morbidity and
mortality. NEJM 353:2442-2449.
– Studied 12 Quebec hospitals, 1719 patients, 22.5/1000
admissions
– Attributable mortality was 6.9%
– Of 157 isolates from 9 hospitals, 129 were identical
– All isolates were susceptible to metronidazole and
vancomycin
– Aminoglycosides and penicillins were protective (odds
ratio), cephalosporins, fluoroquinolones and
clindamycin were associated with disease
Recent studies
• McDonald, et al. 2005. An epidemic, toxin
gene-variant strain of Clostridium difficile.
NEJM 353:2433-2442
– Collected 187 strains from 8 hospitals in Georgia,
Illinois, Maine, New Jersey, Oregon and
Pennsylvania in 2003
– Typed by restriction endonuclease typing, PFGE,
toxin typing
– Compared with a library of older C. difficile strains
– Most of the new strains were identical, and were
different from all strains collected before 2001
– The new toxin genes and fluoroquinolone
resistance are new
Infection Prevention Mitigation
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.
Prevention Strategies:
Supplemental
•
•
•
•
•
•
•
Extend use of Contact Precautions beyond duration of
diarrhea (e.g., 48 hours)*
Presumptive isolation for symptomatic patients
pending confirmation of CDI
Evaluate and optimize testing for CDI
Implement soap and water for hand hygiene before
exiting room of a patient with CDI
Implement universal glove use on units with high CDI
rates*
Use sodium hypochlorite (bleach) – containing agents
for environmental cleaning
Implement an antimicrobial stewardship program
* Not included in CDC/HICPAC 2007 Guideline for Isolation Precautions
Supplemental Prevention Strategies:
Consider presumptive isolation for patients
with > 3 unformed stools within 24 hours
• Patients with CDI may contaminate environment and
hands of healthcare personnel pending results of
diagnostic testing
• CDI responsible for only ~30-40% of hospital-onset
diarrhea
• However, CDI more likely among patients with >3
unformed (i.e. taking the shape of a container) stools
within 24 hours
– Send specimen for testing and presumptively isolate patient
pending results
– Positive predictive value of testing will also be optimized if
focused on patients with >3 unformed stools within 24 hours
– Exception: patient with possible recurrent CDI (isolate and test
following first unformed stool)
Supplemental Prevention Strategies:
Glove Use
•
•
•
•
Rationale for considering universal glove use
(in addition to Contact Precautions for patients
with known CDI) on units with high CDI rates
Although the magnitude of their contribution is
uncertain, asymptomatic carriers have a role in
transmission
Practical screening tests are not available
There may be a role for universal glove use as a
special approach to reducing transmission on units
with longer lengths of stay and high endemic CDI
rates
Focus enhanced environmental cleaning
strategies and avoid shared medical equipment on
such units as well
Supplemental Prevention Strategies:
Environmental Cleaning
• Bleach can kill spores, whereas other standard
disinfectants cannot
• Limited data suggest cleaning with bleach (1:10
dilution prepared fresh daily) reduces C. difficile
transmission
• Two before-after intervention studies demonstrated
benefit of bleach cleaning in units with high endemic
CDI rates
• Therefore, bleach may be most effective in reducing
burden where CDI is highly endemic
Mayfield et al. Clin Infect Dis 2000;31:995-1000.
Wilcox et al. J Hosp Infect 2003;54:109-14.
Supplemental Prevention Strategies:
Environmental Cleaning
Assess adequacy of cleaning before changing
to new cleaning product such as bleach
• Ensure that environmental cleaning is adequate and
high-touch surfaces are not being overlooked
• One study using a fluorescent environmental marker to
asses cleaning showed:
– only 47% of high-touch surfaces in 3 hospitals were cleaned
– sustained improvement in cleaning of all objects, especially in
previously poorly cleaned objects, following educational
interventions with the environmental services staff
• The use of environmental markers is a promising method
to improve cleaning in hospitals.
Carling et al. Clin Infect Dis 2006;42:385-8.
