C. difficile Prevention Partnership Collaborative. Clostridium difficile Management in Healthcare Facilities January 19, 2012. Clostridium difficile Management in Healthcare Facilities. Phenelle Segal, RN CIC Modification of Presentation by Gail Bennett, RN, MSN, CIC.
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Clostridium difficile Management in Healthcare Facilities
January 19, 2012
Phenelle Segal, RN CIC
Modification of Presentation by Gail Bennett, RN, MSN, CIC
Describe the changing epidemiology of Clostridium difficile.
State two differences between acute care and long term care in managing patients/residents with C. difficile infection.
List three important strategies for preventing transmission of C. difficile within healthcare facilities.
Antibiotic induced diarrhea
May cause approximately 30% of all cases of healthcare associated diarrhea
Most common cause of acute infectious diarrhea in nursing homes
Disease may be a nuisance or cause life threatening pseudomembranous colitis
Increasing numbers of cases
Cases tripled in US hospitals from 2000 until 2005
Increasing disease severity and mortality
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 annuallyBackground: Impact
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.
Acquisition of C. difficile
? Gastric acid suppression
Main modifiable risk
Rates of recurrence
despite routine preventive measures
Perform hand hygiene
before contact with the patient/resident
after removing gloves
after contact with the environment
Hand Hygiene for Clostridium difficile
Boyce et al. Infect Control Hosp Epidemiol 2006;27:479-83.
Washing away the spores may be the optimal way to perform hand hygiene when transmission of C. difficile is occurring
Many facilities choose to use the enhanced strategy all of the time
Hand Hygiene for Clostridium difficile (continued)
Designed to reduce the risk of transmission of microorganisms by direct or indirect contact
physical transfer (turning patients/residents, bathing patients, other patient/resident care activities)
High touch surfaces
Private room preferred
2nd option: Cohorting with other patient/resident with C. difficile
3rd option: In LTCFs, consider infectiousness and resident-specific risk factors to determine rooming with a low risk roommate and socializing outside the room
Patient care equipment dedicated to single patient/resident if possible. If not, disinfect equipment prior to leaving the room.Contact Precautions
CDC’s Web Site
After treatment, repeat C. difficile testing is not recommended if the patient’s symptoms have resolved, as patients may remain colonized.
May consider alternative signage to ensure staff awareness
Evaluate current system for patient/resident placement
Consider contact precautions for all patients/residents that develop diarrhea until CDI is ruled out
Increase monitoring of isolation precautions and hand hygiene
Extend use of contact precautions even when diarrhea stops
Xrepresents VRE culture positive sites
~ Contaminated surfaces increase cross-transmission ~
Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.
Colonization or asymptomatic fecal carriage of C. difficile
C. difficile infection
HAI-CDI (INDEX FACILITY)
HAI-CDI (OTHER FACILITY)
With cases of diarrhea, consider C. difficile
Take a detailed history for risk factors
Norovirus, dietary changes, medications, and other things may also be causes of diarrhea
Watch for dehydration
Automatic contact precautions for all patients/residents with orders for C. difficile labs AND for all patients/residents with a known history of CDI
Consider allowing nurses to initiate the lab order and contact precautions
Consider universal glove usage on units that have a high incidence/rate of CDI
Use EPA approved germicide for routine disinfection during non-outbreak situations
Ensure staff training and contact time
Disinfect shared items between patients/residents
Use 10% sodium hypochlorite (bleach) for disinfecting room and equipment (or use EPA registered sporicidal agent)
In outbreak, consider bleach solution for cleaning all rooms
Use bleach wipes as an adjunct to cleaningEnvironmental Disinfection: Tiered Approach
Identification of cases
Appropriate use of antibiotics
Antibiotic overuse contributes to the growing problems of Clostridium difficile infection and antibiotic resistance in healthcare facilities.
Improving antibiotic use through stewardship interventions and programs improves patient outcomes, reduces antimicrobial resistance, and saves money.
Interventions to improve antibiotic use can be implemented in any healthcare setting—from the smallest to the largest.
Improving antibiotic use is a medication-safety and patient-safety issue.
F441: Because of increases in MDROs, review of the use of antibiotics is a vital aspect of the infection prevention and control program.
An area of increased surveyor focus - an area where you need to assess if you are meeting the surveyor guidance
42 CFR §483.25(l), F329, Unnecessary Drugs
Determine if the facility has reviewed with the prescriber the rationale for placing the resident on an antibiotic to which the organism seems to be resistant or when the resident remains on antibiotic therapy without adequate monitoring or appropriate indications, or for an excessive duration
Right drug - Right dosage - Right monitoring - Feedback of data to MDs
Protect patients…protect healthcare personnel…
promote quality healthcare!