1. Update on Revised McGeer Criteria, Clostridium difficile Infections (CDI) and UTIs in the Long Term Care Facility
Edward C. Oldfield, III, MD
Virginia Medical Directors Association
September 29, 2012

2. Ageing Population
By 2030, 20% of the U.S. population will be over 65 years old.
Currently, > 16,000 nursing homes/LTCFs with 1.5 million residents in the U.S.

3. Infections in the LTCF
Infections in LTCFs are more frequent than hospital acquired infections; about 2.5 million each year.
Infections cause 25-50% of all hospital transfers or 250,000 admissions each year.
30-50% of all hospital admissions for those over 65 y.o.
Over 100,000 deaths in LTCFs each year at a cost of $1 billion.

4. Antibiotics and Nursing Homes
54% of nursing home patients receive a course of antibiotics each year.
Most common indication is for urinary tract infections; 36% of all antibiotics.
9% of all prescriptions are for asymptomatic bacteriuria, which is inappropriate.
Warren J. J Am Geriatr Soc 1991;39:

5. Infection Control in LTCFs
LTCFs pose multiple challenges to infection control:
High prevalence of infections.
High rates of colonization with antimicrobial resistant organisms.
Frequent and often inappropriate prescribing of antimicrobials.
Moro M. Infect Control Hosp Epidemiol. 2012;33:

6. Infection Control in LTCFs
Frequent transfer of residents from the hospital.
Growing elderly populations with increasingly complex medical problems.
Scarce resources.
Absent/poor coordination of clinical and nursing care.

7. “The Perfect Storm of Antimicrobial Resistance”

8. Surveillance in LTCFs
Surveillance of infections is universally recommended as the core of infection control efforts.
Increases awareness of the problem.
Establishes an infection control “presence” in the facility.
Identifies critical areas for infection control.
Determines trends.
Identifies and prevents outbreaks in a timely fashion.

9. Revisiting the McGeer Criteria.
Mc Geer Criteria. Definitions of Infections in Long Term Care Facilities. Am J Infect Control 1991;10:1-7.
Revisiting the McGeer Criteria.
Surveillance Definitions of Infections in Long Term Care Facilities.
SHEA/CDC Position Paper.
Stone N. Infection Control Hosp Epidemiol.
2012;33:

10. Revised McGeer Criteria
Focus was to increase the specificity and PPV of the criteria to limit unnecessary interventions and curb misallocation of scarce resources.
Will be less sensitive than clinical diagnoses.
Revised criteria provide explicit definitions for fever, acute confusion or altered mental status and acute functional decline.
Attempt to harmonize the definitions used in acute and LTCFs (using > 2 days at the facility to define a HAI).

11. Revised McGeer Criteria
Criteria for systemic infections, common cold, conjunctivitis, ear infections, herpes simplex and zoster were left unchanged.
Influenza was modified only to track cases outside the influenza season, as a consequence of pandemic H1N1.
Criteria for gastrointestinal infections were unchanged, but specific criteria for norovirus and C. difficile were added.
Skin infection criteria were not substantially changed, but NHSN criteria for surgical site infections was added.

12. Revised McGeer Criteria
Major changes were made to the criteria for defining respiratory track and UTIs.
Original McGeer criteria did not include a positive urine culture to define a UTI.
More than half of residents suspected of having a UTI have negative cultures despite the high prevalence of asymptomatic bacteriuria.
Juthani-Mehta M. J Am Geriatric Soc 2007;55:

13. Revised McGeer Criteria
Urinary tract symptoms alone are not sufficient to identify cases of UTI with a high level of specificity.
Revised criteria require a positive urine culture as a necessary condition to diagnose a UTI.

14. Revised McGeer Criteria
Define which infections should have priority in LTCF infection control, either because they are avoidable or cause significant morbidity and mortality.
Priorities include:
Viral respiratory, GI and conjunctivitis due to high transmissibility.
UTI, pneumonia, GI infections, SSTI (morbidity).
Infections that can lead to serious outbreaks (hepatitis, norovirus, scabies, influenza, group A streptococci). Even a single case should trigger a more intensive investigation.

15. HBV and Glucose Monitoring
8 residents hospitalized, 6 died of acute HBV in a North Carolina assisted-living facility in 2010 related to facility staff assisting with blood glucose monitoring.
16 outbreaks of HBV have been reported related to sharing of glucose monitoring equipment in assisted-living facilities since 2004.
Moore Z. MMWR 2011;60:182

16. HBV and Glucose Monitoring
VDH was notified of acute HBV infections in residents from 4 assisted living facilities regulated by state agencies (not CMS) between 2/2009 and 11/2011.
All infections were among residents receiving assisted monitoring of blood glucose (AMBG).
Attack rates by facility among susceptible residents receiving AMBG ranged from 17-92%.
AMBG has been responsible for 27 of 29 (93%) HBV outbreaks in LTCFs since 1996.
MMWR 2012;61:339.

17. HBV and Glucose Monitoring
3 of 4 facilities had lapses in infection prevention practices:
Shared use of penlet-style reusable finger stick devices (intended only for a single patient).
Failure to clean and disinfect shared glucometers.
Poor hand hygiene techniques.

18. Diabetes and HBV
10/2011: ACIP recommended that adults y.o. be vaccinated against HBV.
Adults >59 y.o. with DM may be vaccinated at the discretion of their physician.

20. Blood Glucose Meters
Whenever possible, blood glucose meters should not be shared.
If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer’s instructions.
If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared.

