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1 Clostridium difficile Elizabeth Boldon, RN, MSN Elizabeth Boldon is a Nurse Education Specialist at Mayo Clinic in Rochester, Minnesota. She received a BSN from Allen College in Waterloo, Iowa in 2002 and an MSN with a focus in education from the University of Phoenix in 2008. She has bedside nursing experience in medical neurology and the neuroscience ICU. Abstract Clostridium difficile infection (CDI) is a major cause of infectious disease concern in the United States. It is the associated with hospital-acquired intestinal inflammation and diarrhea and, most commonly, with normal intestinal flora disruption due to poor prescribing practices of antibiotics. It has been reported that antibiotics prescribed in hospitals are often unnecessary or incorrect. Using infection control recommendations and more careful antibiotic use can prevent clostridium difficile infection. The risk of CDI associated with antibiotic use and other risk factors, including disease recognition, treatment and prevention are discussed. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 Continuing Nursing Education Course Planners William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster, Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 2 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Statement of Learning Need Nurses need to recognize and stay informed of the risk factors, symptoms, diagnosis, treatment and prevention of clostridium difficile. Importantly, C. difficile is caused by normal intestinal flora disruption due to poor prescribing practices of antibiotics. Nurses can identify and educate patients and peers of the risk of antibiotic prescribing and other risk factors associated with C. difficile morbidity and mortality. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 Course Purpose To provide nursing professionals with knowledge to care for patients with clostridium difficile, and to promote prevention strategies of disease occurrence and recurrence. Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Elizabeth Boldon, RN, MSN, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Activity Review Information Reviewed by Susan DePasquale, MSN, FPMHNP-BC Release Date: 2/15/2016 Termination Date: 9/30/2018 Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 1. Each year, more than _____________ people get sick from C. difficile. a. 1/4th million b. 1/3rd million c. half million d. None of the above 2. Complications of C. difficile infections include: a. dehydration b. hypotension c. kidney failure d. All of the above 3. Standard treatment for C. diff is a _________ day course of another antibiotic. a. 5 - 7 b. 10 – 14 c. 20 – 30 d. > 30 4. For more severe and recurrent cases, _____________ , may be prescribed a. ampicillin b. flagyl c. vancomycin d. Answers a and b above 5. True/False. Research has shown FMT has a success rate higher than 50 percent for treating C. difficile infections. a. True b. False nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 Introduction Clostridium difficile infection (CDI), also called C. difficile or C. diff, is an important cause of concern for health professionals in the United States due the infectious disease morbidity and mortality rates reported with its occurrence. It has been estimated (in 2011) that CDI had caused almost half a million infections in the U.S. population. Approximately 83,000 of the patients who developed CDI experienced at least one recurrence and 29,000 individuals died within 30 days of the initial diagnosis.1 Poor prescribing practices put patients at risk for C. difficile infections. More than half of all hospitalized patients will receive an antibiotic at some point during their hospital stay, but studies have shown that 30 - 50% of antibiotics prescribed in hospitals are unnecessary or incorrect. C. difficile infections can be prevented by using infection control recommendations and more careful antibiotic use.1 What Is Clostridium difficile? Clostridium difficile is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. Illness from C. difficile most commonly affects older adults in hospitals or in long-term care facilities and typically occurs after use of antibiotic medications. However, studies show increasing rates of C. difficile infection among people traditionally not considered high risk, such as younger, healthier individuals without a history of antibiotic use or exposure to healthcare facilities. Each year, more than a half million people get sick from C. diff. In recent years, C. difficile infections have become more frequent, severe and difficult to treat.2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 Symptoms of Clostridium difficile Some people carry the bacterium C. difficile in their intestines but never become sick, though they can still spread the infection. Clostridium difficile illness usually develops during or within a few months after a course of antibiotics.2 Mild to moderate infection The most common symptoms of mild to moderate C. difficile infection are listed below. These are: Watery diarrhea three or more times a day for two or more days Mild abdominal cramping and tenderness Severe infection In severe cases, people