Presentation is loading. Please wait.

Presentation is loading. Please wait.

Clostridium difficile : Biology, Diagnosis and Infection Control Clostridium difficile Disease.

Similar presentations


Presentation on theme: "Clostridium difficile : Biology, Diagnosis and Infection Control Clostridium difficile Disease."— Presentation transcript:

1 Clostridium difficile : Biology, Diagnosis and Infection Control Clostridium difficile Disease

2 Clostridium difficile Microbiology and Clinical disease Microbiology and Clinical disease Laboratory detection Laboratory detection Infection Control considerations Infection Control considerations Treatment Treatment

3 Microbiology

4 Clostridium spp. - Characteristics Gram-positive bacillus - Usually large Gram-positive bacillus - Usually large Produce endospores Produce endospores May appear terminal or central May appear terminal or central excellent survival in environment excellent survival in environment Strictly anaerobic metabolism Strictly anaerobic metabolism Produce variety of potent toxins Produce variety of potent toxins

5 Clostridium perfringens Gas gangrene Food poisoning Clostridium tetani Tetanus Clostridium botulinum Botulism Clostridium difficile Antibiotic associated diarrhea and colitis Clostridium spp. of clinical importance

6 Clostridium difficile Normal flora in 1-3% normal adult Normal flora in 1-3% normal adult ~ 70% of children less than 12 months GI flora ~ 70% of children less than 12 months GI flora 50% of individuals with exposure to inpatient health care facilities may be asymptomatic carriers of C. difficile 50% of individuals with exposure to inpatient health care facilities may be asymptomatic carriers of C. difficile

7 Accounts for 15-25% of all antimicrobial- associated diarrhea Accounts for 15-25% of all antimicrobial- associated diarrhea Accounts for % of antibiotic associated pseudomembranous colitis Accounts for % of antibiotic associated pseudomembranous colitis Fecal-oral transmission Fecal-oral transmission contaminated environment contaminated environment hands of healthcare personnel hands of healthcare personnel Produce 2 exotoxins Produce 2 exotoxins A enterotoxin, B cytotoxin A enterotoxin, B cytotoxin Clostridium difficile

8 Toxin A Binds to specific CHO receptors on intestinal epithelium Binds to specific CHO receptors on intestinal epithelium Toxin induced inflammatory process Toxin induced inflammatory process neutrophils neutrophils inflammatory mediators inflammatory mediators fluid secretion fluid secretion altered membrane permeability altered membrane permeability haemorrhagic necrosis haemorrhagic necrosis

9 Toxin B Binding site not yet identified Binding site not yet identified Depolymerization of filamentous actin Depolymerization of filamentous actin destruction of cell cytoskeleton destruction of cell cytoskeleton rounding of cells rounding of cells

10 Clinical Manifestations Asymptomatic carriage (neonates) Asymptomatic carriage (neonates) Diarrhea days after starting antibiotics Diarrhea days after starting antibiotics maybe be 1 day after starting maybe be 1 day after starting may be up to 10 weeks after stopping may be up to 10 weeks after stopping may be after single dose may be after single dose Spectrum of disease Spectrum of disease brief, self limiting brief, self limiting cholera-like - 20X/day, watery stool cholera-like - 20X/day, watery stool

11 Clinical Manifestations Additional symptoms Additional symptoms abdominal pain, fever, nausea, malaise, anorexia, hypoalbuminaemia, colonic bleeding, dehydration abdominal pain, fever, nausea, malaise, anorexia, hypoalbuminaemia, colonic bleeding, dehydration Acute toxic megacolon Acute toxic megacolon acute dilatation of colon acute dilatation of colon systemic toxicity systemic toxicity obstruction obstruction high mortality (64%) high mortality (64%) Colonic perforation Colonic perforation

12 Pathogenesis Microflora of gut Microflora of gut bacteria/gram bacteria/gram species species colonisation resistance colonisation resistance Acquisition of spores by faecal/oral Acquisition of spores by faecal/oral Disruption of normal colonic flora Disruption of normal colonic flora