22. Fingerstick Devices
Fingerstick devices should never be used for more than one person.
Single-use, auto-disabling fingerstick devices: These are devices that are disposable and prevent reuse through an auto-disabling feature.
In settings where assisted monitoring of blood glucose is performed, single-use, auto-disabling fingerstick devices should be used.

24. Insulin Pens
Insulin pens containing multiple doses of insulin are meant for use on a single person only, and should never be used for more than one person, even when the needle is changed.
Insulin pens should be clearly labeled with the person’s name or other identifying information to ensure that the correct pen is used only on the correct individual.

25. Insulin Pens
Hospitals and other facilities should review their policies and educate their staff regarding safe use of insulin pens and similar devices.
If reuse is identified, exposed persons should be promptly notified and offered appropriate follow-up, including bloodborne pathogen testing.

26.
CDC’s National Healthcare Safety Network (NHSN) web site provides LTCFs a customized system to track infections in a streamlined and systematic way. Site provides NHSN enrollment, forms, toolkits, protocols and training to report C. difficile, MRSA and other drug-resistant infections, UTIs, and prevention process measures, including hand hygiene adherence.

27. New Case surveillance definition. Who to treat
UTI
New Case surveillance definition.
Who to treat

28. New UTI Surveillance Definition
For residents without an indwelling catheter (both criteria
1 and 2 must be present).
Criteria 1: At least 1 of the following sign or symptom:
Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate.
Fever or leukocytosis and at least 1 of the following localizing urinary tract symptoms (must be new or marked increase): acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, incontinence, urgency, frequency.

29. UTI Surveillance Definition
In the absence of fever or leukocytosis, then 2 or more of the following localizing urinary tract symptoms:
Suprapubic pain
Gross hematuria
New or marked increase in incontinence
New or marked increase in urgency
New or marked increase in frequency

30. UTI Surveillance Definition
Criteria 2. One of the following microbiologic subcriteria:
At least 100,000 cfu/mL of no more than 2 species of microorganisms in a voided urine sample.
At least 100 cfu/mL of any number of organisms in a specimen collected by in-and-out catheter
Urine specimens for culture should be processed as soon as possible, preferably within 1–2 h.
If urine specimens cannot be processed within 30 min of collection, they should be refrigerated. Refrigerated specimens should be cultured within 24 h.

31. UTI Surveillance Definition
UTI should be diagnosed when there are localizing genitourinary signs and symptoms and a positive urine
culture result.
A diagnosis of UTI can be made without localizing symptoms if a blood culture isolate is the same as the organism isolated from the urine and there is no alternate site of infection.

32. UTI Surveillance Definition
In the absence of a clear alternate source of infection, fever or rigors with a positive urine culture result in the noncatheterized resident or acute confusion in the catheterized resident will often be treated as UTI.
However, evidence suggests that most of these episodes are likely not due to infection of a urinary source.

33. UTI Surveillance Definition
For residents with an indwelling catheter (both criteria 1
and 2 must be present):
Criteria1 (at least 1 of the following signs/symptoms):
Fever, rigors, or new-onset hypotension, with no alternate site of infection.
Either acute change in mental status or acute functional decline, with no alternate diagnosis and leukocytosis.
New-onset suprapubic pain or costovertebral angle pain or tenderness.
Purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostate

34. UTI Surveillance Definition
Criteria 2. Urinary catheter specimen culture with at least:
100,000 cfu/mL of any organism(s).
Recent catheter trauma, catheter obstruction, or new onset hematuria are useful localizing signs that are c/w UTI but are not necessary for diagnosis.
Urinary catheter specimens for culture should be collected following replacement of the catheter (if current catheter has been in place for >14 d).

35. UTI Surveillance Definition
Pyuria (>/= 10 WBC/hpf) does not differentiate symptomatic UTI from asymptomatic bacteriuria.
Absence of pyuria in diagnostic tests excludes symptomatic UTI in residents of long-term care facilities.

36. Acute Functional Decline
A new 3-point increase in total ADL score (range, 0–28) from baseline, based on the following 7 ADL items, each scored from 0 (independent) to 4 (total dependence):
Bed mobility
Transfer
Locomotion within LTCF
Dressing
Toilet use
Personal hygiene
Eating

37. Acute Change in Mental Status
Acute change in mental status from baseline (all criteria must be present):
Acute onset.
Fluctuating course.
Inattention.
AND
Either disorganized thinking or altered level of consciousness.

38. Confusion Assessment Method Criteria
Acute change in resident’s mental status from baseline
Fluctuating Behavior: coming and going or changing in severity during the assessment.
Inattention: difficulty focusing attention (eg, unable to keep track of discussion or easily distracted).
Disorganized thinking: thinking is incoherent (rambling conversation, unclear flow of ideas, unpredictable switches in subject).
Altered level of consciousness: level of consciousness is described as different from baseline (hyperalert, sleepy, drowsy, difficult to arouse, nonresponsive).

