What’s the ? with Clostridium Difficile
Recently hospitals across the country pushed out new policies regarding the testing, treatment and prophylaxis of Clostridium Difficle (C. diff). Nurses are on the front lines, fighting C. diff infections, reducing outbreaks and containing costs. So, what has changed in the past year? and why are we seeing less testing nationwide. Before we wade into recent events, a C-Diff review from start to finish is necessary.
The CDC estimates that 500,000 C. diff infections occur per year and15,000 deaths, within 30 days of diagnosis, per year are directly related toC.diff. Hence, this is a serious infection, and nurses should understand C. diff infection and treatment.
C. diff is a gram-positive rod and exists in spore form.This gut bacteria causes inflammation, diarrhea and sepsis. Spores are difficult to treat secondary resistance to; heat, antibiotics and UV light.This ensures easier spread of spores in hospitals and other healthcare facilities. At work right now? Grab a chlorhexidine/bleach wipe, and wipe down the keyboard, mouse and workstation, spores can travel (more on that later). C. diff incidence in the public ranges 2-3%, whereas nurses and hospitalized patients ranges from 20 to 40%. This drastic difference demonstrates the nature of outbreaks in facilities and the rationale for isolation.
1.Why are these infections on the rise and what is recurrent C. diff?
Antibiotics destroy the normal flora of the gut and hopefully treat an infection. Over the past 20 years antibiotic use and misuse prompted resistant organisms to flourish. Z-Packs were prescribed with impulse like candy purchases in checkout lanes of grocery stores. The flagrant disregard for safe prescribing practices led to a culture of patients controlling medications (a factor in the opioid crisis as well). As a result antibiotic stewardship programs reigned in some providers, however, the damage is done, resistance is everywhere and the culture of unnecessary antibiotics remains. When good gut bacteria are absent C. diff has an easier time colonizing and infecting patients.
Patients who had antibiotics in the last three months, recent hospitalization, advanced age, previous C.diff infection, chronic PPI use and or immunosuppressed patients carry a higher risk of infection and recurrent infection. Risk factors mentioned above are applicable to a significant percentage of hospitalized patients. Due to an aging demographic and prescribing practices mentioned above the incidence of C. diff has spiked nationally.
Recurrent C. difficile infection (rCDI) is defined as two C.diff infections within 8 weeks. Patients with hyper-virulent strains, PPI’s, renal insufficiency, advanced age and antibiotics for a non-C. diff infections carry an elevated risk of rCDI. The incidence of reoccurrence ranges from 5-50%. Healthcare associated infections have a higher rate of reoccurrence compared to community acquired C. diff. Furthermore recurrent infections are difficult to treat, time consuming for patient and provider and potentially expensive.
2.Welcome to 4 North, we test everyone for C. diff!
In the past nurses tested anyone with diarrhea for C. diff, despite C.diff accounting for only 30% of diarrheal illnesses. Therefore this practice altered unit culture. Unnecessary testing is not cost effective and does not help patients. Two tests are generally used for C. diff: glutamate dehydrogenase (GDH) or (GDH) plus toxin and arbitrated by nucleic acid amplification test (NAAT) or NAAT plus toxin. GDH and NAAT have high sensitivities and low specificity. Free toxins have a low sensitivity and moderate specificity. The timing of testing is a determinant of accuracy as patients may have disease without symptoms and the sample is subject to corruption. Limitations on testing technologies hinder an accurate diagnosis.
Multiple studies attempted to calculate a correlation of C. diff with a set number of stools in a given time period in the past 40 years. These studies were poorly powered and a significant number of participants were excluded from multiple studies for not meeting minimum loose stools. Despite this, hospitals gate control patients with 3 or more loose stools in 24 hours, prior to testing. A patient not meeting this threshold is discouraged from testing. Consequently, the evidence level for testing is weak, as well as the evidence for repeat testing. Repeat testing within 7 days of the same diarrhea episode is not supported by current guidelines.
Medicare recognized the incidence of infections and introduced a rule that requires hospitals to report C. diff infections and with holds payment for hospital acquired C. diff. Sound familiar, this is akin to the 30-day heart failure readmission rule. This idea was to aid hospitals in curbing C. diff, however this resulted in less testing, treatment without testing, fewer positive results and fewer dollars lost. Hospitals advocate for testing in the ER prior to admission to navigate around this rule.
3.Vanco and Zosyn for everyone!
Treatment is centered on prophylaxis, initial, secondary and tertiary. Antibiotics should be restricted to specific clinical indications using the narrowest spectrum for treatment. Patients who are placed on systemic or multiple antibiotics may have probiotics started. Data supporting probiotic use is underwhelming for prophylaxis and adjunct therapy, however use of probiotics carries minimal risk. In contrast, patients with rCDI probiotics have demonstrated efficacy and should be started twice daily. Infection control measures; using single patient rooms, isolation gowns, gloves, hand washing, bleach/chlorhexidine wipes and nursing education are proven methods of prevention and outbreaks ofC. diff.
Initial and secondary treatment focuses on several antibiotics and strain sensitivity. Narrowing antibiotic choices to agent(s)sensitive to the strain reduces reoccurrence rates and length of stay. Patients who have rCDI with multiple infections can consider fecal transplant (FMT). Donor stool is screened and administered via enema, NG tube or colonoscopy, with a 90% cure rate. Finally, rifaximin and monoclonal antibodies have gained traction in rCDI. Data supporting their use is slowly growing.
|Initial||Vancomycin125mg po qid x 10 days|
|Initial Severe||Vancomycin 125mg po qid and Metronidazole 500mg IV tid|
|Secondary||Vancomycin 125mg po qid x 10 days, tid x 7 days, bid x 7 days, qd x 7 days, q48h x 7 days and 3x/week for one week. Or – Fidaxomicin 200mg po bid x 10 days|
|Tertiary||Vancomycin taper above and Fidaxomicin 200mg po bid x 10 days or consider fecal transplant.|