Clinical Practice Guidelines for Clostridium difficile ...€¦ · 3. Without “good bacteria”...

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Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the IDSA and SHEA Mandee Novack, MD Co-Medical Director of Antimicrobial Stewardship Baptist Health

Transcript of Clinical Practice Guidelines for Clostridium difficile ...€¦ · 3. Without “good bacteria”...

Page 1: Clinical Practice Guidelines for Clostridium difficile ...€¦ · 3. Without “good bacteria” to keep it in check, C diff grows and releases Toxins (Toxin-A and Toxin-B) 4. Those

ClinicalPracticeGuidelinesforClostridiumdifficile Infectionin

AdultsandChildren:2017UpdatebytheIDSAandSHEA

Mandee Novack,MD

Co-MedicalDirectorofAntimicrobialStewardship

BaptistHealth

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AboutClostridiumdifficile

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AboutClostridiumdifficile

1. Normalmicrobiota getsdisturbed(byantibiotics,or

evenpoordiet)

2. GutisexposedtoClostridiumdifficile spores(which

cansurvivestomachacid)

3. Without“goodbacteria”tokeepitincheck,Cdiff

growsandreleasesToxins(Toxin-AandToxin-B)

4. Thosetoxinsdamagethegut,causeinflammation,

diarrhea,andpseudomembranes

NotallClostridiumdifficile havethegenetomaketoxins,

andeventheonesthathavethegenearen’tnecessarily

makingthetoxinallthetime.

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Epidemiology• HowareCDIcasesbestdefined?• 1)thepresenceofdiarrhea(orileus,ormegacolon)AND

• 2)apositivelabdiagnostictestorpseudomembranesdemonstratedonendoscopyorhistology

• Anincident caseis{symptoms+labtest}withnoepisodesintheprevious8weeks

• Arecurrentcaseisdefinedas{symptoms+labtest}whentherehasbeenanotherepisodeof{symptoms+labtest}inthelast8weeks

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EpidemiologyDefinitions

• CDI=ClostridiumdifficileInfection

• HO=Healthcarefacility-onset

• CO-HCFA=Community-onsethealthcarefacility-associated

• CA=Community-associated

• NHSN=NationalHealthcareSafetyNetwork

• LabID-CDI=LaboratoryIdentifiedCdiffinfection

• SIR=Standardizedinfectionratio

• HAI=Healthcareassociatedinfection

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Epidemiology

• HO-CDI casesaredefinedasLabID eventscollected>3daysafteradmission(onorafterday4)

• CO-HCFA CDIcasesaredefinedas{symptoms+labtest}thatoccurwithin28daysafterdischargefromahealthcarefacility

• CA-CDI casesaredefinedas{symptoms+labtest}thatarenotassociatedwithadmission/dischargeinthelast4weeks

HO:HealthcarefacilityonsetCO-HCFA:Community-onsetHealthcarefacilityassociatedCA:Communityassociated

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Epidemiology

From2010guidelines

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Prevalence,Incidence,Morbidity,Mortality

• 2010rateofLabID-CDIwas7.4per10,000patient-days

• In2011,therewereanestimated453,000cases(147/100,000person)

• Ofthose,64.7%wereconsideredhealthcareassociated:• 37%werehospitalonset

• 36%hadtheironsetinlong-termcarefacilities

• 28%wereCO-HCFA(i.e.withadmissionintheprior12weeks)

• Ofthe35.3%thatwereconsideredcommunity-associated:

• 82%wereassociatedwithoutpatienthealthcareexposure

• Therefore,94%ofallCDIcaseshadarecenthealthcareexposure

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Prevalence,Incidence,Morbidity,Mortality

• Cdifficile isthemostcommoncausativepathogeninHAIs

• Afterafirstepisode,10-30%ofpatientsdeveloprecurrence

• Endemicperiods:CDI-attributablemortalityis4.5%- 5.7%

• Epidemicperiods:CDI-attributablemortalityis6.9%- 16.7%

• CDIattributablecost is$3427- $9960perepisode

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IncreasedRisk

• Advancedage

• Antibiotics

• PPIs

• Cancer

• Inflammatoryboweldisease

• Solidorgantransplant

• CKDandESRD

• Hematopoieticstemcelltransplant(9xgreatriskthanotherhospitalizedpatients)

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Colonization• Asymptomaticcolonizationinadultinpatientsis3%-26%

• (inthegeneralpopulationwithouthealthcareexposure,itis<2%)

• Colonizationà Infectionisprobably3-7days

• Prolongedcolonizationincreasesriskforinfection,butthatriskofprogressiondecreasesovertime(thatis,ifyou’vebeencolonizedfor2weeks,yourriskofprogressionishigherthanifyou’vebeencolonizedfor6weeks).