39. Treating Asymptomatic Bacteriuria
Prospective randomized trials of screening for or treating asymptomatic bacteriuria have shown:
No decrease in the rate of symptomatic infection.
No improvement in survival.
No change in chronic genitourinary symptoms.
Nicolle L. Am J Med 1987;83:27-33.
Nicolle L. NEJM 1983;309:
Abrutyn E. Ann Intern Med 1994:120:

40. Asymptomatic UTI Nursing Home
172 nursing home residents with an abnormal urinalysis and no Foley catheter.
146 did not meet criteria for treatment, 76 were not treated.
None developed adverse consequences.
No deaths or hospitalizations attributed to worsening infection or sepsis occurred during the following 3 months.
Rotjanapan P. Arch Int Med 2011;171:

41. Chronic Incontinence Ouslander et al Ann Int Med 122: 753
Randomized, placebo controlled trial of antibiotic therapy

42. Detrimental Effects of Treating Asymptomatic UTI
By 6-8 weeks after treating asymptomatic patients with bacteriuria, 60-80% will have recurrence with the same or a new infecting organism.
Subjects who receive antimicrobial therapy for asymptomatic bacteriuria have:
Increased frequency of adverse events from the antibiotics.
Increased reinfection with resistant organisms.
Increased cost.

43. UTI and C. difficile
172 nursing home residents with an abnormal urinalysis and no Foley catheter.
85% did not meet criteria for treatment, but 41% of them were started on antibiotics.
12% who received inappropriate antibiotics developed C. difficile infection within 3 weeks.
Overall, those who received inappropriate antibiotics were 8-fold more likely to develop C. difficile within 3 months.
Rotjanapan P. Arch Int Med 2011;171:

44. Antibiotics and Warfarin
Exposure to any antibiotic within 15d increased the chance of bleeding with hospitaliztion by 2-fold.
Azoles (eg fluconazole) increased risk by 4.5-fold, TMP SMZ 2.7, cephalosporins 2.5, penicillins 1.9, macrolides 1.9, quinolones 1.7.
Interference with metabolism (azoles, TMP SMZ) and disruption of bacteria that synthesize Vit K.
Monitor INR one week after starting antibiotics.
Baillargeon J. Am J Med 2012;125:183-9.

45. Mortality, Elderly Men
NEJM, 1983

46. Asymptomatic Bacteriuric: Elderly Women
Amer J Med, 1987

47. Residents with Chronic Catheterization
Bacterial colonization of residents with chronic indwelling foley catheters approaches 100%, usually with 2-5 different organisms.
Indwelling catheters develop a biofilm on the interior of the catheters where the organisms reside.
Urine cultures in chronically catheterized residents often reflect the bacteriology of the catheter biofilm; not the bladder urine.

48. Treatment of Asymptomatic Bacteriuria in Chronically Catheterized Residents
Asymptomatic bacteriuria is universal in patients with long term indwelling catheters.
Antimicrobial therapy will not prevent bacteriuria or symptomatic infection.
Antimicrobial therapy will lead to side effects, increasing resistance and cost.
Asymptomatic bacteriuria should not be treated.

49. How do I decide which resident to treat for suspected UTI?

50. Is It a UTI ? No easy Answers.
For residents of LTCFs without a foley, 25-50% of women and 15-40% of men have significant bacteriuria, but no symptoms.
At the same time, UTI is also the most common cause of bacteremia in LTCF residents.
Common cause of transfer to acute care facilities.
How do I separate the large number of asymptomatic patients with bacteria in their urine who don’t need treatment from those with serious infections that need treatment?

51. Does Pyuria Help ?
90% of residents with asymptomatic bacteriuria will have white blood cells in their urine (pyuria).
In fact, 30% of all residents without bacteriuria will have pyuria.
High rates are related to genital, bladder, prostatic or renal inflammation, usually non-infectious.
Absence of pyuria essentially excludes UTI, but the presence of white cells is not helpful.

52. Does Appearance or Smell Help ?
Foul smelling and cloudy urine have been used in the past to help determine who to treat.
Neither foul smell or cloudy urine have been clearly associated with symptomatic UTI.

53. Cloudy/Foul Smelling Urine
Nursing staff observes change in appearance or smell of urine (develop order set/policy):
Not an indication for urinalysis or culture if asymptomatic.
Provide scheduled toileting q2-4 hours.
Gently cleanse perineum once daily and after each episode of incontinence.
Monitor closely for symptoms/change in mental status.
Khandelwal C. Annals of Long Term Care 2012;20:23-9.

54. Fever and Asymptomatic Bacteriuria
A common diagnostic dilemna is the presence of fever with no localizing findings in a resident with bacteriuria and pyuria.
Only 10% of these episodes are attributable to a urinary source in residents who do not have an indwelling foley catheter.
Orr P. Am J Med 1996;100:71-77.

55. Clinical Deterioration and UTI
UTI has been used as an explanation for nonspecific symptoms, such as:
“clinical deterioration”
UTI was a cause of clinical deterioration in only 11% of episodes.
If UTI was the cause, all were febrile.
Berman P. Age Ageing 1987;16:201-7.

56. Acute Change in Function and UTI’s
“An acute deterioration in stable chronic symptoms may indicate an acute infection. Multiple co-existing findings such as fever with hematuria are more likely to be from a urinary source.
In someone with nonspecific symptoms such as a change in function or mental status, bacteriuria alone does not necessarily warrant antibiotic treatment.
Although sepsis, including urosepsis, can cause dizziness or falling, there is not clear evidence linking bacteriuria or a localized UTI to an increased fall risk.” F315

57. The Never Ending Dilemna
Clinically, the health care provider is faced with a difficult dilemna:
Indwelling bladder catheters are the #1 risk for bacteremia in LTCFs, but…
Essentially all urine cultures will be positive in residents with chronic catheterization.

