1. Clostridium difficile Presented by Nate Smith, MD, MPH Carole Yeung, RN CIC

2. 2 Outline Epidemiology Treatment Prevention

3. 3 What is Clostridium difficile? Anaerobic spore-forming bacillus Present in the soil and environment Produces two toxins – Toxins A and B Common cause of antibiotic associated diarrhea (AAD). 15 – 25 % all episodes of AAD Health care settings are major reservoirs 20 – 40% hospital patients colonized 4 – 20% LTCF residents colonized

4. 4 What are C. difficile-associated diseases (CDAD) Pseudomembranous colitis (PMC) Toxic megacolon Perforations of the colon Sepsis Death (rarely) but increasing!

5. 5 CDAD-related deaths - Arkansas *2005 data incomplete

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7. 7 Symptoms of CDAD Watery diarrhea Fever Loss of appetite Abdominal pain Nausea and vomiting Severe cases: increase WBC and/or creatinine Can occur up to 8 weeks after antimicrobial therapy

8. 8 Which patients are at increased risk for CDAD? Antibiotic exposure – clindamycin, penicillins, cephalosporins, floroquinolones Gastrointestinal surgery Length of stay in healthcare settings A serious underlying illness Immunocompromising conditions Advanced age

9. 9 C. difficile colonization Patient exhibits no clinical symptoms Patient tests positive for C. difficile organism and/or its toxin More common than CDAD

10. 10 C. difficile disease (CDAD) Patient exhibits clinical symptoms Patient tests positive for C. difficile organism and/or its toxin

11. 11 Laboratory Tests for CDAD Stool culture Antigen detection Toxin testing

12. 12 C. difficile Transmission C. difficile spores are shed in feces Any surface, device or material that becomes contaminated with feces may serve as a reservoir Transferred by hands of healthcare personnel

13. 13 Treatment Discontinue antibiotics if feasible Metronidazole orally for 10 days Vancomycin orally Relapses are common Repeat testing NOT recommended NO antiperistalic agents

14. 14 Infection Control Preventive Methods Use antibiotics judiciously Early diagnosis Contact precautions for patients with CDAD Hand hygiene Environmental cleaning and disinfection

15. 15 Contact Precautions Private room or cohort Gloves Gowns Dedicated patient care equipment

16. 16 Hand Hygiene Soap and water for at least 15 seconds: Wet hands under running water Apply soap Good friction rub for 15 seconds Rinse hands Dry well with paper towel

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30. 30 Cleaning and Disinfection Clean/disinfect environmental surfaces and reusable items Hospital disinfectant 1:10 bleach

31. 31 Discontinuing Precautions NO diarrhea. NO precautions! Repeat testing NOT recommended

32. 32 Transfer of Patients Notify receiving facility if patient has a history of C. difficile Observe for recurrence

33. 33 References SHEA Position Paper CDAD, ICHE 1995 SHEA Position Paper C. difficile in LTCF for the elderly, ICHE 2002

34. 34 QUESTIONS?