Download Guidelines_Clostridium difficile

Running Head: GUIDELINES_C.DIFF._GROUP 8
Clostridium difficile Infection in Adults
National Guidelines Summary Group Assignment
Melanie Schlittenhardt, Jamie Slettedahl, Carlee Thomson, Sandra Thorson
University of Mary
NUR 510
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National Guidelines Summary Group Assignment
Clostridium difficile Infection in Adults
Scope
Disease condition. Healthcare workers are often put on the spot as a vector in the spread
of diseases. In order to combat the transmission of diseases vigilant efforts to educate proper
hand washing techniques, identify and implement contact precautions are incorporated into the
daily routine of healthcare workers. Nevertheless, the Centers for Disease Control and
Prevention (2015) indicate that the hands of healthcare personnel are the main route in
transferring the bacteria Clostridium difficile (C.diff.) from patient to patient (Centers for
Disease Control and Prevention, 2015). Medical professionals, as well as governmental agencies
continue to collaborate to provide and update guidelines for safe practice to reduce the spread of
bacteria such as C. diff.
C. diff. is shed in feces and when surfaces, devices, or material that become contaminated
with feces, it may serve as a reservoir for the bacteria (Centers for Disease Control and
Prevention, 2015). In addition, the bacteria have a protective coating or spore that allows it to
survive for a long period of time. Individuals become particularly susceptible to C. diff. when
taking antibiotics, which destroy the infectious bacteria, as well as the normal flora of the
gastrointestinal tract. Therefore the combination of patients taking antibiotics and their
frequency of either clinic visits or hospital admission places the patient at increased risks on
contracting the bacteria.
C. diff. is an infection of the colon that results in watery diarrhea from toxins that damage
the mucosa (McCance, Huether, Brashers, & Rote, 2014). Clostridia are anaerobic bacteria that
produce some of the most powerful toxins known. In addition to watery diarrhea, Clostridium
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difficile infection (CDI) can cause fever, loss of appetite, nausea, abdominal tenderness (Center
for Disease Control and Prevention, 2015).
Guideline categories. According to the National Guideline Clearinghouse (2010), the
guidelines are diagnosis, prevention, and treatment. The diagnosis of CDI includes a stool
culture, enzyme immunoassay (EIA), toxin testing (2-step method using EIA detection of
glutamate dehydrogenase and then cell cytotoxicity assay or toxigenic culture), and polymerase
chain reaction (PCR; National Guidelines Clearinghouse, 2010). The prevention of CDI include
the use of gloves and gowns, proper hand hygiene, private patient use with unshared restroom(s),
maintaining contact precautions, environmental cleaning and disinfection, and antimicrobial use
restriction (National Guidelines Clearinghouse, 2010). The treatment of CDIs includes
avoidance of antiperistaltic agents, initiate empirical antibiotics such as metronidazole,
vancomyacin and/or fidaxomicin, and possibly stool transplantation or colectomy (National
Guidelines Clearinghouse, 2010).
Guideline objectives. According to the National Guideline Clearinghouse (2010),
guideline objectives are to provide recommendations for the diagnosis and management of
patients with CDI as well as for the prevention and control of outbreaks while supplementing
previously published guidelines.
Methodology
Description of methods used. An expert panel from the Society of Healthcare
Epidemiology of America and Infectious Disease Society of America (SHEA-IDSA) completed
a review and analysis in 2010 for the CDI guideline. Electronic databases were utilized to collect
information and a literature search with PubMed was executed. Dates included in the search
GUIDELINES_C.DIFF._GROUP 8
were 1994 through April, 2009. Only English literature was included in the review (National
Guideline Clearinghouse, 2010).
Rating scheme for strength. In evaluating the evidence regarding the management of
CDI, the expert panel followed a process of systematic weighting and included the following:
Quality of the evidence.
I. Evidence was acquired from at least one properly randomized and
controlled trial.
II. Evidence was acquired from at least one well-designed clinical trial
without randomization, or cohort study or case controlled study from
multiple time series or from dramatic results from uncontrolled
experiments.
II. Evidence was acquired from respected authorities based on expert
clinical experience, descriptive studies or committee reports (National
Guideline Clearinghouse, 2010).
Strength of recommendations.
A. Respectable and good quality evidence to support an approval for or
against the use.
B. Moderate evidence to sustain an approval for or against use.
C. Poor evidence to support an approval (National Guideline
Clearinghouse, 2010).
Number of sources. The quantity of sources utilized was not reported in the guideline
(National Guideline Clearinghouse, 2010).
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Cost analysis. A formal cost analysis was not published (National Guideline
Clearinghouse, 2010); although, financial support for this guideline was provided by the SHEAIDSA (Cohen et al., 2010).
Method of guideline variations. The epidemiology, diagnosis, infection control
measures, and agents for treatment were validated through a peer review process; however, the
description of method was not published (Cohen et al., 2010; National Guideline Clearinghouse,
2010).