58. Who Do You Treat ?
Urinalysis and urine culture are only really helpful if negative (excludes a UTI).
Fever is the most frequent clinical presentation of UTI in the chronically catheterized resident.
Catheter obstruction is often a precipitating event for fever and systemic infection.
Fever with hematuria or catheter obstruction has a high probability of being from a urinary source.

59. F315
“Because many residents have chronic bacteriuria, the research-based literature suggests treating only symptomatic UTIs.
Symptomatic UTIs are based on the following criteria:

60. F315: Indications to Treat a UTI
Residents without a catheter should have at least three of the following signs and symptoms:
Fever (increase of >2 degrees F/ rectal T >99.5 F/single T >100 F).
New or increased burning, pain on urination, frequency or urgency.
New flank or suprapubic pain/tenderness.
Change in character of urine (new bloody urine, foul smell or amount of sediment) or lab report (new pyuria or microscopic hematuria).
Worsening of mental or functional status (confusion, lethargy, unexplained falls, recent onset incontinence, decreased activity or appetite).

61. F315: Indications to Treat a UTI
Residents with a catheter should have at least two of the following signs and symptom:
Fever or chills.
New flank pain or suprapubic pain/tenderness.
Change in character of urine.
Worsening of mental status or function.
Local findings such as obstruction, leakage or mucosal trauma (hematuria) may also be present.

62. Annals of Long Term Care April 2012

63. How should I treat? Remove the Foley catheter? Which antibiotic?

64. Catheter Change in Suspected UTI
If urine culture is obtained from the old catheter, culture is polymicrobial in 52% vs. only 11% after changing the catheter.
Patients who had catheter changes responded faster to treatment and had a lower relapse rate at 28 days (11% vs 41%).
Raz R. J Urol 2000;164:

65. Treatment of Symptomatic UTI
When a patient has fever and the source is felt to be the urinary tract in a patient with a chronic Foley catheter, there is a more rapid response and a lower rate of recurrent symptoms if the Foley catheter is changed prior to initiation of antibiotics.
Suggests removal of the biofilm laden catheter is beneficial.
Raz R. J Urol 2000;164:

66. Choosing Antibiotics for UTI
Be aware of local antimicrobial sensitivity patterns.
Balance efficacy and collateral damage (resistance, C. difficile, antibiotic side effects).
Use of an antibiotic in the last 3-6 months increases the risk of resistance.
For acute cystitis, avoid antibiotics with > 20% resistance
For pyelonephritis, avoid antibiotics with >10% expected resistance.
International Practice Guidelines for Rx of Uncomplicated Cystitis and Pyelonephritis. Clin Infect Dis 2011;52:e103-e120.

67. Sentara Antimicrobial Resistance, 2011
E. coli Resistance
Ampicillin % (40)*
Ciprofloxacin % (7)
TMP/SMX % (21)
Nitrofurantoin % (0.5)
Ceftriaxone %
Zosyn %
Gentamicin %
Meropenem
*2010 % E. coli resistance for urine isolates, yo U.S. women

68. Predicting Resistance
633 E. coli UTIs with 36% trimethoprim resistant and 12% ciprofloxacin resistant.
Odds of resistance increased with each TMP prescription in the preceding year: one Rx 1.4 fold, two 5-fold, three or more 6-fold.
Odds of resistance increased with each cipro prescription in the preceding year: one Rx 3- fold, two or more 7-fold.
Vellinga A. J Antimicrob Chemother June Epub

69. The More You Use It, The Faster You Lose It !

70. International Clinical Practice Guidelines for the Treatment of
Acute Cystitis and Pyelonephritis
in Women
Gupta K. Clin Infect Dis 2011;52:e103-e120.

71. Antibiotics for UTI First-line therapy: Cystitis/Bladder infection
Nitrofurantoin (Macrodantin, Macrobid, Furadantin susp): mg twice daily for 5 days.
Common side effects: N, V
Rare: acute, subacute chronic pulmonary reactions 1 or less/100,000.
Contraindicated for CrCl < 60 (minimal levels in urine).
Not used for pyelonephritis/possible urosepsis (low or undetectable serum levels).

72. Antibiotics for UTI
Trimethoprim-sulfamethoxazole DS one 160 mg-800 mg tablet twice daily for 3 days.
One TMP 80 mg- SMZ 400 mg tablet twice daily for CrCl < 30; not recommended for CrCl < 15. (sulfamethoxazole may be subtherapeutic with
CrCl < 50).
Trimethoprim 100 mg twice daily; 100 mg every 18 h for CrCl 30. (excellent levels in urine even with low CrCl).

73. Bactrim (TMP-SMZ) Resistance
104 women with a TMP-SMZ resistant isolate who were treated with TMP-SMZ vs. 33 with a sensitive isolate.
Clinical success rate of TMP-SMZ was 54% if the isolate was resistant vs. 96% if the isolate was sensitive.
Brown P. Clin Infect Dis 2002;34:
Urine concentrations of TMP are 100-fold higher than serum.

74. Fosfomycin (Monurol)
Phosphonic acid antimicrobial, bactericidal, inhibits peptidogylcan synthesis disrupting cell wall.
Available as 3 gm packet, mixed in water, ~$50.
Very well tolerated, nausea is major side effect.
Long half life, dosing q2-3d.
Good tissue levels, excreted unchanged in urine, high levels in urine (100 ug for 48 hours).