tend to become dehydrated and may need hospitalization. Clostridium difficile causes the colon to become inflamed (colitis) and sometimes may form patches of raw tissue that can bleed or produce pus (pseudomembranous colitis). Signs and symptoms of severe infection include:2 Watery diarrhea 10 to 15 times a day Abdominal cramping and pain, which may be severe nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7 Fever Blood or pus in the stool Nausea Dehydration Loss of appetite Weight loss Swollen abdomen Kidney failure Increased white blood cell count Causes of Clostridium difficile Clostridium difficile bacteria are found throughout the environment — in soil, air, water, human and animal feces, and food products, such as processed meats. A small number of healthy people naturally carry the bacteria in their large intestine without experiencing ill effects from the infection. Most commonly associated with healthcare, C. difficile infection occurs in hospitals and other healthcare facilities where a much higher percentage of people carry the bacteria. However, studies show increasing rates of community-associated C. difficile infection, which occurs among populations traditionally not considered at high risk, such as children and people without a history of antibiotic use or recent hospitalization.2 Clostridium difficile bacteria is passed in feces and spread to food, surfaces and objects when people who are infected are negligent in washing their hands thoroughly. The bacteria produce spores that can persist in a room for nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8 weeks or months. If someone touches a surface contaminated with C. difficile, they may then unknowingly swallow the bacteria. The intestines contain millions of bacteria, many of which help protect the body from infection. However, when an individual is taking an antibiotic to treat an infection, the drug can destroy some of the normal, helpful bacteria as well as the bacteria causing the illness. Without enough healthy bacteria, C. difficile can quickly grow out of control. Once established, C. difficile can produce toxins that attack the lining of the intestine. The toxins destroy cells and produce patches (plaques) of inflammatory cells and decaying cellular debris inside the colon and cause watery diarrhea.2 Emergence of a new strain An aggressive strain of C. difficile has emerged that produces far more toxins than other strains do. The new strain may be more resistant to certain medications and has shown up in people who have not been in the hospital or taken antibiotics. This strain of C. difficile has caused several outbreaks of illness since 2000.2 Risk Factors for Clostridium difficile Although people — including children — with no known risk factors have become sick from C. difficile, certain factors increase the risk. These risk factors are briefly outlined below. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9 Taking antibiotics or other medications Medication-associated risk factors relate to a variety of scenarios. Examples of medication-associated risk factors include: Currently taking or having recently taken antibiotics Taking broad-spectrum antibiotics that target a wide range of bacteria Using multiple antibiotics Taking antibiotics for a long time Taking medications to reduce stomach acid, including proton pump inhibitors (PPIs) Staying in a healthcare facility The majority of C. difficile cases occur in, or after exposure to, healthcare settings — including hospitals, nursing homes and long-term care facilities — where germs spread easily, antibiotic use is common and people are especially vulnerable to infection. In hospitals and nursing homes, C. difficile spreads mainly on hands from person to person, but also on cart handles, bedrails, bedside tables, toilets, sinks, stethoscopes, thermometers — even telephones and remote controls.2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10 Having a serious illness or medical procedure Having a serious illness, such as inflammatory bowel disease or colorectal cancer, or a weakened immune system as a result of a medical condition or treatment (such as chemotherapy), cause people to be more susceptible to a C. difficile infection. The risk of C. difficile infection is also greater in those who have had abdominal surgery or a gastrointestinal procedure. Older age is also a risk factor for C. difficile infection. In one study, the risk of becoming infected with C. difficile was 10 times greater for people age 65 and older compared with younger people. After having a previous C. difficile infection, the chances of having a recurring infection can be up to 20 percent, and the risk increases further with every subsequent infection.2 Diagnosis of Clostridium difficile Medical providers often suspect C. difficile in anyone with diarrhea who has recently taken antibiotics or when diarrhea develops a few days after hospitalization. In such cases, the following tests may be performed: Stool tests Toxins produced by C. difficile bacteria can usually be detected in a sample of stool. Several main types of lab tests exist, and they include: nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11 Enzyme immunoassay: Most labs use