Recommendations
Major recommendations. The epidemiological data desired is used to increase
comparability between clinical (HCF)-onset, HCF-associated CDI; 2) community-onset, HCFassociated CDI; and 3) community-associated CDI (B-III). At a minimum, for epidemiological
purposes, conduct surveillance for HCF-onset, HCF-associated CDI in all inpatient healthcare
facilities, to detect outbreaks and monitor patient safety (B-III). This data would express the rate
of healthcare-associated CDI as the number of cases per 10,000 patient-days (B-III). If CDI rates
are higher compared to those at other facilities or if an outbreak is noted, stratify rates by patient
location in order to target control measures (B-III; National Guideline Clearinghouse, 2010).
The best testing strategy to diagnose CDI in the clinical laboratory includes testing for
C.diff. or its toxins only on diarrheal (unformed) stool, unless ileus due to C. diff. is suspected
(B-II). Testing of stool from asymptomatic patients is not clinically useful (B-III). Stool culture
is the most sensitive test and is essential for epidemiological studies (A-II). Although stool
culture is not clinically practical because of its slow turnaround time, the sensitivity and
specificity of stool culture followed by identification of a toxigenic isolate provides the standard
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against which other clinical test results should be compared (B-III; National Guideline
Clearinghouse, 2010).
For infection control and prevention, all healthcare workers and visitors must use gloves
(A-I) and gowns (B-III) upon entry to a room of a patient infected with CDI. Hand hygiene is of
the utmost importance and compliance should be emphasized (A-II). Patients infected with CDI
should be accommodated with a private room and contact precautions (B-III). If single rooms
are not available, cohort patients are provided a private commode for each patient (C-III).
Contact precautions for the duration of diarrhea should be maintained (C-III). Routine
identification of asymptomatic carriers (patients or healthcare workers) for infection control
purposes is not recommended (A-III) and treatment of such identified patients is not effective
(B-I; National Guideline Clearinghouse, 2010).
Environmental cleaning and disinfection include identification and removal of
environmental sources of C. difficile, including replacement of electronic rectal thermometers
with disposables (B-II). This can reduce the incidence of CDI. The use of chlorine-containing
cleaning agents or other sporicidal agents should be used to address environmental
contamination in areas associated with increased rate of CDI (B-II). Routine environmental
screening for C. diff. is not recommended (C-III; National Guideline Clearinghouse, 2010).
The frequency and duration of antimicrobial therapy, and the number of antimicrobial
agents prescribed should be minimized to reduce the risk of CDI (A-II). An antimicrobial
stewardship program should be implemented (A-II). Antimicrobials to be targeted should be
based on the local epidemiology and the C. diff. strains present, but restricting the use of
cephalosporin and clindamycin (except for surgical antibiotic prophylaxis) may be useful (C-III;
National Guideline Clearinghouse, 2010).
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Whenever possible, avoid the use of antiperistaltic agents, as they may obscure symptoms
and precipitate toxic megacolon (C-III). Metronidazole is the drug of choice for the initial
episode of mild-to-moderate CDI. The dosage is 500 mg orally 3 times per day for 10-14 days
(A-I). Vancomycin is the drug of choice for an initial episode of severe CDI. The dosage is 125
mg orally 4 times per day for 10-14 days (B-I). Vancomycin administered orally (and per
rectum, if ileus is present) with or without intravenously administered metronidazole is the
regimen of choice for the treatment of severe, complicated CDI. The vancomycin dosage is 500
mg orally 4 times per day and 500 mg in approximately 100 mL normal saline per rectum every
6 hours as a retention enema, and the metronidazole dosage is 500 mg intravenously every 8
hours (C-III; National Guideline Clearinghouse, 2010).
A colectomy may be considered for severely ill patients. Monitoring the serum lactate
level and the peripheral blood white blood cell count may be helpful in prompting a decision to
operate, because a serum lactate level rising to 5 mmol/L and a white blood cell count rising to
50,000 cells per uL have been associated with greatly increased perioperative mortality. If
surgical management is necessary, perform subtotal colectomy with preservation of the rectum
(B-II; National Guideline Clearinghouse, 2010).
Treatment of the first recurrence of CDI is usually with the same regimen as for the initial
episode (A-II), but should be stratified by disease severity (mild-to-moderate, severe, or severe
complicated), as is recommended for treatment of the initial CDI episode (C-III; National
Guideline Clearinghouse, 2010).
