Download Introduction to Clostridium difficile

Introduction to C. difficile
Justin Moriarty
Peel LTC IPAC Education Day
October 10, 2013
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What is C. diff ?
• Clostridium difficile bacteria
• Many different types (strains)
• Pathogenic strains = capable
of causing illness
• Non-pathogenic strains
• Found everywhere in the
environment
• Colonizes 3-5% of adults
without causing symptoms
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Why is C. diff a problematic pathogen?
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Produces toxins
Produces spores
Naturally highly resistant to antibiotics
Some strains have evolved additional antibiotic
resistance
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What are toxins?
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Chemicals produced by the bacteria that damage cells
Toxins are produced by the living (vegetative) bacteria
A
B
Binary (sometimes)
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What are spores?
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Spores are like seeds
Not really “alive”
Have potential to grow into living bacteria (germinate)
Spores are extremely resistant
– Boiling, freezing, drying [5]
– Stomach acid
– Most common hospital-grade disinfectants
• Clostridium spores from Greenland ice cores from a
depth of 834 m (4,000 years old) started to germinate
within the first 5 min [4]
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What are the two forms of C. diff ?
• Vegetative
• Living
• Easy to kill
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Spore
Not really “alive”
Almost indestructible
Germinate and grow into
vegetative C. diff
How bad can C. diff infection get?
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Asymptomatic colonization
Mild to moderate diarrhea
Pseudomembranous colitis
Toxic dilation of the colon (megacolon)
Sepsis
Death
Colitis
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Megacolon
What is the role of antibiotics?
• Most Clostridium difficile infections (CDI) are associated
with antibiotic use
• Antibiotics kill the normal gut bacteria, clearing the way
for the resistant C. diff to flourish
• Even a single dose of antibiotics increases the risk of
CDI [2]
• People remain at increased risk for CDI for at least 3
months after they have stopped antibiotic treatment [2]
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What are the other risk factors?
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Immunosuppressive therapy post-transplant
Proton pump inhibitors
Bowel disease and bowel surgery
Chemotherapy
Hospitalization
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How is C. diff spread?
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Fecal oral route (ingestion of spores)
Inadequate hand hygiene
Inadequate environmental cleaning
Sloppy handling of bedpans and commodes
Direct or indirect contact with contaminated surfaces or
objects
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When should I suspect C. diff ?
• DIARRHEA
• Liquid stool
– Lab will only test liquid stool that takes the shape of the
container
• 3 or more episodes of diarrhea within a 24h period
– Unusual for the person, no known cause
• Other symptoms: fever, loss of appetite, nausea, and
abdominal pain/tenderness
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What are my immediate actions?
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Isolate resident
Initiate contact precautions
Obtain a sample
Send sample to lab for analysis
• Every case of C. diff is top priority
• The spores are extremely persistent and you can’t give
them a chance to accumulate in the environment
(bioburden)
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What are the additional interventions for CDI?
• Residents isolated while symptomatic
• Contact precautions
– Signs
– Gloves and gown
– Direct care minimum (Any staff touching anything in the room)
• Gloves and gown removed in the room
– Large garbage can with foot pedal (no-touch) [3]
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Dedicated toilet or commode
If bedpans are used, they should be disposable
Bedpan cleaning wands or toilet taps should not be used
Dedicated equipment where possible
– Sling for mechanical lift
• Soiled linen into no-touch receptacle at point of use [3]
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What are the environmental cleaning requirements?
• Special SPORICIDAL cleaning products are essential
• Sporicides:
– Sodium hypochlorite (bleach) solution at 5000 parts per
million chlorine (10 min contact time)
– Hydrogen peroxide enhanced action formulation at 4.5%
concentration (10 min contact time)
• Fresh bucket and mop head for each CDI room
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What are the environmental cleaning requirements?
• Twice daily cleaning and disinfection of the room and
bathroom with a sporicide
• If a commode is used, twice daily cleaning with a
sporicide
• Cleaning of shared equipment with a sporicide after
every use
– Mechanical lift
– BP machine
• Items used to clean the bathroom must be disinfected
before use in another room
• Dedicated toilet brush (discarded after)
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What are the environmental cleaning requirements?