Summary of Prevention
Measures
Core Measures
• Contact Precautions for
duration of illness
• Hand hygiene in
compliance with
CDC/WHO
• Cleaning and disinfection
of equipment and
environment
• Laboratory-based alert
system
• CDI surveillance
• Education
Supplemental Measures
•
•
•
•
•
•
•
Prolonged duration of
Contact Precautions*
Presumptive isolation
Evaluate and optimize
testing
Soap and water for HH
upon exiting CDI room
Universal glove use on
units with high CDI rates*
Bleach for environmental
disinfection
Antimicrobial stewardship
program
* Not included in CDC/HICPAC 2007 Guideline for Isolation Precautions
Measurement: Process
Measures
• Core Measures:
– Measure compliance with CDC/WHO
recommendations for hand hygiene and Contact
Precautions
– Assess adherence to protocols and adequacy of
environmental cleaning
• Supplemental Measures:
– Intensify assessment of compliance with process
measures
– Track use of antibiotics associated with CDI in a
facility
HAND HYGIENE MONITORING TOOL
Patient Care Unit/Dept.:___________________________ Day of Week: ________ Date:
Initials of Monitor:
Time: ________AM/PM to
__AM/PM
Healthcare Worker (HCW) Type:
Key:
1 = Physician
8 = Physical Medicine Staff
HW = Hand Wash
2A = House Officer
9 = Environmental Services Worker
HA = Alcohol Hand Antiseptic
2B= Medical Student
10 = Patient Transporter
Y = Yes
2C= PA
11 = Radiology Tech.
3 = Physician Support Staff
12 = Respiratory Therapist
N/A = Not Applicable
4 = Nursing/Nursing Support
13 = Dietitian
5 = Continuing Care/Social Worker
14 = Traypasser
6 = Pastoral Care
15 = Other
7 = IV Team
BED LOCATION
()
D
W
CONTACT PRECAUTIONS: Y, N, N/A
HEALTH CARE WORKER TYPE
()
OPPORTUNITY REQUIRING HAND
HYGIENE INTERVENTION
Before Patient Contact
After Contact With Patient’s Skin
After Contact With Patient’s Gown/Linen
D
W
D
W
D
W
D
W
D
W
D
W
D
W
D
W
N= No
D = Bed closest to door
W = Bed closest to window
D
W
Strategies for LTC
2007 Isolation Precautions *
• Multidisciplinary HICPAC
group
• Standard Precautions
• Transmission-based
Precautions
• Respiratory Hygiene
added
• Safe injection practices
added
• Term “nosocomial”
replaced by “healthcareassociated” infection
* http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf
2007 HICPAC Isolation
Precautions*
•
•
•
•
•
•
Administrative measures
MDRO education
Judicious use of antimicrobials
Surveillance
Infection Precautions
Environmental measures
*http://www.cdc.gov/ncidod/dhqp/gl_isolation.html
Standard Precautions
• Previously called Universal Precautions
• Assumes blood and body fluid of ANY patient
could be infectious
• Recommends PPE and other infection control
practices to prevent transmission in any
healthcare setting
• Decisions about PPE use determined by type
of clinical interaction with patient
• Standard precautions INCLUDES Hand
Hygiene
PPE for Standard Precautions
(1)
• Gloves – Use when touching blood,
body fluids, secretions, excretions,
contaminated items; for touching mucus
membranes and nonintact skin (remove
before leaving the area)
• Gowns – Use during procedures and
patient care activities when contact of
clothing/ exposed skin with blood/body
fluids, secretions, or excretions is
anticipated
PPE for Standard Precautions
(2)
• Mask and goggles or a face shield –
Use during patient care activities likely
to generate splashes or sprays of blood,
body fluids, secretions, or excretions
PPE for Expanded Precautions
 Expanded Precautions include
 Contact Precautions
 Droplet Precautions
 Airborne Infection Isolation
Modes of Transmission of Infectious
Diseases:
– Contact:
• Direct = germ transferred directly from patient to
caregiver; e.g. scabies
• Indirect = transfer of germs via intermediate object
or person; e.g. caregiver picks up germs from
contaminated surface and transfers to the patient
– Droplet: germ in droplets (> 5µ) produced from person
with infection when they cough or sneeze; droplets
only travel 3 feet; example: influenza
– Airborne: germ in droplet nuclei (< 5µ) that become
airborne and can travel long distance and be inhaled
deep into lung; example: TB
– Additional Modes: Common source vehicle = e.g.