the enzyme immunoassay (EIA) test, which is faster than other tests, but is not sensitive enough to detect many infections and has a higher rate of falsely normal tests. Polymerase chain reaction: This sensitive molecular test can rapidly detect the C. difficile toxin B gene in a stool sample and is highly accurate. It is now being adapted by several laboratories and becoming more widely available. Cell cytotoxicity assay: A cytotoxicity test looks for the effects of the C. difficile toxin on human cells grown in a culture. This type of test is sensitive, but it is less widely available, more cumbersome to do and requires more than 24 to 48 hours for test results. Some hospitals use both the EIA test and cell cytotoxicity assay to ensure accurate results. Testing for C. difficile is unnecessary in the absence of diarrhea or watery stools.2 Colon examination In rare instances, to help confirm a diagnosis of C. difficile infection, a care provider may examine the inside of the colon. A colonic examination, through a flexible sigmoidoscopy or colonoscopy procedure, involves inserting a flexible endoscope with a small camera on one end into the colon to look for areas of inflammation and pseudomembranes. This procedure allows the endoscopist to remove tissue samples through biopsy or snare instruments for laboratory (pathology) testing. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12 Imaging tests If a medical provider is concerned about possible complications of C. difficile, he or she may order an abdominal X-ray or a computerized tomography (CT) scan, which provides images of the colon. The scan can detect the presence of complications such as thickening of the colon wall, expanding of the bowel, or more rarely, a perforation in the lining of the colon. Complications of Clostridium difficile Complications of C. difficile infections include the following conditions.2 Dehydration: Severe diarrhea can lead to a significant loss of fluids and electrolytes. This makes it difficult for the body to function normally and can cause severe hypotension. Kidney failure: In some cases, dehydration can occur so quickly that kidney function rapidly deteriorates (kidney failure). Toxic megacolon: In situations of toxic megacolon, the affected patient becomes unable to expel gas and stool, causing the colon to become greatly distended (hence, the term megacolon). Left untreated, the colon can rupture, causing bacteria from the colon to enter the abdominal cavity. A ruptured colon requires emergency surgery and may be fatal. Bowel Perforation: A bowel perforation is rare and results from extensive damage to the lining of the large intestine. A perforated bowel can spill bacteria from nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13 the intestine into the abdominal cavity, leading to a life-threatening infection (peritonitis). Death: Even mild to moderate C. difficile infections can quickly progress to a fatal disease if not treated promptly. Treatment Of Clostridium difficile The first step in treating C. difficile is to stop taking the antibiotic that triggered the infection, when possible. Depending on the severity of the infection, treatment may include the following medical and surgical interventions. Antibiotics Ironically, the standard treatment for C. difficile is a 10 - 14 day course of another antibiotic. These antibiotics keep C. difficile from growing, which treats diarrhea and other complications. For mild to moderate infection, medical providers usually prescribe metronidazole (Flagyl), taken by mouth. Metronidazole is not approved by the U.S. Food and Drug Administration (FDA) for C. difficile infection, but has been shown to be effective in mild to moderate infection. Side effects of metronidazole include nausea and a bitter taste. For more severe and recurrent cases, vancomycin (Vancocin), also taken by mouth, may be prescribed. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 14 Another oral antibiotic, fidaxomicin (Dificid), has been approved to treat C. difficile. In one study, the recurrence rate of C. difficile in people who took fidaxomicin was lower than among those who took vancomycin. However, fidaxomicin costs considerably more than metronidazole and vancomycin. Common side effects of vancomycin and fidaxomicin include abdominal pain and nausea.2 Surgery For people with severe pain, organ failure or inflammation of the lining of the abdominal wall, surgery to remove the diseased portion of the colon may be the only option. Recurrent infection and situations when surgery may be considered are outlined below. Recurrent infection Up to 20 percent of people with C. difficile get sick again, either because the initial infection never went away or because they're reinfected with a different strain of the bacteria. But after one or more recurrences, rates of further recurrence increase up to 65 percent.2 The risk of recurrence is higher for the following individuals. People older than 65 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 15 Those taking other antibiotics for a different condition while being treated with antibiotics for C. difficile infection Those having a severe underlying medical disorder, such as chronic kidney failure, inflammatory