75. Fosfomycin (Monurol)
Very broad spectrum: VRE, MRSA, most GNR, including ESBL and KPC, but Pseudomonas and Acinetobacter usually resistant.
Approved for treatment of uncomplicated UTI (single dose 3 gm).
Off label use for complicated UTI (3 gm every 2-3 days x 3 doses), prostatitis (3 gm q3d x 21 days).

76. Antibiotics for UTI
Alternatives: More resistance and collateral damage (C. difficle, MRSA colonization).
Ciprofloxacin hydrochloride 250 mg twice daily for 3 days; 250 mg every 18 h for CrCl < 30; 250 mg/d for CrCl < 10.
Levofloxacin 250 mg/d for 3 days; 250 mg every 48 h for CrCl < 20.

77. Quinolone and Tendon Rupture
1,367 with achilles tendon rupture vs. 50,000 controls.
Risk increased 6.4-fold for y.o. and 20.4-fold for those > 80 y.o. who used quinolones at a median of 7d.
2 - 6% of all achilles tendon ruptures in people > 60 y.o. can be attributed to quinolones.
Concomitant use of steroids significantly increased the risk in those > 60 y.o. by ~3-fold.
Van der Linden P. Arch Int Med 2003;163:
No current quinolone users < 60 y.o. had tendon rupture. Almost all use was UTI/respiratory track infection.

78. Quinolones and Retinal Detachment
4,384 cases of retinal detachment vs. 43,840 controls who had visited an ophthalmologist.
Current use of quinolones had a 4.5-fold increased risk of retinal detachment; time to onset: 5 days.
No association with recent or past use.
Absolute risk of 4 per 10,000 person years; number needed to harm: 2,500 for any use.
Estimated 1,440 cases of retinal detachment in the U.S. annually from quinolone use.
Etminan M. JAMA 2012;307:

79. Quinolones and Hepatitis
Trovafloxacin removed from the market for hepatotoxicity.
2009: European Medicines Agency called for restriction of moxifloxacin in rx of CAP; 2010: Health Canada released a warning for rare severe hepatotoxicity.
Patients over 65 y.o. had a 2.2-fold and levofloxacin a 1.9-fold increased risk of admission for hepatotoxicity, 61% died during hospitalization. (~8 cases/100K exposures).
No increased risk for ciprofloxacin.
Paterson J. CMAJ Aug 2012.

80. Ciprofloxacin Resistance
87 adult patients with UTI with an organism resistant to ciprofloxacin who were treated with ciprofloxacin.
75% microbiologic cure, 77% clinical response.
Pseudomonas had a lower response than other pathogens (46 vs. 82%).
Jeffries M. Ann Pharmacother 2011;45:
Levels of ciprofloxacin in urine are 100X > than serum.

81. Duration of Treatment
Most experts recommend that antimicrobial treatment should be for as short a period as possible; 5-7 days for catheter associated UTI.
Rationale is to decrease emergence of resistance, but will also decrease cost.

82. Pyelonephritis Residents not requiring hospitalization:
Ciprofloxacin 500 mg bid x 7 days.
If ciprofloxacin resistance exceeds 10%, initial long acting parenteral antimicrobial (ceftriaxone 1 gm or single daily dose aminoglycoside (gentamicin or tobramycin 4-7 mg/kg q24h).
Tailor antibiotics according to sensitivity.
Duration: days

83. Should I do a test of cure culture?

84. F315: Follow-Up of UTIs
“The goal of treating a UTI is to alleviate systemic or local symptoms, not to eradicate all bacteria. Therefore, a post-treatment culture is not routinely necessary but may be useful in certain situations.
Continued bacteriuria without residual symptoms does not warrant repeat or continued antibiotic therapy.”

85. Exception for Follow Up Culture
If the resident is in contact isolation because of a resistant organism, such as an extended spectrum beta lactaamase (ESBL) producing E. coli or Klebsiella or another highly resistant gram negative rod (such as Acinetobacter), MRSA, or VRE, then a negative culture is required to remove them from contact isolation.
If the repeat urine culture is positive, treatment is only indicated if the resident is symptomatic.
Retreatment is not used to eradicate colonization or in an asymptomatic resident.

86. Clostridium difficile Infection
Surveillance definition
Diagnosis and treatment of infection

87. CDI and Health Care MMWR 2012;61:157-62.
300,000 annual cases of healthcare associated CDI each year at a cost of $3.2 billion.
20% of hospital onset CDI occurred in residents of nursing homes.
67% of nursing home onset CDI occurred in patients recently discharged from an acute care hospital.
Antibiotic use increases the risk of CDI 10-fold while the patient is taking antibiotics and for one month after stopping and 3-fold for the next 2 months.
MMWR 2012;61:

88. Clostridium difficile Infection
Most common cause of hospital acquired diarrhea due to an infectious cause.
100% increase in cases and a 400% increase in mortality in the last decade.
90% of deaths are in persons > 65 y.o.
Redelings M. Emerg Infect Dis 2007;

89. Zilberberg M. Emerg Infect Dis 2008;14;929-31.

90. Epidemic C. difficile Strain
Epidemic C. difficile strains have acquired resistance to fluoroquinolones.
Ciprofloxacin was the antibiotic associated with the highest risk of developing CDI (3.4-fold).
In Quebec, 55% of CDI patients had received a quinolone.
Pepin J. Clin Infect Dis 2005;41:

91. Polgreen P. Infect Control Hosp Epidemiol 2010;31:382-7. Seasonal assoc. with Influenza.

92. CDI and PPIs
Gastric acidity is “nature’s disinfectant,” killing vegetative C. difficile, Shigella, Salmonella and Vibrios.
Dial found a strong association with PPI use (OR 3.5) among outpatients, but none with H2 receptor antagonists. CMAJ 206;175:
Lowe found no correlation with PPIs in hospitalized patients after adjusting for other medications and comorbidity. Clin Infect Dis 2006;43:
2/2012: FDA safety notice on risk of CDI with PPIs.

