C’est difficile…?

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C’est difficile…? Martin Kiernan Nurse Consultant Southport and Ormskirk NHS Trust Vice President, Infection Prevention Society

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C’est difficile…?. Martin Kiernan Nurse Consultant Southport and Ormskirk NHS Trust Vice President, Infection Prevention Society. Clostridium difficile. 1935 first described by as bacillus difficilis by Hall and O’Toole and classified as a commensal 1977 - PowerPoint PPT Presentation

Transcript of C’est difficile…?

Page 1: C’est difficile…?

C’est difficile…?Martin Kiernan

Nurse ConsultantSouthport and Ormskirk NHS Trust

Vice President, Infection Prevention Society

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Clostridium difficile

1935first described by as bacillus difficilis by Hall and

O’Toole and classified as a commensal1977

toxin isolated from stool samples produced a cytopathic effect in cell culture

1978C. difficile identified as source for toxin and

cause of psuedomembranous colitis

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Microbiology

Gram positive, spore forming rod shaped bacillus

Obligate anaerobeProduces 2 major toxins

toxin A and toxin Bboth contribute to disease

Toxins responsible for manifestation of disease and marker for diagnosis

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Annual Cases (England)

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The authors of the latest 2009 guidelines considered that ‘it is the failure to implement the guidance described in the 1994 report that has contributed to the recent rise’Noted by the HPA and the HCC in 2006

So why are we where we are?

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Financial Burden of C. difficileWilcox, Cunniffe et al, JHI; 1996

Cases stay an average of 21.3 days longerExtra costs

Treatment, Investigations, ‘Hotel costs’

Total identifiable costs over £4,000 per case2006 costs

My Trust - £400KNW SHA - 6,946 cases - £28 millionNHS - 55,681 cases - £222 million

NHS lost nearly 1.2 million bed days

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Risk factors for disease

Chang and Nelson (2000)Age > 65 yearsAntibiotic therapy, particularly cephalosporins,

clindamycinUnderlying bowel diseaseProton pump inhibitorsPEG feedsPhysical proximity to symptomatic patient

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C.difficile, ABx, PPIs

0

10000

20000

30000

40000

50000

60000

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

CDAD Antibiotic x1000 PPI x 1000

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Case control study of Community CdI Wilcox, Mooney et al (2008)

Exposure to Abx in previous 4 weeksesp. multiple agentsHalf had no abx in the previous month

Hospitalisation in previous 6 monthsA third had neither hospitalisation not ABxContact with infants >2 years oldPPI not significantly more common

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C. difficile strains

160 ribotypes of C. difficileType 001 most common in UK hospitals,

Community epidemiology differs Type 010 most common

All sensitive to metronidazole and vancomycinso far

Epidemiology of C. difficile is changingType 106

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C. difficile 027

Hyper-toxin producer18 base pair deletion ? Red herring

16-20 times more toxin producedToxin produced earlier in the disease processOverwhelming of immune responsePresence of binary toxin

? Red herring

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Diagnosis of C.difficile

Clinical diagnosissigmoidoscopy radiology

Toxin isolationcytotoxin assay 92% sensitivity & specificity

expensive and lengthy incubation requiredculture less efficientrapid immunoassay (less expensive, quick)

Smell…

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Clinical manifestations of C.difficile

Asymptomatic carriage2% healthy adults16-35% recently treated with antibiotics

important reservoir in medical facilitiesshed organisms, contaminate environment

carriage not reduced by treatment with metronidazole or vancomycin

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Clinical manifestations of C.difficile

Antibiotic colitis presents as diarrhoea, lower abdominal painstarts during or shortly after antibiotics commence

(a few days) but may present much later (1-2 months)

systemic symptoms often absentexamination often normal including sigmiodoscopytoxins in stool

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Clinical manifestations of C.difficile

Psuedomembranous colitissymptoms more marked, bloody stoolscharacteristic yellow plaques 2-10mm

intervening mucosa mild inflammationplaques may conjoin

rectum and sigmoid most commonmay progress to fulminant colitis

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Fulminating Disease

Five AlertsAbdominal distension and tendernessHigh (very high) WCC

( can be 40-50 x109/l)Raised CRP/ drop in HbNon response

To oral metronidazole/vancomycinLow albumin

all these features could denote the presence of Toxic Mega Colon - IMMEDIATE senior review, abdominal Xray and surgical referral

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Management of C.difficile

Treatmentresuscitation stop causative antibiotic (if possible)antibioticsrestore normal gut floraSurgery

Mortality from surgery 25-100%Low Serum Albumin a good predictor of certain

death (<25g/L) or a fall by 11g/L at the onset of infection

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Saccharomyces boulardii

Produces a protease that inhibits effect of toxins A and B in human colonic mucosacolonisation by 72 hours 107-108 cfucleared when therapy discontinuednot absorbed ExpensiveDifferent preparations have differing activity

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Other options?

Brewers yeast Saccharomyces cerevisae less expensive than S.boulardiibut distinct and not equivalent

Faeces from related donorsGiven as enema or via Nasogastric TubeNot very acceptable to staff or patients

Immunoglobulin

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Transmission

Faecal-oral routeEnvironment becomes contaminated by sporesHands become contaminated by sporesVulnerable patients acquire spores after contact

with contaminated staff and the environmentAnd then they eat them..

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What is Critical?

Prevent environmental contaminationConsider faecal containment if liquid stool

Rapid isolation of the patientSimple things

Pulling back the sheetsCommode cleaningSide room with toiletNo exposed foodCareful with that bedding

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C.difficile spores

Environment floors toilets bedpans beddingmopsscales

Health Care professionalshands ringsstethoscopes faecal carriage rare

Am J Epidemiology 1988 127:1289-94

Am J Med 1981;70:906

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Just how important IS the environment?

Samore et alpresence on hands correlates with density of

environmental contamination (AmJ Med 1996)0-25%sites + 0% hands +26-50% + 8% hands +>50% + 36% hands +

Fawley (Epid Infect 2001)incidence correlates significantly with level of

environmental contamination

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Isolation Wards

They workThey also free up isolation capacity elsewhere

in the organisationThey ensure consistency of care for all

patients, whose primary diagnosis should now be considered to be the infection

They are not permanentThey do allow you to get the situation back under

control and draw breath

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Cross-infection risksIs it only the symptomatic patient?

One paper recently published in Clinical Infectious Diseases in October 06 says not

56% of skin tests were positive for C. difficile in the asymptomatic patientSpores present on the skin can be effectively

transmitted to HCW hands and the environmentHands must be washed with soap and water

after dealing with faecal matter for every patient

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Efficacy of Alcohol Hand Sanitizers

Provide an overall 3-4 log10 (99.9-99.99%) reduction in most bacterial and viral pathogens with a contact time of 15 seconds

NOT C. difficile sporesNOT Norovirus

Norovirus are reduced by only 1-2 log10

(90-99%) with a 30 second contact time

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C. difficile in the over-65sQuarterly Cases - England, 2006-8

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C’est tres difficile

Increasing elderly populationAverage age of inpatients up 1.5 years each year

Acute beds falling in numbersCreates a filtered inpatient population

Expectation to treatHave sympathy for the poor house officer

The ‘old man’s friend’ is now his greatest enemy