• Consider showers instead of baths
• Last bath of the day, then disinfect tub with sporicide
– Standard tub disinfectants are not sporicidal
• Rooms should be cleaned last if possible
• Discharge = double clean
• Audit – Who is responsible for cleaning each item /
surface?
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How should I manage C. diff in a multi-bed room?
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One resident assigned to the toilet
Physical separation
Curtains drawn between beds at all times
Dedicated toilet or commode for each individual with
diarrhea
• Laundry hamper, PPE cart and garbage as close as
possible
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What about hand hygiene?
• Hands that are visibly soiled must be washed with soap and
water
• Always use ABHR following the four moments of hand hygiene
• After removing gloves staff should use ABHR (unless a
dedicated hand hygiene sink is available)
• When caring for a resident with CDI, also wash with soap and
water periodically throughout the day
– Alcohol does not kill C. diff spores
• Staff and visitors should not use resident sinks for hand hygiene
• Educate the resident on the importance of hand washing
– Help the resident wash their hands if necessary
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When do I discontinue Contact Precautions?
• For lab confirmed CDI:
– After a MINIMUM of 48 hours of “normal” stools, by the ICP
– Contact Precautions are not discontinued until the room and
bathroom have been terminally cleaned
– We do not re-test stool (no test for cure)
• For suspected CDI:
– Consult with ICP
– 2 negative EIA toxin test or 1 negative molecular (PCR) test
• Relapse
– Relapse of CDI is common
– 30%
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What is the role of education?
• Education is a key component in C. diff management
• Educate the resident, visitors, and staff
• Resident
– Hand hygiene
– PIDAC Annex C: Sample Patient Information
• Visitors
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Hand hygiene
PPE (same as staff)
Not eating or drinking in resident's room
Not visiting other residents
Not using the resident’s bathroom
When do I have an outbreak?
• Every case of C. diff is top priority
• Legally required to report outbreaks
• If you have more than one case of CDI at a time, please
call Public Health to discuss IPAC measures
• Multiple cases of CDI on a unit = additional cleaning
requirements
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References
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2.
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5.
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Ontario Agency for Health Protection and Promotion (Public Health Ontario),
Provincial Infectious Diseases Advisory Committee. Annex C: Testing, Surveillance
and Management of Clostridium difficile in All Health Care Settings. Revised.
Toronto, ON: Queen’s Printer for Ontario; January 2013.
Association for Professionals in Infection Control and Epidemiology, Inc. (APIC).
APIC Implementation Guide: Guide to Preventing Clostridium difficile Infections.
2013.
Public Health Agency of Canada. Clostridium Difficile Infection. Infection Prevention
and Control Guidance for Management in Long-term Care Facilities.
http://www.phac-aspc.gc.ca/nois-sinp/guide/c-dif-ltc-sld/index-eng.php
Validation of a Clostridium Endospore Viability Assay and Analysis of Greenland
Ices and Atacama Desert Soils. Appl. Environ. Microbiol. April 2011 vol. 77 no. 7
2352-2358.
Measures to Control and Prevent Clostridium difficile Infection. Clin Infect Dis.
(2008) 46 (Supplement 1): S43-S49. doi: 10.1086/521861.
Ontario Agency for Health Protection and Promotion (Public Health Ontario),
Provincial Infectious Diseases Advisory Committee. Best Practices for
Environmental Cleaning for Prevention and Control of Infections in All Health Care
Settings. Revised. Toronto, ON: Queen’s Printer for Ontario; May 2012.
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Photo References
• http://en.wikipedia.org/wiki/Pseudomembranous_colitis
• http://www.examiner.com/slideshow/c-diff#slide=6
• http://nationalnursingreview.com/tag/stop-nail-bitinghypnosis/
• http://www.nytimes.com/imagepages/2007/08/01/health/
adam/9856Fecalsample.html
• http://fineartamerica.com/featured/4-clostridium-difficilebacteria-tem-biomedical-imaging-unit-southamptongeneral-hospital.html
• http://upload.wikimedia.org/wikipedia/commons/thumb/2
/29/C_Diff_ToxB_2BVM.png/618pxC_Diff_ToxB_2BVM.png
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Questions?
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