bowel disease or chronic liver disease. Medical Treatment for Recurrent CDI The medical treatment for recurrent C. difficile infection may include the following interventions. Antibiotics Antibiotic therapy for recurrence of C. difficile infection may involve one or more courses of a medication (typically vancomycin), a gradually tapered dose of medication or an antibiotic given once every few days, a method known as a pulsed regimen. For a first recurrence, the effectiveness of antibiotic therapy is around 60 percent and further declines with each subsequent recurrence. Fecal microbiota transplant (FMT) Also known as a stool transplant, fecal microbiota transplant, or FMT, is emerging as an alternative strategy for treating recurrent C. difficile infections. Though not yet approved by the FDA, clinical studies of FMT are currently underway. Fecal microbiota transplant restores healthy intestinal bacteria by placing another person's (donor's) stool in the colon, using a colonoscope or nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16 nasogastric tube. Donor stools are carefully and repeatedly screened for parasites, viruses, bacteria and certain antibodies before being used for an FMT. Research has shown FMT has a success rate higher than 90 percent for treating C. difficile infections. One small, randomized, controlled trial stopped early because the results were so positive, with a 94 percent success rate overall.2 Probiotics Probiotics are organisms, such as bacteria and yeast, which help restore a healthy balance to the intestinal tract. Yeast called Saccharomyces boulardii, in conjunction with antibiotics, might help prevent further recurrent C. difficile infections. Prevention Of Clostridium difficile Prevention of C. difficile transmission is especially challenging because the organism forms spores, which can persist on environmental surfaces for months and are resistant to commonly used hospital cleaning agents and alcohol-based hand gels. Thus, prevention and control of C. difficile requires a number of interventions. This was illustrated in a report of a C. difficile hypervirulent strain outbreak; the outbreak was successfully controlled with introduction of successive interventions and through the guidance of ongoing surveillance. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17 Statewide programs and national initiatives emphasizing public reporting, antibiotic stewardship, and infection control measures have also demonstrated successful prevention.3 To help prevent the spread of C. difficile, hospitals and other healthcare facilities follow strict infection-control guidelines. A detailed practice recommendation for prevention of C. difficile infection in acute-care hospital settings from the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America is available. The recommendations of each are summarized briefly here. Surveillance Rates of C. difficile infection should be tracked using standard surveillance definitions and be grouped into three hospital facility (HCF) and community categories: (1) HCF-onset, HCF-associated; (2) community-onset, HCFassociated; and, (3) community-associated. Such data can be compared with other facilities and used to evaluate trends within the same facility. Rising rates or rates above published benchmarks should prompt further investigation and intervention. Since 2013, all United States hospitals participating in the Centers for Medicare & Medicaid Services' Inpatient Prospective Payment System Quality Reporting Program are required to report facility-wide C. difficile events using the National Healthcare Safety Network (NHSN); and, public reporting of hospital rates began in 2014 at the Hospital Compare website. As of 2015, all long-term acute care hospitals are required to report facility-wide C. difficile events.3 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 18 Prevention Strategies Early detection and isolation Early detection of C. difficile with rapid implementation of contact precautions is essential for preventing transmission. It requires vigilant screening for new onset diarrhea in patients at risk and rapid, accurate testing. Contact precautions Patients with suspected or proven C. difficile infections should be placed on contact precautions, including assignment to a single room with dedicated toileting facilities or cohorting with other infected patients. Gloves and gowns should be donned upon room entry and removed prior to exiting the room. When cohorting is necessary, gowns and gloves should be removed and hand hygiene performed when moving from one patient to the other. It may be reasonable to continue contact precautions beyond the duration of diarrhea, since persistent stool shedding of C. difficile spores is common; further study is needed on this.3 Hand hygiene Healthcare personnel should wash their hands with soap and water when caring for C. diff patients. This is particularly important in the setting of a C. difficile outbreak. Alcohol-based hand rub (ABHR) does not eradicate C. difficile spores. Hand washing with soap and water involves vigorous mechanical scrubbing and rinsing, so it is more effective than ABHR for physical removal of nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19 