• ColonizationwithanontoxigenicstrainconfersprotectionagainstCDI

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Diagnosis

• Whototest:• Patientswithunexplainednew-onsetdiarrhea,with≥3unformedstoolsin24hours

• Examplesof“explaineddiarrhea”• Inflammatoryboweldisease

• Enteraltubefeeding

• Intensivechemotherapyforcancer

• Laxatives

“However,someoftheseconditionsandinterventionsassociatedwithdiarrheaintheirownright,suchasIBD

andenteraltubefeeding,havebeenshowntohaveincreasedriskofCDIwhencomparedwithamatched

cohort.So,inpracticeitisdifficulttoexcludethepossibilityofCDIonclinicalgroundsalone”

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Improvinglaboratorytestrelevance

• Donotroutinelyteststoolwithin48hoursafteralaxative

• Laboratorycanrejectspecimensthatarenotliquid

• Includecriteriafortesting(#ofunformedstoolsin24hours,orincludeotherclinicalriskfactors/signs/symptomsofCDI)

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AboutCdiff testing

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AboutCdiff testing

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AboutCdiff testing

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AboutCdiff testing

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AboutCdiff testing

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Diagnostictesting• 2017Update

• Onlytestunformedstools

• Donottestasymptomaticpatients,anddonottestfor

cure

• (Newguidelinesmentionstoolculturedeepinthe

“summaryofevidence”,notintherecommendations)

• (NewguidelinesendwithNAATtestingratherthan

cellcytotoxicityassayortoxigenicculture)

• PCRtakesamuchmoreprominentrole

• Repeattestingisstilldiscouraged

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Diagnostictesting

• VII.Whatisthebest-performingmethod(ie,inusepositiveandnegativepredictivevalue)fordetectingpatientsatincreasedriskforclinicallysignificantC. difficileinfectionincommonlysubmittedstoolspecimens?

• Useastooltoxintestaspartofamultistepalgorithm(ie,glutamatedehydrogenase[GDH]plustoxin;GDHplustoxin,arbitratedbyNAAT;orNAATplustoxin)ratherthanaNAATaloneforallspecimensreceivedintheclinicallaboratorywhentherearenopreagreedinstitutionalcriteriaforpatientstoolsubmission

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Diagnostictesting

• VIII.WhatisthemostsensitivemethodofdiagnosisofCDIinstoolspecimensfrompatientslikelytohaveCDIbasedonclinicalsymptoms?Recommendation

• UseaNAATaloneoramultistepalgorithmfortesting(ie,GDHplustoxin;GDHplustoxin,arbitratedbyNAAT;orNAATplustoxin)ratherthanatoxintestalonewhentherearepre-agreedinstitutionalcriteriaforpatientstoolsubmission

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WhentotestforCdiff…

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Ifyes…

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Ifno(butyou’refibbing)…

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WhentotestforCdiff

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Ifthey’vehadfewerthan3waterystools,it’snottimetotestyet…

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Aboutrepeattesting…

• Ifusing2-stagealgorithmorstand-aloneNAAT,asingletestshasanegativepredictivevalueof>99%

• DONOTREPEATTESTINGWITHIN7DAYS

• Testingforrecurrence(followingsuccessfultreatmentanddiarrhea)shouldincludetoxindetection(sincePCRcanremainpositiveforalongtimeafterCDI)

• Empirictreatmentforrecurrenceisdiscouraged(andmaybeharmfultomicrobiomerestoration)

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ButIagree,realCdiffisrealbad

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InfectionControl

• Privateroomsanddedicatedtoilets• Prioritizeprivateroomsforpatientswithincontinence

• Gownandgloves

• IsolatewhenCDIissuspected“iftestresultscannotbeobtainedonthesameday”

• Continueisolationforatleast48hoursafterdiarrheahasresolved• KeepitgoinguntildischargeifCDIratesremainhigh

• Cdiffissuppressedtoundetectablelevelsinstoolsamplesbythetimediarrhearesolves,inmostpatients,butskin/environmentalcontaminationremainshigh

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Routesoftransmission

• Handsofhealthcarepersonnel

• Environmentalcontamination

• High-riskfomites(electronicrectalthermometers,bedpans,commodes)

• Asymptomaticallycolonizedpatients

• Formostcases,theexactrouteoftransmissionisneverdetermined

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Infectioncontrol- Handhygiene

• “Inroutineorendemicsettings,performhandhygienebeforeandaftercontactofapatientwithCDIandafterremovinggloveswitheithersoapandwateroranalcohol-basedhandhygieneproduct”

• InCDIoutbreaksorhyperendemic settings,usesoapandwaterpreferentiallyoveralcohol-basedproducts

• Ifthereisdirectcontactwithfeces,washwithsoapandwater.

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Infectioncontrol

• “Encouragepatientstowashhandsandshowertoreducetheburdenofsporesontheskin”

• Usedisposablepatientequipmentwhenpossible,andensurethatreusableequipmentiscleanedanddisinfectedwithsporicidalproducts(thatareequipmentcompatible)

• “TerminalroomcleaningwithsporicidalagentshouldbeconsideredinconjunctionwithothermeasuretopreventCDIduringendemichighratesoroutbreaks,orifthereisevidenceofrepeatedcasesofCDIinthesameroom”• Dataonautomated disinfectionaretoolimitedtomakearecommendationfornow

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Infectioncontrol

• Dailysporicidaldisinfection“shouldbeconsidered”duringoutbreaks

• Thereisnorecommendationtoscreen/isolateasymptomaticpatients

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AntimicrobialStewardship

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AntimicrobialStewardship

• Minimizethefrequencyanddurationofhigh-riskantibiotictherapy,andthenumberofagentsprescribed

• Implementanantibioticstewardshipprogram

• AntibioticstobetargetedshouldbebasedonlocalepidemiologyandstrainsofCdiffinthecommunity.

