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Outline   C. difficile overview  Pathogenesis  Brief description of various tests  Transmission of C. difficile  Identifying high-touch surfaces  Daily cleaning vs. terminal cleaning  Proper use of bleach  Brief intro to alternative cleaning products 2

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Historical Perspective  Bacillus difficilis (now C. difficile) was cultured from healthy neonates in 1935  In the 1960’s it was noted that patients on antibiotics developed diarrhea  “Staphylococcal Colitis”  Originally thought to be caused by S. aureus and treated with oral bacitracin  Stool cultures routinely ordered for S. aureus

 Early 1970’s, a new explanation  “Clindamycin Colitis”

 Severe diarrhea, pseudomembrane colitis, and occasional deaths documented in patients on clindamycin

CDI Overview   Spore‐forming, anaerobic,  gram‐positive bacterium   Causes gastrointestinal  infections resulting in diarrhea  and colitis  –

Severity ranges from mild colitis  to toxic megacolon and death 

 Leading cause of healthcare‐associated infectious  diarrhea in US   Rivals methicillin‐resistant Staphylococcus aureus (MRSA) as the most common organism to cause  healthcare‐associated infections in US 

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Prevalence   C. difficile causes about 500,000 illnesses in the United States every year (Kuchn, 2011).  In the United States, estimated 15000-20000 patients die from the illness each year (Barbut, Jones, & Eckert, 2011).  In the general population, one to three percent of adults are colonized with the organism (Barbut et al., 2011). However, about 20 percent of hospitalized adults are C. difficile carriers (LaMont, 2009). 5

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Strains of C. difficile

  Anaerobic, gram-positive, spore-forming, bacillus  Non-toxin producing C. difficile  Toxin A (tcdA)  Toxin B (tcdB)  NAP1/BI/027 (deletion tcdC)  Down regulation of toxin production  Enhance capability for production of toxin A and B.

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NAP1/BI/027 (deletion tcdC)

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Pathogenesis 

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Two forms of C. difficile  Vegetative

Spore

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Crypts 

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Normal vs. compromised

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Pathogenesis cont.

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Toxin effects on colon 

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Pseudomembranes 

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Clinical Symptoms   Watery diarrhea is the cardinal clinical symptoms  Diarrhea can be up to 15 times per day  Fever, cramping, abdominal discomfort, and peripheral leukocytosis (cohen, 2010)  Colonic ileus or toxic dilatation may present with no or minimal diarrhea.

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Methods of testing C. difficile   Culture  Cell cytotoxicity neutralization assay  Enzyme immunoassays (EIA) C. difficiletoxin A (Tcd A)  EIA TcdB or TcdA/B  EIA, glutamate dehydrogenase (GDH)  Nucleic acid amplification tests

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Culture   Target: organism  Advantages:  High sensitivity (often considered as the gold standard)

 Disadvantages:    

Turn-around time >7 days Labor intensive Lacks specificity Isolates must be further tested for the presence of toxins 18

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Cell cytotoxin neutrlization assay   Functional assay for C. difficile toxin B (TcdB)  Advantages:  Moderate-to-high sensitivity  High specificity

 Disadvantages:  48-72 hrs turn-around time  Subjective interpretation  Labor intensive

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Enzyme immunoassays (EIA) C. difficiletoxin A (Tcd A)

  Target: Toxin A detection  Advantages:    

Easy to perform Rapid turn-around time Inexpensive High specificity

 Disadvantages:  Low sensitivity  Missess TcdA-/TcdB+ isolates 20

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EIA TcdB or TcdA/B   Target: Toxin A or B detection  Advantages:    

Easy to perform Rapid turn-around time Inexpensive High specificity

 Disadvantages:  Low sensitivity

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EIA, glutamate dehydrogenase (GDH)

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 Method: common antigen detection  Advantages:  High sensitivity  Good screening test

 Disadvantages:  Low specificity  Must test further

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Nucleic acid amplification tests

  Method: Toxin gene detection  Advantages:    

High sensitivity High specificity Short-turn around time Easy to perform, minimal hands on

 Disadvantages:  Expensive  Detection of asymptomatic colonization 23

Combination method and algorithm

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Enzyme immunoassay (EIA) GDH and Toxin(s)

• GDH Negative • Toxin(s) negative

Enzyme immunoassay (EIA) GDH and Toxin(s)

• GDH positive • Toxin(s) positive

Enzyme immunoassay (EIA) GDH and Toxin(s

• GDH positive • Toxin(s) negative

Report as negative

Report as positive

Need further testing 24

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Combination method and algorithm

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Enzyme immunoassay (EIA) GDH and Toxin(s)

GDH positive

Toxin negative

Nucleic acid amplification tests

positive Report as positive

negative Report as negative

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Consequences of Bad Tests  Repeat testing  Low sensitivity –

False negative patients don’t get treated and spread the organism

 Low specificity –

False positive patients get costly treatments and IC protocols

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Practice change  Send stool to lab right away or refrigerate If GDH and EIA method are used  Test only symptomatic patient (3 loose stools in 24 hours)  Test only loose stool (stick or conform)  Test only one stool per patient per week  Do not test for cure  Assess patient for other reasons for the diarrhea

Clinical Practice Guidelines 2010 SHEA and IDSA Summary  Test only unformed stool (exception: ileus)  Do not perform a test of cure  Stool cultures sensitive but not practical except for epidemiological studies  EIA is rapid, not very sensitive and is sub-optimal  2 step GDH and EIA is a interim recommendation  More data needed on PCR before they can recommend  Repeat testing discouraged Cohen, S.H. et al. 2010. ICHE. 31: 431-455