Hazard/complications. When treating CDI, discontinue therapy with the inciting
antimicrobial agent(s) as soon as possible, as this may influence the risk of CDI recurrence (AII). As soon as the diagnosis of severe or complicated CDI is suspected, initiate empirical
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treatment (C-III). If the stool toxin assay result is negative, decisions to initiate, stop, or continue
treatment must be individualized (C-III; National Guideline Clearinghouse, 2010), 2010). Do
not us metronidazole beyond the first recurrence of CDI or for long-term chronic therapy
because of potential for cumulative neurotoxicity (B-II). Treatment of the second or later
recurrence of CDI with vancomycin therapy using a tapered and/or pulse regimen is the preferred
next strategy (B-III; National Guideline Clearinghouse, 2010).
Limitations. There are no recommendations regarding prevention of recurrent CDI in
patients who require continued antimicrobial therapy for an underlying infection (C-III; National
Guideline Clearinghouse, 2010).
Benefits/Harms
Potential Benefits. It is hard to imagine that benefits could be considered when
associated with C. diff. The inoculation of C. diff. can be prevented. The CDC has a list of
recommendations for contact precautions to be put into place for the duration of the diarrhea.
The recommendations include proper hand hygiene, adequate cleaning and disinfection of all
equipment and the environment, and a laboratory based alert system which would notify proper
personnel with positive test results. It is also beneficial to educate all staff about C.diff., such as
housekeeping, administration, all care providers as well as patients and families. Health care
facilities could also consider extending the use of contact precautions beyond the duration of the
diarrhea, isolating a patient with symptoms until lab confirmation can be confirmed; using soap
and water for hand hygiene before leaving the room and using EPA-registered disinfectants with
sporicidal claim (e.g., bleach) (Top CDC recommendations to prevent HAIs, 2013, p. 3). By
implementing the precautions, an organization could help prevent or spread the disease.
Potential Harms. The harms could also be considered some of the symptoms as well.
An individual with C. diff. could suffer from fever, dehydration, abdominal cramping and watery
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diarrhea lasting for a minimum of two days (Joint Subcommittee on Anti-Infective Use, 2011, p.
1). Additional symptoms could include Frank bleeding, a soft abdomen, increased bowel sounds
and mild tenderness over the left-lower quadrant. The severity of the infection could be
influenced by additional health concerns such as age, comorbidity, a host’s immune response,
bacterial genotype and also toxin production (Deshpande, Pimentel, & Choure, n.d.,p. 1).
Contraindications. In severe cases toxic megacolon could occur. The patient would
have a marked colonic distention, peritoneal irritation, elevated white count and a fever. Surgery
is usually required with a significant morbidity and mortality rate noted (Deshpande, Pimentel, &
Choure, n.d., p. 1). Recurrence can occur in six – twenty five percent of patients with symptoms
usually occurring by the eighth week after discontinuing the previous therapy. Many patients
will respond to the initial treatment. A consultation with Infectious Disease is highly encouraged
as well (Joint Subcommittee on Anti-Infective Use, 2011, p. 3).
Conclusion
The benefits of this guideline are to reduce the occurrence and complications of C. diff.
Preventing disease transmission is everyone’s responsibility including Advanced Practice
Nurses. By understanding the current guidelines and utilizing them in practice, healthcare
professionals can work towards promoting a work environment that further promotes health
without causing harm to patients.
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References
Centers for Disease Control and Prevention (2013, March 23). Top CDC recommendations to
prevents HAIs. Retrieved from http://www.cdc.gov/HAI/prevent/top-cdc-recs-prevent-hai.html
Centers for Disease Control and Prevention. (2015). Clostridium difficile Infection. Retrieved from
http://www.cdc.gov/hai/organisms/cdiff/Cdiff-patient.html
Cohen, S., Gerding, D., Johnson, M., Kelly, C., Loo, V., McDonald, L.…Wilcox, H., (2010). Clinical
practice guidelines for Clostridium difficile infection in adults: 2010 Update by the Society for
Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America
(IDSA). Infection Control and Hospital Epidemiology, 31(5), 431–455. doi:10.1086/651706
Deshpande, A., Pimentel, R., & Choure, A. (n.d.). Antiobiotic-associated diarrhea and clostridium
difficle. Retrieved from Cleveland Clinic:
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastroenterology/antibi
otic-associated-diarrhea/#top
Joint Subcommittee on Anti-Infective Use. (2011, March). Clostridium difficile infection (CDI):
Guidelines for the management of adult patients. Retrieved from New York Presbyterian
Hospital:
http://www.cumc.columbia.edu/dept/id/documents/Clinical%20References/Clostridium_Difficile
_Infection_Guidelines_for_the_Management_of_Adult_Patients.pdf
McCance, K.L., Huether, S.E., Brashers, V. L., & Rote, N.S. (2014). Pathophysiology: The biologic
basis for disease in adults and children (7th ed.) St. Louis, MO: Mosby-Elsevier.
National Guideline Clearinghouse. (2010). Clinical practice guidelines for Clostridium difficile
infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA)
and the Infectious Diseases Society of America (IDSA). Retrieved January 14, 2015, from
http://www.guideline.gov/content.aspx?id=15952