bacterial spores. However, bacterial spore removal through soap and water hand washing is less effective than ABHR inactivation of vegetative (i.e., non-spore forming) bacteria. Thus, adherence to glove use in the care of symptomatic patients is critically important for preventing transmission of C. difficile. Patients with C. difficile infection should also be encouraged to wash hands with soap and water. In particular, patients should wash their hands after using the commode, before eating, and when hands are visibly soiled.3 Environmental Cleaning Clostridium difficile spores can survive on dry surfaces for up to several months and resist killing by standard disinfectants. Therefore, careful attention to environmental cleaning is critical for reducing surface contamination. One study on a bone marrow transplant unit noted that switching to 1:10 hypochlorite solution from quaternary ammonium was effective for reducing C. difficile infection rates, from 8.6 to 3.3 cases per 1000 patient-days.3 A disinfectant with a C. difficile sporicidal label that has been registered with the Environmental Protection Agency (EPA) should be considered for disinfection of patient rooms and bathroom. Some sporicidal agents can cause caustic damage to equipment surfaces and serve as an irritant for patients and healthcare personnel. These issues should be considered in the selection and implementation of such agents in healthcare facilities as well as other public settings. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 20 Multiuse medical equipment such as blood pressure cuffs, stethoscopes, and thermometers can serve as vectors for transmission of C. difficile. When possible, disposable equipment should be used; otherwise, such equipment should be dedicated to a single patient with C. difficile infection. Equipment that must be shared between patients should be cleaned and disinfected with a sporicidal agent between uses.3 Chlorhexidine Bathing Chlorhexidine (CHG) bathing may reduce hospital-acquired C. difficile. This was illustrated in a study including administration of more than 68,000 CHG baths over an 18-month period, during which the incidence of C. difficile decreased with bathing daily or three times weekly compared with a oneyear baseline observation period.3 Antibiotic Stewardship Administration of antibiotics disrupts the intestinal microbiota and has been definitively linked to both colonization and disease caused by C. difficile. Antibiotic use increases the risk for developing C. difficile by 7- to 10-fold during and up to one month after treatment and by approximately threefold for two months thereafter. Targeted restriction of a particular antibiotic agent or class of agents can facilitate control of hospital outbreaks and reduce C. difficile rates in the community.3 Antibiotics frequently associated with increased C. difficile risk include clindamycin, fluoroquinolones, cephalosporins, and penicillins. These are outlined briefly below. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21 Clindamycin Clindamycin restriction has been followed by rapid reductions in C. difficile cases in several outbreaks. Similar findings have been observed in outbreaks caused by the highly clindamycin-resistant J strain. In one study, for example, a policy requiring infectious disease physician approval for clindamycin use led to reduction in CDI cases (from 11.5 to 3.3 cases per month).3 Fluoroquinolone Fluoroquinolone use has been associated with outbreaks caused by the hypervirulent NAP1/BI/027 strain. Restriction of all fluoroquinolones may be required for effective control in such circumstances. In one study, elimination of fluoroquinolone use was associated with a reduction in C. difficile cases and in the proportion of cases due to the NAP1/BI/027 strain. Third-generation Cephalosporins Restriction of third-generation cephalosporins has been successful in reducing C. diff rates. Other studies have noted associations between formulary restrictions and reduced C. difficile rates by limiting antibiotics to penicillin, trimethoprim-sulfamethoxazole, and aminoglycosides in the setting of an outbreak. Avoiding Gastric Acid Suppression Whenever possible, gastric acid suppression should be avoided. Proton pump inhibitors are a widely used medication to control symptoms of gastric nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22 hyperacidity and reflux, which has led to adverse effects associated with C. difficile. Summary The average human digestive tract is home for as many as 1,000 species of microorganisms. Most of them are harmless - or even helpful - under normal circumstances. But when something upsets the balance of these organisms in the gut, otherwise harmless bacteria can grow out of control and cause illness. One of the worst offenders is the C. difficile bacterium. As the C. difficile bacteria overgrow they release toxins that attack the lining of the intestines, causing a potentially fatal condition. This article has described this condition, as well as the symptoms, causes, risk factors, diagnosis, complications, treatment and prevention. Clostridium difficile is a serious, potentially life-threatening infection that can be treated and prevented by careful infection control practices. Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23 1. Approximately _________ of patients who developed C. difficile experienced at least one recurrence: a. 25,000 b.40,000 c. 65,000 d.83,000 2. Studies show that _________ % of antibiotics prescribed in hospitals are unnecessary or incorrect. a. 15 – 20 b. 25 – 35 c. 30 – 50 d. > 50 3. Each year, more than _____________ people get sick from C. difficile. a. 1/4th million b. 1/3rd million c. half million d. None of the above 4. Signs and symptoms of severe C. difficile infection include: a. fever b. blood or pus in the stool c. dehydration and weight loss d. All of the above nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 24 5. The antibiotics that most often lead to C. difficile infections include: a. fluoroquinolones b. cephalosporins c. clindamycin and penicillins d. All of the above 6. Complications of C. difficile infections include: a. dehydration b. hypotension c. kidney failure d. All of the above 7. For mild to moderate infection, medical providers usually prescribe a. Penicillin b. Vancomycin c. Metronidazole (Flagyl) d. Either a or b above 8. ___________ of people with C. difficile get sick again a. 10 percent b. 20 percent c. 30 percent d. 50 percent nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25 9. After one or more recurrences, rates of further recurrence of C. difficile increase up to ________________. a. 20 percent b. 35 percent c. 50 percent d. 65 percent 10. True/False. The goal of FMT is to restore healthy intestinal bacteria. a. True b. False 11. Research has shown FMT has a success rate higher than ______ percent for treating C. difficile infections. a. 35 b. 50 c. 90 d. None of the above 12. Suspected or proven C. difficile cases should be placed on _____________ a. isolation b. contact precaution c. reverse isolation d. Answers a and c above nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26 13. C. difficile spores can survive on dry surfaces for up to a. Days b. Weeks c. Several months d. None of the above 14. True/False. Alcohol-based hand rub (ABHR) eradicates C. difficile spores. a. True b. False 15. Removal through soap and water hand washing is less effective than ABHR inactivation of vegetative (i.e., non-spore forming) bacteria. a. True b. False Correct Answers: 1. Approximately _________ of patients who developed C. difficile experienced at least one recurrence: Correct Answer: 83,000 2. Studies show that _________ % of antibiotics prescribed in hospitals are unnecessary or incorrect. Correct Answer: 30 – 50 3. Each year, more than _____________ people get sick from C. difficile. Correct Answer: half million nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27 4. Signs and symptoms of severe C. difficile infection include: Correct Answer: All of the above 5. The antibiotics that most often lead to C. difficile infections include: Correct Answer: All of the above 6. Complications of C. difficile infections include: Correct Answer: All of the above 7. For mild to moderate infection, doctors usually prescribe Correct Answer: Metronidazole (Flagyl) 8. ___________ of people with C. difficile get sick again Correct Answer: 20 percent 9. After one or more recurrences, rates of further recurrence of C. difficile increase up to ________________. Correct Answer: 65 percent 10. True/False. The goal of FMT is to restore healthy intestinal bacteria. Correct Answer: True 11. Research has shown FMT has a success rate higher than ______ percent for treating C. difficile infections. Correct Answer: 90 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 28 12. Suspected or proven C. difficile cases should be placed on _____________ Correct Answer: contact precaution 13. C. difficile spores can survive on dry surfaces for up to Correct Answer: Several months 14. True/False. Alcohol-based hand rub (ABHR) eradicates C. difficile spores. Correct Answer: False 15. Removal through soap and water hand washing is less effective than ABHR inactivation of vegetative (i.e., non-spore forming) bacteria. Correct Answer: True nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 29 References Section The reference section of in-text citations include published works intended as helpful material for further reading. Unpublished works and personal communications are not included in this section, although may appear within the study text. 1. Clostridium difficile infection (2015). Centers for Disease Control and Prevention. Retrieved September 10, 2015 from www.cdc.gov 2. C. difficile infection (2013). Mayo Foundation for Medical Education and Research. Retrieved September 18, 2015 from www.mayoclinic.org 3. Gould, C. & McDonald, L.C. (2015.) Clostridium difficile infection: Prevention and control in Calderwood, S.B. (Ed.), UpToDate. Waltham, Mass: UpToDate. Retrieved September 19, 2015 from www.uptodate.com Additional Helpful Resources: C diff. (2015.) WebMD. Retrieved September 4, 2015 from www.webmd.com Kelly, C.P. & Lamont, J.T. (2015.) Clostridium difficile in adults: Treatment in Calderwood, S.B. (Ed.), UpToDate. Waltham, Mass: UpToDate. Retrieved September 1, 2015 from www.uptodate.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com