• Restrictionsoffluouroquinolones,clindamycin,andcephalosporin(exceptforsurgicalantibioticprophylaxis)shouldbeconsidered

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Probiotics• “ThereisinsufficientdataatthistimetorecommendadministrationofprobioticsforprimarypreventionofCDIoutsideofclinicaltrials”

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Treatment

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Oldguidelines(donotmemorize!!!)

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Newguidelines

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Initialepisode

• Initialepisode,non-severe• Vancomycin125mg4x/dfor10days

• Fidaxomycin 200mgBIDx10days

• Ifthoseareunavailable,metronidazole500mgTIDx10d

• Initialepisode,severe• Vancomycin125mg4x/dfor10days

• Fidaxomycin 200mgBIDx10days

• Initialepisode,fulminant• Vancomycin500mg4x/d,plusrectalinstillation,plusIVmetronidazole

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Fulminantdisease

• POVancomycin500mg 4x/d+IVmetronidazole500mgQ8h

• Ifileusispresent,vancomycincanbeadministeredPR(500mg/100mLq6hasaretentionenema)

• “itmaybeappropriatetomonitortroughserumconcentrationtoruleoutdrugaccumulation”whenhighdosesareused

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RecurrentCDI

• Firstrecurrence:tapered/pulsedVancomycin,notanother10-daycourse

OR

• Treatafirstrecurrencewith10-dayfidaxomicin

OR

• Ifyou(wrongly)usedflagyl thefirsttimearound,try10daysofPOVanc

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Multiplerecurrences

• POVanc tapered+pulsed(weak,lowquality)

• POVancomycinfollowedbyPORifaximin (weak,lowquality)

• POFidaxomicin (weak,lowquality)

• Fecalmicrobiotatransplantation(strong,moderatequality)

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Take-HomeMessage

• PreventCdiffbymakingbetterantibioticchoicestobeginwith

• PreventspreadofCdiffwithexcellentInfectionControladherence

• Ourtestisoverlysensitive,soweneedtobepickieraboutwhenweuseit(notforpatientsonlaxatives,orwithlessthan3stoolsin24h)

• Firstlinetreatmenthaschanged(POFlagyl isnolongerrecommended)

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Questions?


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toxin A Clostridium difficile J. L. Johnson. 1990 ...

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Clostridium difficile - who.int · Clostridium difficile Dr Gill Douce University of Glasgow 1 Prepared for the WHO`S Product ... third toxin – Binary toxin Presentaon to WHO Vaccine

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Clostridium difficile PCR Cycle Threshold Predicts Free Toxin · Clostridium difficile PCR Cycle Threshold Predicts Free Toxin Fiona Senchyna, aRajiv L. Gaur, Saurabh Gombar,a Cynthia

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Clostridium difficile from stool samples - CHROMagar€¦ · production of binary toxin. ... “Emergence of Clostridium difficile-associated disease in North America and ... like

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Evaluation of the VIDAS Clostridium difficile Toxin A&B ... · toxins with good performance compared to the gold standard CTA. Evaluation of the VIDAS Clostridium difficile Toxin

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Clostridium difficile Infection (CDI) Guideline Update ......Clostridium difficile • Gram positive, spore forming rod • Obligate anaerobe • Toxin A and Toxin B • Required to

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Genes Encoding Toxin of Clostridium difficile in Children ... et al. 2014.pdf · Genes Encoding Toxin of Clostridium difficile in Children with and without Diarrhea VictorR.C.Merino,

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Clostridium difficile Enteritis nach NTx - uni-tuebingen.de · Clostridium difficile Hygienemaßnahmen 19 06.06.2018 • alle symptomatische Patienten mit Clostridium difficile müssen

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Epidemiology, Diagnosis, and Prevention of Clostridium ... · Epidemiology, Diagnosis, and Prevention of . Clostridium difficile Infection. ... more toxin A and B production – Binary

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Clostridium difficile Toxin B causes epithelial cell necrosis through ...

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Clostridium difficile-Associated Colitis: Role of the ...€¦ · Clostridium difficile-Associated Colitis: ... 4.2 Binary toxin In addition to toxins A and B, a further toxigenic

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Treatment of Clostridium difficile - Rackham Presentations/Treatme… · additional “binary” toxin hypersporulationcapacity high-level resistance to fluoroquinoloneantibiotics

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Update on Clostridium difficile - Glasgow, Scotland, UK · Update on Clostridium difficile pathogenesis and epidemiology prof. dr. Maja Rupnik ... binary toxin CDT - two nonlinked

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