13 Pathogenesis Colonisation with C. difficile Colonisation with C. difficile Late log / early stationary phase - toxin production Late log / early stationary phase - toxin production Production of toxin A +/- B Production of toxin A +/- B Mucosal injury Mucosal injury

14 Pathogenesis Colonic mucosa - raised yellow / white plaques Colonic mucosa - raised yellow / white plaques initially small initially small enlarge and coalesce enlarge and coalesce Inflamed mucosa Inflamed mucosa

15 Epidemiology - Current epidemic strain BI/NAP1/027, toxinotype III BI/NAP1/027, toxinotype III Historically uncommon – epidemic since 2000 Historically uncommon – epidemic since 2000 More resistant to fluoroquinolones More resistant to fluoroquinolones Higher MICs compared to historic strains and current strains Higher MICs compared to historic strains and current strains More virulent More virulent Increased toxin A and B production Increased toxin A and B production Polymorphisms in binding domain of toxin B Polymorphisms in binding domain of toxin B Increased sporulation Increased sporulation Stabler et al. J Med Micro. 2008;57:771–5. Akerlund et al. J Clin Microbiol. 2008;46:1530–3.

16 Epidemiology -Risk Factors for Disease Antimicrobial exposure Antimicrobial exposure Acquisition of C. difficile Acquisition of C. difficile Advanced age Advanced age Underlying illness Underlying illness Immunosuppression Immunosuppression Tube feeds Tube feeds ? Gastric acid suppression ? Gastric acid suppression

17 Antibiotic Risk High Risk Antibiotics Cefotaxime/CeftriaxoneCefalexinCefuroximeCeftazidimeCiprofloxacinMoxifloxacin Clindamycin (low dose) Medium Risk Antibiotics MeropenemErtapenem Clindamycin (high dose) Amox/clavPiperacillin/TazoErythromycinClarithromycin

18 Antibiotic Risk Low Risk Antibimobial agents Benzyl penicillinGentamicin AmoxicillinMetronidazole CloxacillinVancomycin TetracyclinesTeicoplanin TrimethoprimQuin/Dalfo NitrofurantoinLinezolid Fusidic acidTigecycline RifampicinDaptomycin

19 Disease Impact

20 Hospital-acquired, hospital-onset: 165,000 cases, $1.3 billion in excess costs, and 9,000 deaths annually Hospital-acquired, hospital-onset: 165,000 cases, $1.3 billion in excess costs, and 9,000 deaths annually Hospital-acquired, post-discharge (up to 4 weeks): 50,000 cases, $0.3 billion in excess costs, and 3,000 deaths annually Hospital-acquired, post-discharge (up to 4 weeks): 50,000 cases, $0.3 billion in excess costs, and 3,000 deaths annually Nursing home-onset: 263,000 cases, $2.2 billion in excess costs, and 16,500 deaths annually Nursing home-onset: 263,000 cases, $2.2 billion in excess costs, and 16,500 deaths annually

21 Age-Adjusted Death Rate* for Enterocolitis Due to C. difficile, 1999–2006 *Per 100,000 US standard population Rate Year Male Female White Black Entire US population

22 Laboratory Testing

23 Current Testing Options Cytotoxin Neutralization Assay* Cytotoxin Neutralization Assay* Toxigenic Culture Toxigenic Culture Microwell EIA* Microwell EIA* Rapid Cartridge EIA* Rapid Cartridge EIA* Glutamate Dehydrogenase Based Combination Procedures* Glutamate Dehydrogenase Based Combination Procedures* Molecule Procedures* Molecule Procedures* * DIDTL Research Lab published or presented