93. CDI: Surveillance Definition
Clostridium difficile infection (both criteria 1 and 2 must be present):
Criteria1. One of the following.
Diarrhea: 3 or more liquid or watery stools above what is normal for the resident within a 24-h period.
Presence of toxic megacolon (abnormal dilatation of the large bowel, documented radiologically).

94. CDI: Surveillance Definition
Criteria 2. One of the following:
Stool sample yields a positive laboratory test result for C. difficile toxin A or B, or a toxin-producing C. difficile organism is identified from a stool sample culture or by a molecular diagnostic test such as PCR.
Pseudomembranous colitis is identified during endoscopic examination or surgery or in histopathologic examination of a biopsy specimen.

95. CDI: Surveillance Definition
“Primary episode” of C. difficile infection is defined as one that has occurred without any previous history of C. difficile infection.
or has occurred > 8 weeks after the onset of a previous episode of C. difficile infection.

96. CDI: Surveillance Definition
“Recurrent episode” of C. difficile infection is defined as an episode that occurs 8 wk or sooner after the onset of a previous episode, provided that the symptoms from the earlier (previous) episode have resolved.
Individuals previously infected with C. difficile may continue to remain colonized even after symptoms resolve.

97. CDI: Clinical
Broad range from mild self limited diarrhea to colitis with or without pseudomembranes to fulminating colitis with toxic megacolon.
Bloody diarrhea is uncommon (5-10%); only 25% have occult blood; fecal leukocytes in 28-40%.
Fever is noted in 30-50%; usually low but can be as high as 106 degrees F.

98. CDI: Diagnosis Leukocytosis and hypoalbuminemia are very suggestive.
In one study, the mean WBC with CDI was 15,800 with 26% having a WBC >20K and 6% >30K.
For all patients with WBC >30,000 who do not have a hematologic malignancy, 25% have CDI.
Wanahita A. Clin Infect Dis 2002;34:

99. The Nose Knows
“Urban legend” exists among nurses that they can accurately diagnose CDI on smell alone.
Study of 138 nursing staff; sensitivity was 55%, but NPV was 92%; overall accuracy was 79%.
Nurses were “able to exclude a diagnosis of CDI with a high degree of confidence and accuracy.”
Burdette S. CID 2007;44:1142.
May lead to a new certification: AOCDCRN
(advanced olfactory C. difficile certified RN)

100. CDI: EIA
Enzyme immunoassay for C. difficile toxin is rapid and less expensive than other tests.
Reported sensitivity is 75-85% (in a study from Johns Hopkins, sensitivity was only 40%).
Test only on specimens that take the shape of the container; 13% of liquid specimens were toxin (+), 17% of soft were (+).

101. C. Diff x 3: Don’t Do It
Repeated assays may account for 36% of all tests ordered, but only 1% of positive assays.
Renshaw A. Arch Pathol Lab Med 1996;120:49-52.
Repeat assays represented 17% of all assays, only 1% (+) at a cost of $128/assay.
Mohan S. Am J Med 2006;119;356.E7.

102. EIA: Repeat Testing
Testing 1,000 patients with prevalence of 10% and sensitivity of 73%, specificity 98%.
True Positive False Positive Undetected
First
Second
Third
Peterson L. Ann Intern Med 2009;151;176-9.

103. CDI: EIA
No indication for serial monitoring or end-of-treatment-test-of-cure; 1/3 have a positive toxin assay at the end of successful treatment.
Bartlett J. NEJM 2002;346:334-9.
Stool carriage may persist for 3-6 weeks after successful treatment and has not been found to predict relapse.
Issack M. Lancet 1990;335:

104. CDI: Treatment Basics Stop the offending antibiotic.
Up to 25% will resolve spontaneously, observation alone may be adequate.
If antibiotics can not be stopped, change to lower risk antibiotics. (aminoglycosides, sulfonamides, macrolides, and tetracyclines).
Avoid antimotility agents.
Novak E. JAMA 1976;235:
Opiates may prevent diarrhea, obscuring the diagnosis.

105. Metronidazole vs. Vancomycin
Metronidazole has been the preferred drug because of risk of VRE and the cost.
No patients developed VRE in a study of 20 patients treated with oral vancomycin.
Selgado, C. Infect Control Hosp Epidemiol 2004;25:
….But vancomycin capsules 125 mg qid are $36.80 each AWP ($60-$120/day retail) vs. $2.19/day for metronidazole 500 mg tid. (most facilities use the intravenous powder compounded in a flavored solution; < $5.00/day).

106. CDI: Vancomycin Vancomycin has been called a “pharmacologic dream.”
“You put it in the mouth and it all winds up in the colon.”
Very minimal absorption with stool levels of >1000 ug/ml, which exceeds the MIC by 1000-fold.
Cure rates have been 86-99%; relapse rates of 15-33%.
Dose of 125 mg qid po has been shown to be as effective as 500 mg qid.
Reserved for metronidazole failures (no response at 3-5 days) or severe CDI.

