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Preventing Transmission of C. difficile: Practice Elise Tamplin, M(ASCP), MPH, CIC Brigham & Women’s Hospital Objectives • Discuss practical challenges in implementing infection control measures • Illustrate the value of periodic assessment of compliance *Excludes NICU Jul-Sep08 Apr-Jun08 Jan-Mar08 Oct-Dec07 Jul-Sep07 Apr-Jun07 Jan-Mar07 Oct-Dec06 Jul-Sep06 Apr-Jun06 Jan-Mar06 Oct-Dec05 Jul-Sep05 Apr-Jun05 Jan-Mar05 Oct-Dec04 Jul-Sep04 Apr-Jun04 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Jan-Mar04 Number of CDI cases per 1000 patient days BWH healthcare-associated CDI rates 1.55 1.19 1.29 1.12 1.06 1.01 1 0.86 0.78 0.78 ar 04 Ap r- J un 04 Ju l-S ep 04 O ct -D ec 04 Ja nM ar 05 Ap r- J un 05 Ju l-S ep 05 O ct -D ec 05 Ja nM ar 06 Ap r- J un 06 Ju l-S ep 06 O ct -D ec 06 Ja nM ar 07 Ap r- J un 07 Ju l-S ep 07 O ct -D ec 07 Ja nM ar 08 Ap r- J un 08 Ju l-S ep 08 Ja nM Number of cases CDI leading to colectomy and/or death: Nosocomial & non-nosocomial cases 8 7 6 5 4 3 2 1 0 Death Colectomy Colectomy +/- Death Challenges • Preventing acquisition/transmission • Improving outcomes for patients with CDI CDI Control Interventions • Sentinel event and root cause analysis • Increase case finding & early identification—quicker lab turn around time • Enhance Infection Control measures • Aggressive CDI management & surgical evaluation (BWH CDI Treatment Guidelines) • Staff education • Minimize antibiotic utilization Laboratory Testing • Change in test methodology – Cytotoxicity assay to EIA • From 3 day TAT to same day results – Lower sensitivity – Need for clinical judgment in interpretation of negative result – Increased possibility of false negatives if specimen taken while on antibiotics Basic Infection Control Practices • Hand hygiene • Contact precautions for infected patients • Ensure cleaning and disinfection of equipment and the environment • Implement a laboratory-based alert system • Conduct CDI surveillance • Educate patients and families about CDI Special Approaches to prevent transmission by healthcare personnel • Perform hand hygiene with soap and water after contact with a patient with CDI – Pro: Alcohol is not sporicidal – Con: Hand hygiene compliance is lower for handwashing with soap and water vs. use of an alcohol-based hand disinfectant Special Approaches to prevent spread through the environment • Use a hypochlorite-based room cleaning agent – Pro: Sporocidal and benefit has been reported in outbreak settings – Con: Can corrode equipment and can be a chemical irritant for patients and staff Special Approaches to prevent transmission by healthcare personnel • Prolong the duration of contact precautions after the patient becomes asymptomatic until hospital discharge – Patients may shed C. difficile in their stool after diarrhea resolves Bobulsky GS et al. Clin Infect Dis 2008; 46:447–50 New Infection Control Measures • Enhancements to Contact Precautions • Contact Precautions Plus – Soap & water hand hygiene – Hypochlorite based disinfectantdetergent upon discharge/transfer – Precautions for duration of admission Contact Precautions Plus • Discontinuation upon cessation of symptoms problematic • Administration buy-in required for continuation during entire admission • Automated “flag” developed by IS like those for MRSA & VRE but expiring upon discharge • Education of Admitting staff re empiric precaution status Soap & Water Hand Hygiene • Major change from routine use of waterless hand sanitizer • Visibility of sign key issue – Several design changes • Sink availability challenging – Few in central areas of inpatient units – Reluctance to use patient room sink – Hand washing 101 *Bleach-based Do not remove sign until after room has been cleaned Hypochlorite Disinfectant • Infection Control & Safety approvals • Odor/symptom complaints from staff - OHS evaluation/tracking - MNA discussion re safety concerns - Evaluation of new products - Change from liquid to impregnated wipes - Adequacy of surface wetting evaluated Hypochlorite Disinfectant • Compliance with use – Tracking mechanisms Daily patient log from Infection Control to Environmental Service Some rooms still missed Daily review/verification by ES & return to Infection Control – Signs taken down before cleaning CPP room status added to housekeeping page Staff Education • Physicians – Early severe patient outcomes helped – M&M conferences, Grand Rounds, etc. • Nursing – Empiric precautions – Specimen collection prior to treatment Staff Education • Support (Environmental Services) – Balance between emphasis on need for special measures vs. fostering undue personal safety concerns – Regroup with supervisors • Administrative (Admitting) – Achieving support for empiric precautions CDI Management Guidelines • Consensus document – Infection Control – Infectious Disease – Medical Intensive Care – General Surgery – Microbiology – Pharmacy – Nursing CDI Management Guidelines • Infection Control Precautions • Diagnostic testing • Clinical management of patients CDI Management Guidelines • Clinical categories based on specific clinical criteria – Appropriate management for each Stop non-essential medications antimicrobials & antiperistaltics Appropriate antibiotic therapy Infectious Disease & Surgical consults Rectal vancomycin (when & how) 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Jan-Mar04 Apr-Jun04 Jul-Sep04 Oct-Dec04 Jan-Mar05 Apr-Jun05 Jul-Sep05 Oct-Dec05 Jan-Mar06 Apr-Jun06 Jul-Sep06 Oct-Dec06 Jan-Mar07 Apr-Jun07 Jul-Sep07 Oct-Dec07 Jan-Mar08 Apr-Jun08 Jul-Sep08 Oct-Dec08 Jan-Mar09 Apr-Jun09 Jul-Sep09 Oct-Dec09 Jan-Mar10 Number of CDAD cases per 1000 patient days BWH healthcare-associated CDI rates Contact Precautions Plus BWH Treatment 1.55 Guidelines 1.29 1.19 1.12 1.061.01 1 0.79 0.86 0.69 0.74 0.780.78 0.7 0.6 0.6 0.6 0.6 0.5 0.5 0.50.5 0.63 0.55 *Excludes NICU Ja nM Ap ar 0 r- J 4 u Ju n 04 l-S O ep0 ct -D 4 e Ja c0 n- 4 M Ap ar 0 r- J 5 u Ju n 05 l-S O ep0 ct -D 5 e Ja c0 n- 5 M Ap ar 0 r- J 6 u Ju n 06 l-S O ep0 ct -D 6 e Ja c0 n- 6 M Ap ar 0 r- J 7 u Ju n 07 l-S O ep0 ct -D 7 e Ja c0 n- 7 M Ap ar 0 r- J 8 u Ju n 08 l-S O ep0 ct -D 8 e Ja c0 n- 8 M Ap ar 0 r- J 9 u Ju n 09 l-S O ep0 ct -D 9 ec 09 Number of cases Severe CDI leading to colectomy+/-death Nosocomial vs. non-nosocomial 8 Contact Precautions Plus 7 6 5 4 3 2 1 0 Nosocomial Other source Objectives • Discuss practical challenges in implementing infection control measures • Illustrate value of periodic assessment of compliance