24 History of testing at CCHMC Antigen testing followed by cell culture based cytotoxin assay - 48 hour TAT Antigen testing followed by cell culture based cytotoxin assay - 48 hour TAT Cell culture cytotoxin assay only – 48 hour TAT Cell culture cytotoxin assay only – 48 hour TAT Plate based EIA for toxin A and B - 24 hour TAT Plate based EIA for toxin A and B - 24 hour TAT Lateral flow EIA - Same day TAT Lateral flow EIA - Same day TAT NAAT Testing – Same day TAT NAAT Testing – Same day TAT

25 Molecular Based Tests BD GeneOhm Cdiff Assay BD GeneOhm Cdiff Assay Gen-Probe Prodesse® ProGastro Cd Gen-Probe Prodesse® ProGastro Cd Cepheid® Xpert C. difficile Cepheid® Xpert C. difficile Meridian illumi gene C. difficile Meridian illumi gene C. difficile

26 Current Testing Options Peterson L R, Robicsek A Ann Intern Med 2009;151:

27 Quinn, et.al JCM, 48: Noren, et.al JCM, 49: Current Testing Options

28 The Key =Good Specimens Only diarrheal stools (≥ 3/day) should be submitted for testing Only diarrheal stools (≥ 3/day) should be submitted for testing no asymptomatic patient stools no asymptomatic patient stools Only a single specimen should be tested Only a single specimen should be tested Test should be used for diagnosis only and not “test-of-cure” Test should be used for diagnosis only and not “test-of-cure” One specimen per 7 days One specimen per 7 days Children < 1 year old? Children < 1 year old?

29 Value of Repeat Testing Peterson L R, Robicsek A Ann Intern Med 2009;151:

30 Aichinger et.al. J Clin Microbiol 2008;46: Conclusion: “..little value of repeat testing for C. difficle by EIA or PCR.” Value of Repeat Testing

31 Luo and Banaei, J Clin Microbiol, 2010;48: Conclusion: “Repeat PCR within 7 days appears rarely useful, except for patients with evidence of a new infection.”

32 Studies Peterson L R, Robicsek A Ann Intern Med 2009; 151: 176 Peterson L R, Robicsek A Ann Intern Med 2009; 151: 176 “Diagnoses of CDI will be more accurate if clinicians use tests with a higher sensitivity, reduce the frequency of testing for a single episode of diarrhea, and give more attention to key elements of the patient's history.” “Diagnoses of CDI will be more accurate if clinicians use tests with a higher sensitivity, reduce the frequency of testing for a single episode of diarrhea, and give more attention to key elements of the patient's history.” Aichinger et.al. J Clin Microbiol 2008;46: Aichinger et.al. J Clin Microbiol 2008;46: “..little value of repeat testing for C. difficle by EIA or PCR.” “..little value of repeat testing for C. difficle by EIA or PCR.”

33 C. difficle testing conclusions Many C. difficile toxin testing options Many C. difficile toxin testing options Molecular assays perform very well Molecular assays perform very well Test only patients with diarrhea Test only patients with diarrhea Repeat testing for toxin within 7 days of little value Repeat testing for toxin within 7 days of little value

34 Infection Control

35 Clostridium difficile (CDI) Infections Toolkit Carolyn Gould, MD MSCR Cliff McDonald, MD, FACP Division of Healthcare Quality Promotion Centers for Disease Control and Prevention

36

37 Prevention Strategies: Core Contact Precautions for duration of diarrhea Contact Precautions for duration of diarrhea Hand hygiene in compliance with CDC/WHO Hand hygiene in compliance with CDC/WHO Cleaning and disinfection of equipment and environment Cleaning and disinfection of equipment and environment Laboratory-based alert system for immediate notification of positive test results Laboratory-based alert system for immediate notification of positive test results Educate about CDI: HCP, housekeeping, administration, patients, families Educate about CDI: HCP, housekeeping, administration, patients, families