107. SHEA/IDSA Guidelines for CDI
Mild – Moderate: WBC <15,000; < 50% increase in Cr from baseline.
Severe: WBC >/= 15,000 or 50% increase of Cr from baseline.
Severe complicated: severe disease plus ICU admission, need for colectomy, ileus, toxic megacolon, hypotension, colonic perforation.
Cohen S. Infect Control Hosp Epidemiol. 2010;31:

108. CDI Treatment Mild – Moderate: oral metronidazole 500 mg tid.
Severe: oral vancomycin 125 mg qid
Severe complicated: high dose oral vancomycin 500 mg qid by nasogastric tube if necessary and/or metronidazole IV 500 – 750 mg q8h.
For complete ileus, IV metronidazole plus vancomycin by retention enema.

109. Fidaxomicin
Fidaxomycin is a macrocyclic antibiotic with minimal absorption and high fecal levels.
Bactericidal against C. difficile and 8-fold more active than vancomycin, which is bacteriostatic.
Minimal activity against fecal flora, especially Bacteroides sp., while vancomycin has significant activity against Bacteroides sp.

110. Fidaxomicin
Randomized to fidaxomicin vs. vancomycin with 92% vs. 90% clinical cure.
Recurrence of infection was 15% for fidaxomicin vs. 25% for vancomycin, overall.
No difference in recurrence with epidemic strain, but for the 64% of patients with other strains there was a 69% reduction in recurrence.
Louie T. NEJM 2011;364:

111. Cost of CDI agents Fidaxomicin 200 mg bid $140./dose $2,800. for 10d
Metronidazole 500 mg tid /dose
$6 for 10d
Vancomycin caps 125 mg qid $30.00/dose
$1,273. for 10d
Vancomycin injection given po $1.68/dose
$67. for 10d

112. CDI Relapse
Recurrence after initial resolution of symptoms occurs in 20-25% after initial episode, usually within 5-8 days, but may be delayed for weeks to years.
Risk for recurrence: > 65 y.o., comorbidities, another antibiotic course, prior recurrence (up to 45% risk).

113. Early Preventative Therapy
Treatment of persons known to be colonized or a recent episode of CDI who require antibiotic treatment.
“Despite the absence of guidelines for this approach, there is remarkable homogeneity in that clinicians who practice this prophylactic strategy use oral metronidazole or vancomycin during the entire course of antimicrobial therapy and for an additional 7 days after the end of its administration.”
Miller M. Clin Infect Dis 2007;45:S122-8.

114. CDI Relapse
First recurrence: Repeat a course of the initial antibiotic used, usually metronidazole.
Second or more: vancomycin preferred (not absorbed, high stool levels) over metronidazole (readily absorbed, stool levels decrease with decreasing inflammation, undetectable when diarrhea resolves).
Vancomycin often tapered and pulsed.

115. CDI Relapse
Oral vancomycin with taper and pulsed dosing at 125 mg qid for 7 days, tapering to bid for 7 days then daily for 7 days Tedesco F. Am J Gastro 1985;80:867-8.
Followed by pulsed dosing, which allows for germination of residual spores during days off, followed by killing of the vegetative form when vancomycin is given again.
Give vancomycin 250 mg every 2-3 days for 3 weeks; others gradually lengthen pulsing interval to once every 10 days. Surawicz C. Nat Clin Pract Gastro Hepatol 2004;1:32-8.

116. Probiotic Problems High % of patients receiving antibiotics (2/3)
(can not use vancomycin; rapidly kills Lactobacilli)
Doses and products vary; results are specific to species and number of viable cells.
Maximum viable cells at end of manufacture; minimum number at end of shelf life, number that transit to colon differ.

117. Probiotics: Saccharomyces
McFarland in a double-blind, randomized, placebo controlled trial of S. boulardii found no decrease in initial recurrence, but found a 50% reduction in further recurrences (35% vs. 65%, p = 0.04).
McFarland L. JAMA 1994;271:
Surawicz conducted a second study with S. boulardii which confirmed a decrease in recurrences only with high dose vancomycin (500 mg qid), but no effect with metronidazole or vancomycin 125 mg qid.
Surawicz C. Clin Infect Dis 2000;31:

118. CDI: Recurrences
Stool transplantation from a donor administered via nasogastric tube or colonoscope.
Donor usually spouse.
Lacks aesthetic appeal, but appears to be highly effective (92%).
Toying with Human Motions
Borody T. J Clin Gastroenterol 2004;38:

120. CDI: Prevention
Numerous hospital and nursing home outbreaks have been reported. Johnson S. NEJM 1999;341:
C. difficile spores can persist in the environment for months on floors, bedding and furniture.
59% of HCW caring for patients with CDI had C. difficile cultured from their hands, including 75% of physicians McFarland L. NEJM 1989;320:

121. CDI: Prevention Private room in contact isolation or cohort.
Gloves have been clearly shown to decrease acquisition of C. difficile by HCW and decrease the incidence of CDI Johnson S. Am J Med 1990;88:
Avoid rectal thermometers.
Neither soap & water or alcohol products can kill the spore form of C. difficile, but soap & water can remove the spores from the hands.
Most effective surface cleaning is with bleach.