contaminated food item; Vectorborne = transmitted by
insect; example: West Nile virus
Use of PPE for Expanded
Precautions
Contact Precautions – Gown and gloves for
contact with patient or environment of care
(e.g., medical equipment, environmental
surfaces)
In some instances these are required for
entering patient’s environment
Droplet Precautions – Surgical masks within 3
feet of patient
Airborne Infection Isolation – Particulate
respirator*
*Negative pressure isolation room also required
SAMPLE
STOP
Visitors please check with nurses
before entering room
Healthcare workers must do the following:
 Gloves and gowns required for all direct patient contacts
 Mask required for direct resident contact
 Door may remain open
 Other instructions _______________
When leaving room:
 Remove all PPE (personal protective equipment)
 Perform hand hygiene
Always follow Standard Precautions PLUS
Questions? Contact ___________________ ext.______
Hand Hygiene
•
Required for Standard and Expanded
Precautions
•
Perform…
Immediately after removing PPE
Between patient contacts
•
Wash hands thoroughly with soap and water
or use alcohol-based hand rub
Opportu
nities for
Hand
Hygiene
Infection Control Precautions
• Hand Hygiene
• Hand washing continued…
– Before and after contact with food, products for food
preparation and before eating
– Following any contact with pets during animal assisted therapy
or visitation and after contact with any pet care item
• Hand sanitizer
– Before any direct patient contact
– After contact with resident’s skin
– After contact with body fluids, mucous membranes, and nonintact skin or dressing, provided hands are not visibly soiled
– After contact with inanimate objects in the care environment
Infection Control Precautions
• Hand Hygiene
• Discourage use of artificial nails
• Educate patient family and volunteers
• Observe compliance
Infection Control Precautions
• Hand Hygiene
– Written policy
– Hand washing facilities, alcohol-based hand
sanitizer available
– When to use each
• Hand washing
– Anytime hands are visibly soiled
– After toileting
Poor Adherence
• Time
• Access
• Understanding
CDC:HICPAC Management of
Multi-drug-Resistant Organisms
• Routine measures
• Enhanced measures
•Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006
MDRO Control Measures
•
•
•
•
•
•
•
Administrative support
Education
Judicious use of antimicrobial agents
MDRO surveillance
–
Surveillance for MDROs isolated from routine clinical cultures
•
Antibiograms
•
MDRO Incidence Based on Clinical Culture Results
•
MDRO Infection Rates
•
Molecular typing of MDRO isolates
–
Surveillance for MDROs by Detecting Asymptomatic Colonization
Infection Control Precautions
–
Standard Precautions
–
Contact Precautions
–
Cohorting and other MDRO control strategies
–
Duration of Contact Precautions
–
Barriers used for contact with patients infected or colonized with MDROs
–
Impact of Contact Precautions on patient care and well-being
Environmental measures
Decolonization
MDRO Infection Precautions
• Prioritize patient placement to single bed room
and use of isolation, Expanded Precautions with
given criteria, discontinue isolation when criteria
met
• Observe compliance to Standard Precautions,
report back to HCW
• Observe compliance to Hand Hygiene, visibly
soiled, before and after patient contact, before
performance of aseptic procedure, and after
removing gloves
MDRO Environmental Measures
• Practices for cleaning /disinfecting are
standardized for all areas -routine, isolation
• Standardized training– monitoring compliance
• Environmental cleaning should focus on
frequently touched surfaces with contaminated
hands
• Sequence of cleaning: cleanest areas to dirtiest
• Minimize dust accumulation
• Use appropriate agent- following mftr rec.