38 Prevention Strategies: Supplemental Extend use of Contact Precautions beyond duration of diarrhea (e.g., 48 hours)* Extend use of Contact Precautions beyond duration of diarrhea (e.g., 48 hours)* Presumptive isolation for symptomatic patients pending confirmation of CDI Presumptive isolation for symptomatic patients pending confirmation of CDI Evaluate and optimize testing for CDI Evaluate and optimize testing for CDI Implement soap and water for hand hygiene before exiting room of a patient with CDI Implement soap and water for hand hygiene before exiting room of a patient with CDI * Not included in CDC/HICPAC 2007 Guideline for Isolation Precautions

39 Prevention Strategies: Supplemental Implement universal glove use on units with high CDI rates* Implement universal glove use on units with high CDI rates* Use sodium hypochlorite–containing agents for environmental cleaning Use sodium hypochlorite–containing agents for environmental cleaning Implement an antimicrobial stewardship program Implement an antimicrobial stewardship program * Not included in CDC/HICPAC 2007 Guideline for Isolation Precautions

40 Rationale for considering extending isolation beyond duration of diarrhea Bobulsky et al. Clin Infect Dis 2008;46:

41 Consider presumptive isolation for patients with > 3 unformed stools within 24 hours Patients with CDI may contaminate environment and hands of healthcare personnel pending results of diagnostic testing Patients with CDI may contaminate environment and hands of healthcare personnel pending results of diagnostic testing CDI responsible for only ~30-40% of hospital-onset diarrhea CDI responsible for only ~30-40% of hospital-onset diarrhea However, CDI more likely among patients with >3 unformed stools within 24 hours However, CDI more likely among patients with >3 unformed stools within 24 hours Send specimen for testing and presumptively isolate patient pending results Send specimen for testing and presumptively isolate patient pending results Positive predictive value of testing will also be optimized if focused on patients with >3 unformed stools within 24 hours Positive predictive value of testing will also be optimized if focused on patients with >3 unformed stools within 24 hours Exception: patient with possible recurrent CDI (isolate and test following first unformed stool) Exception: patient with possible recurrent CDI (isolate and test following first unformed stool)

42 Evaluate and optimize test-ordering practices and diagnostic methods Most laboratories have relied on Toxin A/B enzyme immunoassays Most laboratories have relied on Toxin A/B enzyme immunoassays Low sensitivities (70-80%) lead to low negative predictive value Low sensitivities (70-80%) lead to low negative predictive value Despite high specificity, poor test ordering practices (i.e. testing formed stool or repeat testing in negative patients) may lead to many false positives Despite high specificity, poor test ordering practices (i.e. testing formed stool or repeat testing in negative patients) may lead to many false positives Peterson et al. Ann Intern Med 2009;15:176-9.

43 Evaluate and optimize test-ordering practices and diagnostic methods Consider more sensitive diagnostic paradigms but apply these more judiciously across the patient population Consider more sensitive diagnostic paradigms but apply these more judiciously across the patient population Employ a highly sensitive screen with confirmatory test or a PCR-based molecular assay Employ a highly sensitive screen with confirmatory test or a PCR-based molecular assay Restrict testing to unformed stool only Restrict testing to unformed stool only Focus testing on patients with > 3 unformed stools within 24 hours Focus testing on patients with > 3 unformed stools within 24 hours Require expert consultation for repeat testing within 5 days Require expert consultation for repeat testing within 5 days Peterson et al. Ann Intern Med 2009;15:176-9.

44 Hand Hygiene – Soap vs. Alcohol gel Alcohol not effective in eradicating C. difficile spores Alcohol not effective in eradicating C. difficile spores Discouraging alcohol gel use may undermine overall hand hygiene program with untoward consequences for HAIs in general Discouraging alcohol gel use may undermine overall hand hygiene program with untoward consequences for HAIs in general Boyce et al. Infect Control Hosp Epidemiol 2006;27:

45 Lack of efficacy of alcohol-based handrub against C. difficile Oughton et al. Infect Control Hosp Epidemiol 2009;30:

46 Hand Washing: Product Comparison ProductLog10 Reduction Tap Water0.76 4% CHG antimicrobial hand wash0.77 Non-antimicrobial hand wash0.78 Non-antimicrobial body wash % triclosan antimicrobial hand wash0.99 Heavy duty hand cleaner used in manufacturing environments 1.21* * Only value that was statistically better than others Edmonds, et al. Presented at: SHEA 2009; Abstract 43.

