1. C. difficile Update
Kim Vermedal, RN, MSN, CIC
APIC January 25, 2019

2. The Gut Microbiome & Disease Prevention
Microbiome is a collection of 39 trillion microbes in our GI tract (predominantly the colon)
Healthy microbiome protects the body from disease
Preclude emergence of pathogens/MDRO’s
Prevent changes to the microbial metabolome
Preserve healthy gut function

3. Testing Multistep testing required
One step testing-half of positives are not CDI
25% of CDI resolves on its own
Do not test asymptomatic patients

4. Algorithm

5. Pediatric Testing High prevalence of asymptomatic carriage
Never routinely recommended for neonates or infants < 12 months of age with diarrhea
Should not be performed in children with diarrhea 1-2 years of age unless other infectious or non-infectious causes have been excluded

6. Antibiotic Stewardship
IDSA Guidelines for decreased length of antibiotic therapies
UK eliminated the most toxic subtype of C. difficile with stewardship (Fluorquinolones and Cephalosporin's)
41% increase in abx prescriptions in the outpatient setting by NP’s/PA’s.
15% decrease ordering by physicians

7. Community Acquired On the increase Usually less severe infection
How is it spread in those patients without healthcare contact?
82% with outpatient exposure
It's on surfaces
39.7% on shoe bottoms in one community study

8. Fecal Transplants Can prevent reoccurrence
Many failures related to incorrect initial testing
Trials in process to use for initial acute phase diagnosis
In the near future-capsules

9. The Future is Close Vaccines in clinical trials
New antibiotics with narrow spectrum focus
40 new antibiotics in development-only 1 in phase three trial stage
Other compounds to maintain microbiome
Extended tapers of Vancomycin-QOD
FMT as primary treatment for CDI

10. SARMC Criteria for Testing
Patient must have:
≥3 watery stools in the past 24 hrs (sample conforms to specimen container) Formed stool samples will be rejected.
In rare suspicion of ileus/toxic megacolon 2ndary to C diff, consider rectal swab.
AND
At least 1 of the following:
o Abdominal pain/discomfort (cramping, bloating)
o Antibiotic therapy within last 3 months
o Gastric acid suppression (proton pump inhibitor or H2 blocker)
o GI surgery within last month
o Resident of SNF, age >65
o Chemotherapy within last month
o Hospitalization within last 2 months
o C diff infection within last 90 days (unless tested within last 7 days or tested positive within last 30 days)

11. Criteria None of the following are applicable:
Laxatives, Bowel prep or other current medications that are known to cause diarrhea within last 3 days
TPN infusion
Tube feedings
Other infectious or parasitic sources of diarrhea are unlikely
Acute resolution of bowel obstruction
Expected post-operative diarrhea (post-operative day 0-2)--if unsure, clarify with provider
Ileostomy or short bowel syndrome

12. Testing Algorithm Antigen/toxin testing first PCR if indicated
Remember never order for test of cure

13. Removal for Isolation Has completed at least seven days of therapy
Has formed stool
Is capable of performing personal and hand hygiene with soap and water.

14. Questions?