– Amount
– Dilution
– CONTACT TIME
The Inanimate Environment Can
Facilitate Transmission
X represents VRE culture positive sites
~ 16/151 (10.6%) surfaces sampled where transfer via hands
of HCW was documented ~
Duckro AN, et al. Arch Intern Med 2005;165:302-7
Attention to the Environment
• Frequently touched surfaces
• Areas contaminated with feces
• In an outbreak setting or in highly endemic units
use diluted 5.25-6.15% sodium hypochlorite diluted
1:10 for routine disinfection*
• EPA registered hypochlorite based disinfectant
• Cleaning
– Pre-cleaning
– Order of cleaning
– Dilution, contact time
*Rutala, WA, 2005 http://disinfectionandsterilzation.org
Environmental Measures Con’t
• Laundry

–


Avoid contact with body, clothing
No shaking/aerosolizing bedding
Contain soiled laundry in a bin/bag
segregate soiled from clean
• Patient care equipment
–
–
–
–
Cleaned according to mftr rec
Between patients
Dedicated to isolation rooms
Return to stock protocols
Facility
• Verify facility is using bleach – NOT quaternary
ammonia
• Increase frequency of housekeeping
• Stress importance of all items to disinfect
• Observe housekeeping
– Fresh solution
– Proper bleach concentration
– Order of disinfection
Items to Disinfect
• Faucets, toilet seats, sinks, light switches,
counter tops
• Doorknobs, hand rails, elevator buttons,
washroom door plates
• ANY commonly used item that multiple people
may come in contact with
• Order of disinfection matters!
– “Start out and work in”
Surveillance
• Methods- Standardized, Definitions,
Denominators
– Whole-house limitations
– Targeted, point prevalence
– Device related
– Combination
– Based on high risk, high volume problem
areas
Surveillance
• Purpose
– Improve quality and outcome of healthcare
– Promote public health
– Benchmarking
• NHSN- www.cdc.gov/ncidod/hip
– NNIS
– NaSH
– DSN
Surveillance
• Data Collection
– What
• System
• Process
• Outcome
– Identify sources
•
•
•
•
Lab reports
Unit reports
Pharmacy
observational
Surveillance
• Analysis
• Reports
–
–
–
–
–
–
–
–
Infection Control Committee
Quality Committee
Administrator
Medical Director
Director of Nursing
Unit
Front line personnel
Physicians
Surveillance
• Intervention of risk-reduction measure
– Documented
• Evaluate effectiveness of intervention
• See Websites
– http://www.cdc.gov/ncidod/hip/
http://www.cdc.gov/ncidod/hip/Guide/guide.ht
m
Patient Care Protocols
• Standardized processes for wound care
– Aseptic/clean technique
– covered
• Standardized processes for catheter care
• Teach the patient/family members about
good hand hygiene
– Especially after incontinence care for both
care provider and patient
– Before they eat
Control of C. difficile
• In the healthcare facility:
– Prompt diagnosis
– Isolation precautions,
hand hygiene
– Stop unneeded
antibiotics
– Good environmental
cleaning
• In the community:
– Avoid unnecessary
antibiotic use
Future answers?
• Improve infection control
• Avoid unnecessary antibiotics
• Probiotics to restore the normal microbial
balance
• Vaccine to produce protective antibody
• Immune globulin for passive immunity
• Non-antibiotic therapies like resins
Summary for Prevention in
Healthcare
• Isolate patients with C. difficile in a private
room, or cohorted
• Attention to Hand Hygiene
– Soap and water
– ABHR
• PPE
• Dedicate equipment
• Isolate as long as diarrhea is present
• Individualized patient assessment is required
• Conduct surveillance for CDI
• Judicious use of antibiotics (clindamycin)
• Early detection, isolation and treatment
Resources
• http://www.cdc.gov/HAI/pdfs/toolkits/CDIto
olkitwhite_clearance_edits.pdf
• www.apic.org
• http://www.cdc.gov/hicpac/pubs.html
• www.who.int/patientsafety/en
• http://www.mi-marr.org/ (Long-Term Care
Toolkit)
http://www.cdc.gov/HAI/organisms/
cdiff/Cdiff_infect.html
• Frequently asked
questions document
for healthcare
providers
Additional resources
SHEA/IDSA Compendium of Recommendations
Dubberke et al. Infect Control Hosp Epidemiol 2008;29:S81-92.
Abbett SK et al. Infect Control Hosp Epidemiol 2009;30:1062-9.
CDI Checklist Example
Acknowledgements
• Dr. Richard Van Enk
• Dr Clifford McDonald