47 Hand Hygiene Methods Conclusion: Spores may be difficult to eradicate even with hand washing. Conclusion: Spores may be difficult to eradicate even with hand washing. Since spores may be difficult to remove from hands even with hand washing, adherence to glove use, and Contact Precautions in general, should be emphasized for preventing C. difficile transmission via the hands of healthcare personnel Since spores may be difficult to remove from hands even with hand washing, adherence to glove use, and Contact Precautions in general, should be emphasized for preventing C. difficile transmission via the hands of healthcare personnel Johnson et al. Am J Med 1990;88:

48 Glove Use Rationale for considering universal glove on units with high CDI rates Rationale for considering universal glove on units with high CDI rates Although the magnitude of their contribution is uncertain, asymptomatic carriers have a role in transmission Although the magnitude of their contribution is uncertain, asymptomatic carriers have a role in transmission There may be a role for universal glove use as a special approach to reducing transmission on units with longer lengths of stay and high endemic CDI rates There may be a role for universal glove use as a special approach to reducing transmission on units with longer lengths of stay and high endemic CDI rates

49 Universal Glove Use Riggs et al. Clin Infect Dis 2007;45:992–8. Role of asymptomatic carriers?

50 Environmental Cleaning Bleach kills spores, other standard disinfectants much less so Bleach kills spores, other standard disinfectants much less so Limited data suggest cleaning with bleach reduces C. difficile transmission Limited data suggest cleaning with bleach reduces C. difficile transmission Two before-after intervention studies demonstrated benefit of bleach cleaning in units with high endemic CDI rates Two before-after intervention studies demonstrated benefit of bleach cleaning in units with high endemic CDI rates Bleach may be most effective in reducing burden where CDI is highly endemic Bleach may be most effective in reducing burden where CDI is highly endemic Mayfield et al. Clin Infect Dis 2000;31: Wilcox et al. J Hosp Infect 2003;54:

51 Environmental Cleaning Assess adequacy of cleaning before changing to new cleaning product such as bleach Ensure that environmental cleaning is adequate and high- touch surfaces are not being overlooked Ensure that environmental cleaning is adequate and high- touch surfaces are not being overlooked One study using a fluorescent environmental marker to asses cleaning showed: One study using a fluorescent environmental marker to asses cleaning showed: only 47% of high-touch surfaces in 3 hospitals were cleaned only 47% of high-touch surfaces in 3 hospitals were cleaned sustained improvement in cleaning of all objects, especially in previously poorly cleaned objects, following educational interventions with the environmental services staff sustained improvement in cleaning of all objects, especially in previously poorly cleaned objects, following educational interventions with the environmental services staff

52 Antibiotic Stewardship A prospective, controlled interrupted time- series analysis in 3 acute medical wards for the elderly in the UK demonstrated the impact of antimicrobial management on reducing CDI. A prospective, controlled interrupted time- series analysis in 3 acute medical wards for the elderly in the UK demonstrated the impact of antimicrobial management on reducing CDI. Introduced a narrow-spectrum antibiotic policy Introduced a narrow-spectrum antibiotic policy Reinforced using feedback Reinforced using feedback Associated with significant changes in targeted antibiotics and a significant reduction in CDI Associated with significant changes in targeted antibiotics and a significant reduction in CDI Fowler et al. J Antimicrob Chemother 2007;59:990-5.