122. Bleach Decontamination
Decontamination with a bleach spray with 500 ppm resulted in a 79% reduction in the number of (+) surface cultures. Katz G. Am J Epidemiol 1988;127:
Switch from a quarternary ammonium to a 1:10 hypochorite solution for disinfection of rooms for patients with CDI resulted in a 63% reduction in CDI cases Mayfield J. Clin Infect Dis 2000;31:
Figueroa reported a 68% decrease in HCA CDI, despite stable CDI admission rates, after change to a universal bleach-based cleaning protocol was introduced for all hospital discharges th IDSA Oct Ab3 LB-6

124. MRSA

125. CA MRSA >80% of all SSTIs are caused by MRSA.
Most “spider bites” are MRSA.
Incision and drainage (I&D) alone may be adequate for uncomplicated abscesses.
Antibiotics alone are not adequate for fluctuant abscesses.
For patients with suspected CA MRSA, it is important to obtain specimens for culture and sensitivity (C&S).

126. CA MRSA and Antibiotics
531 episodes of CA MRSA SSTI, 75% abscesses.
8% had treatment failure (repeat I&D, new abscess while on Rx, hospitalization).
Failure to start active antibiotic within 48 hours of initial I&D was the only variable associated with treatment failure (OR 2.8) or 95% vs. 87% success.
Ruhe J. Clin Infect Dis 2007;44:

127. CA MRSA: Treatment
Trimethoprim-sulfamethoxazole (Septra, Bactrim) is a reasonable choice.
Can add rifampin 300 mg bid or 600 mg qd, but never use rifampin alone (rapid resistance).
If ciprofloxacin or another quinolone is used, combine with rifampin to prevent the emergence of resistance.
Doxycycline or minocycline may be of value.
Medical Letter 2006;48:13-4.

128. MRSA Colonization in LTCF
Point prevalence studies in VA units found 25-35% of residents are positive at any given time.
In areas where MRSA is common, 9-12% of residents in free standing LTCF are colonized.
65% are colonized for a long time, the remainder have transient colonization.

129. MRSA and the LTCF
Patients generally acquire MRSA in the acute care facility.
Transmission from resident to resident in the LTCF is infrequent, although occasional outbreaks have been described.
Environmental cultures from common areas are seldom positive, although the residents immediate environment is commonly positive.
Prevalence of colonization may be high, but infection is uncommon.

130. Frequency of MRSA Colonization at Various Patient Body Sites
Forehead %
Nose % - 93%
Neck %
Axilla % - 28%
Hands %
Groin % - 39%
95% of nasal carriers had MRSA at
extranasal sites
Hill RLR et al. JAC 1988;22:377
Sanford MD et al. CID 1994
Rohr U et al. Int J Hyg Environ Health 2004;207;51

131. MRSA and Isolation
Most Desirable: Private room or cohorting with another person who is colonized with MRSA.
Less Desirable: Room with a resident who has intact skin and no “tubes” (PEG, trach, IV, foley).
Should not be placed with resident who has another resistant organism (i.e. VRE).

132. MRSA Colonization and Activities
Resident may attend activities as long as:
Any colonized or infected site can be securely covered.
Resident can observe acceptable hygiene and wash his/her hands.
Resident with MRSA in sputum does not need to wear a mask if he/she can cover mouth and nose with tissue when coughing.
Resident who cannot control secretions should not attend group activities.

133. MRSA and the LTCF
Intensive barrier and isolation precautions have not been shown to be more beneficial than gloving and hand washing.
Decolonization efforts are usually ineffective and have not decreased infections.
Generalized screening is not justified.
No evidence to support non-admission of patients from acute care facilities.

134. MRSA: Infection Control
Staff should use Contact Precautions:
Handwashing: After removing gloves, before leaving the room.
Gloves: When physical contact with resident is anticipated.
Gowns: Substantial contact of clothes with patient or environmental surfaces or ileostomy, colostomy, diarrhea, incontinence, or wound drainage that is not contained.
Masks: When splashes possible (suctioning/irrigation).
No special cleaning of rooms required.

135. MRSA and LTCF
LTCF should not refuse placement if room available (single, cohort or low risk resident).
Leads to overuse of hospital resources and a false sense of security for LTCF management.
MRSA patients in hospitals or LTCF do not need two negative cultures for MRSA prior to transfer, decolonization prior to transfer should not be required.
Inform hospitals or other LTCF of MRSA status on transfer.

136. Termination of Isolation at the LTCF
2 cultures of colonized or infected site are negative, one week apart.
First culture should be taken at least 72 hours after antibiotic treatment has been stopped.
If sputum cannot be obtained, throat swab may be used.
If wound is healed, healed site may be cultured with moist swab.

137. Nares Cultures
Do not obtain nares cultures when obtaining cultures at other body sites.
Nares cultures are not needed to discontinue contact precautions.
Nares cultures only used if resident is implicated in MRSA outbreak.
Decolonization of nares is not routinely indicated.

139. Metronidazole vs. Vancomycin
First randomized, double-blind, placebo controlled trial of metronidazole vs. vancomycin.
Stratified by Scoring System at study entry into mild and severe disease.
Zar F. Clin Infect Dis 2007;45:302-7.

140. CDI Severity Scoring System
Points
Age > 60 y.o
Temp > 38.3 C
Albumin < 2.5 mg/dl
WBC > 15,
Rx in ICU
Pseudomembranes
Mild 0-1, Severe 2 or more.

141. CDI Outcomes: Clinical Cure
Metronidazole Vancomycin Mild CDI 90% 98% Severe CDI 76% 97% Recurrences 15% 14%