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Transmission of C. difficile

  Person to person by swallowing fecal matter.  Periods between exposure C. difficile and the occurrences 2- 3 days (cohen, 2010)  Culprits in healthcare:  Contaminated hands of healthcare worker  Electronic rectal thermometers  Inadequately cleaned commodes or bedpans

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Germs (skin bacteria)  Culture plate showing growth of germs 24 hours after a nurse placed her hand on the plate

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Before entering the room, Clean your hands with:

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OR

Soap and Water

Hand Sanitizer

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After Leaving the room: Wash with soap and water only

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Environmental source  Acquisition of spores on gloved hands occurred as frequently after contact with environmental surfaces as after contact with skin sites (50% vs 50%)

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Portable equipment   Electronic thermometers  Blood pressure cuffs  Bedside commodes  Stethoscopes Cohen SH, et al. ICHE 2010;31:31:431-55 34

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Confusing products 

 Omit confusing products 35

Confusion about who cleans what   House keeping ?  Nurses?  Central supply?  Nobody?

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Sufficient contact time is necessary

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Barbut F, et al. Infect Control Hosp Epidemiol 2009;30:507-14

Stopping the spread: Cleaning and Disinfection

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Cleaning: Removal of organic matter and visible dirt Disinfection: Killing of microorganisms 38

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Reducing contamination of cleaning solution and cleaning tools

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Laundering microfiber/swiffer after each room cleaning. Replace soiled microfiber/swiffer with clean item each time a bucket or detergent/disinfectant is emptied or replaced. Keeping microfibers/swiffers in solutions do not kill all the bugs, some bugs can grow in the solution. Make sufficient cleaning solution for the day, emptying the solution and drying out the container minimize contamination.

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Clostridium difficile Excerpt: Guideline for Environmental Infection Control in Health-Care Facilities, 2003

High-touch surfaces 

Huslage K, et al. A quantitative approach to defining high-touch surfaces in hospitals. Infect Control Hosp Epidemiol 2010;31:850-3.

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Identify frequently touched surfaces 

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Monitor Cleaning 

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Daily Cleaning   Wipe all high-touch surface daily  Two wipe system, Clean and Disinfect  Minimizing mist and aerosol dispersion

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One bleach wipe multiple time vs. fresh one each time

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Terminal/ Dischrage Cleaning

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 Clean all high-touch surfaces and all other area including wall with quaternary solution

 Then disinfect with bleach wipe or bleach solution.  Stay wet for 10 minutes 45

Quat vs Bleach 

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Diluted bleach

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Diluted bleach only stable only for 24 hrs 47

Peroxyacetic acid/ hydrogen peroxide/ Octanoic acid combination

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 One- Step detergent disinfectant  Components:  Peroxyacetic acid 0.05%  Hydrogen peroxide 3.13%  Octanoic acid 0.099%

 Kills C. difficile spores in 10 minutes  Effective with 5% organic load (peracetic acid is not affected as much as bleech by organic load)  Compatible with materials 48

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Peroxyacetic acid/ hydrogen peroxide/ Octanoic acid combination

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 Precautionary Statement:  Danger: Causes irreversible eye damage. Do not get in eyes or on clothing. Wear goggles, face shield, or shielded safety glasses.

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Hydrogen peroxide mist 

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UV light 

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Conclusion   Identify frequently touched surfaces     

List them and give copies to housekeeping personnel Identify ownership of equipment cleaning Use EPA registered sporicidal Clean then disinfect even with one-step products Implement daily cleaning

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Questions 

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References   Association for Professionals in Infection Control and Epidemiology. (2008). Guide to the Elimination of Clostridium difficile in Healthcare Settings Washington, DC: APIC.  Banning, M. (2008, December). Understanding the microbiology, prevalence and pathology of Clostridium difficile. Gastrointestinal Nursing, 6(10). Retrieved from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=4&hid=25&s id=d69405ae-17ec-4e87-b3d7-2fe1cb0adbcb%40sessionmgr12  Barbut, F., Jones, G., & Eckert, C. (2011). Epidemiology and control of Clostridium difficile infections in healthcare settings: an update. Nosocomial and health-related infections. doi: 10.1097/qco.0b013e32834748e5  Clostridium difficile Excerpt: Guideline for Environmental Infection Control in Health-Care Facilities, 2003. (2003). www.cdc.gov/HAI/organisms/cdiff/Cdiff_excerpt.html

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References   Cohen, S. H., Gerding, D. N., Johnson, S., Kelly, C. P., Loo, V. G., McDonald, C., ... Wilcox, M. H. (2010, March 22). Clinical practice guidelines for Clostridium difficle infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control and Hospital Epidemiology, 31(5). doi: 10.1086/651706  Gould, C. V., & McDonald, C. (2008, January). Bench-to-bedside review: Clostridium difficile colitis. Critical Care. doi: 10.1186/cc6207  Huslage K, et al. A quantitative approach to defining high-touch surfaces in hospitals. Infect Control Hosp Epidemiol 2010;31:850-3.  Kuchn, B. (2011). Scientists seek strategies to prevent Clostridium difficile infections. JAMA, 306(17), 1849-1850. doi: 10.1001/jama.2011.1569  LaMont, J. (2012, June 11). Clinical manifestations and diagnosis of Clostridium difficile infection. UpToDate. Retrieved fromhttp://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-ofclostridium-difficile-infection-inadults?source=search_result&search=Clinical+manifestations+and+diagnosis+of+Cl ostridium+difficile+infection&selectedTitle=1%7E150

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