53 Contact Precautions for duration of illness Contact Precautions for duration of illness Hand hygiene in compliance with CDC/WHO Hand hygiene in compliance with CDC/WHO Cleaning and disinfection of equipment and environment Cleaning and disinfection of equipment and environment Laboratory-based alert system Laboratory-based alert system CDI surveillance CDI surveillance Education Education Prolonged duration of Contact Precautions* Prolonged duration of Contact Precautions* Presumptive isolation Presumptive isolation Evaluate and optimize testing Evaluate and optimize testing Soap and water for HH upon exiting CDI room Soap and water for HH upon exiting CDI room Universal glove use on units with high CDI rates* Universal glove use on units with high CDI rates* Bleach for environmental disinfection Bleach for environmental disinfection Antimicrobial stewardship program Antimicrobial stewardship program Core MeasuresSupplemental Measures * Not included in CDC/HICPAC 2007 Guideline for Isolation Precautions

54 Treatment

55

56 Treatment regimens Metronidazole Metronidazole Vancomycin Vancomycin Cholestyramine Cholestyramine Yeast supplement – Saccharomyces (boulardii) cerevisiae Yeast supplement – Saccharomyces (boulardii) cerevisiae Fresh stool instilation Fresh stool instilation Broth cultured bacteria Broth cultured bacteria Probiotics Probiotics

57 References Dubberke ER, Butler AM, Reske KA, et al. attributable outcomes of endemic Clostridium difficile -associated disease in nonsurgical patients. Emerg Infect Dis 2008;14: Dubberke ER, Butler AM, Reske KA, et al. attributable outcomes of endemic Clostridium difficile -associated disease in nonsurgical patients. Emerg Infect Dis 2008;14: Dubberke ER, Reske KA, Olssen MA, et al. Short- and long term attributable costs of Clostridium difficile -associated disease in nonsurgical inpatients. Clin Infect Dis 2008:46: Dubberke ER, Reske KA, Olssen MA, et al. Short- and long term attributable costs of Clostridium difficile -associated disease in nonsurgical inpatients. Clin Infect Dis 2008:46: Edmonds S, Kasper D, Zepka C, et al. Clostridium difficile and hand hygiene: spore removal effectiveness of handwash products. Presented at: SHEA 2009; Abstract 43. Edmonds S, Kasper D, Zepka C, et al. Clostridium difficile and hand hygiene: spore removal effectiveness of handwash products. Presented at: SHEA 2009; Abstract 43.

58 References Elixhauser, A. (AHRQ), and Jhung, MA. (Centers for Disease Control and Prevention). Clostridium Difficile-Associated Disease in U.S. Hospitals, 1993–2005. HCUP Statistical Brief #50. April Agency for Healthcare Research and Quality, Rockville, MD. Elixhauser, A. (AHRQ), and Jhung, MA. (Centers for Disease Control and Prevention). Clostridium Difficile-Associated Disease in U.S. Hospitals, 1993–2005. HCUP Statistical Brief #50. April Agency for Healthcare Research and Quality, Rockville, MD. Fowler S, Webber A, Cooper BS, et al. Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: a controlled interrupted time series. J Antimicrob Chemother 2007;59: Fowler S, Webber A, Cooper BS, et al. Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: a controlled interrupted time series. J Antimicrob Chemother 2007;59: Heron MP, Hoyert DLm Murphy SL, et al. Natl Vital Stat Rep 2009;57(14). US Dept of Health and Human Services, CDC; Available at Heron MP, Hoyert DLm Murphy SL, et al. Natl Vital Stat Rep 2009;57(14). US Dept of Health and Human Services, CDC; Available at

59 References Johnson S, Gerding DN, Olson MM, et al. Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission. Am J Med 1990;88: Johnson S, Gerding DN, Olson MM, et al. Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission. Am J Med 1990;88: Mayfield JL, Leet T, Miller J, et al. Environmental control to reduce transmission of Clostridium difficile. Clin Infect Dis 2000;31:995–1000. Mayfield JL, Leet T, Miller J, et al. Environmental control to reduce transmission of Clostridium difficile. Clin Infect Dis 2000;31:995–1000. McDonald LC, Killgore GE, Thompson A, et al. An epidemic, toxin gene–variant strain of Clostridium difficile. N Engl J Med. 2005;353: McDonald LC, Killgore GE, Thompson A, et al. An epidemic, toxin gene–variant strain of Clostridium difficile. N Engl J Med. 2005;353:

60 References McDonald LC, Coignard B, Dubberke E, et al. Ad Hoc CDAD Surveillance Working Group. Recommendations for surveillance of Clostridium difficile -associated disease. Infect Control Hosp Epidemiol 2007; 28: McDonald LC, Coignard B, Dubberke E, et al. Ad Hoc CDAD Surveillance Working Group. Recommendations for surveillance of Clostridium difficile -associated disease. Infect Control Hosp Epidemiol 2007; 28: Oughton MT, Loo VG, Dendukuri N, et al. Hand hygiene with soap and water is superior to alcohol rum and antiseptic wipes for removal of Clostridium difficile. Infect Control Hosp Epidemiol 2009; 30: Oughton MT, Loo VG, Dendukuri N, et al. Hand hygiene with soap and water is superior to alcohol rum and antiseptic wipes for removal of Clostridium difficile. Infect Control Hosp Epidemiol 2009; 30: Peterson LR, Robicsek A. Does my patient have Clostridium difficile infection? Ann Intern Med 2009;15:176-9 Peterson LR, Robicsek A. Does my patient have Clostridium difficile infection? Ann Intern Med 2009;15:176-9 Riggs MM, Sethi AK, Zabarsky TF, et al. Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis 2007; 45:992–8. Riggs MM, Sethi AK, Zabarsky TF, et al. Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis 2007; 45:992–8.

61 References SHEA/IDSA Compendium of Recommendations. Infect Control Hosp Epidemiol 2008;29:S81–S92. SHEA/IDSA Compendium of Recommendations. Infect Control Hosp Epidemiol 2008;29:S81–S92. Stabler RA, Dawson LF, Phua LT, et al. Comparitive analysis of BI/NAP1/027 hypervirulent strains reveals novel toxin B-encoding gene (tcdB) sequences. J Med Micro. 2008;57:771–5. Stabler RA, Dawson LF, Phua LT, et al. Comparitive analysis of BI/NAP1/027 hypervirulent strains reveals novel toxin B-encoding gene (tcdB) sequences. J Med Micro. 2008;57:771–5. Sunenshine RH, McDonald LC. Clostridium difficile -associated disease: new challenges from and established pathogen. Cleve Clin J Med. 2006;73: Sunenshine RH, McDonald LC. Clostridium difficile -associated disease: new challenges from and established pathogen. Cleve Clin J Med. 2006;73:

62 References Warny M, Pepin J, Fang A, Killgore G, et al. Toxin production by and emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. Lancet. 2005;366: Warny M, Pepin J, Fang A, Killgore G, et al. Toxin production by and emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. Lancet. 2005;366: Wilcox MF, Fawley WN, Wigglesworth N, et al. Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection. J Hosp Infect 2003:54: Wilcox MF, Fawley WN, Wigglesworth N, et al. Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection. J Hosp Infect 2003:54:

63 Additional Reference Slides The following slides may be used for presentations regarding CDI. The following slides may be used for presentations regarding CDI. Explanations are available in the notes section of the slides. Explanations are available in the notes section of the slides.

64 Supplemental Prevention Strategies: Audit and feedback targeting broad-spectrum antibiotics Supplemental Prevention Strategies: Audit and feedback targeting broad-spectrum antibiotics Fowler et al. J Antimicrob Chemother 2007;59:990-5.


Download ppt "Clostridium difficile : Biology, Diagnosis and Infection Control Clostridium difficile Disease."

Similar presentations


Ads by Google