Question 12

College Answer

Treatment:

• Immediate goal is to alleviate the active symptoms of diarrhoea and colitis.
• Ultimate goal is restoration of normal gut flora.
• Discontinue all unnecessary antibiotics.
• Fluid and electrolyte replacement as indicated to compensate for GI losses
• Antibiotic therapy
  • First line agent is PO metronidazole especially in milder disease.
  • Second Line is PO vancomycin for patients with more severe disease, or who are intolerant or do not respond to metronidazole. There has been recent debate that vancomycin should possibly be first line therapy, due to increasing treatment failure rates with metronidazole not seen with vancomycin. Cost and increasing nosocomial vancomycin resistance are other issues within this debate.
• Assess for complications of colitis – severe sepsis or toxic megacolon
• Faecal transplant should be considered to restore normal gut flora

Infection Control and Prevention Strategies:

• The ultimate goal in combating disease is prevention/eradication.
• Specific infection control measures, and thus a Unit Policy, are very important MUST be instituted, championed and audited.
  • Isolation of CDI patients in single rooms or cohorted together o Hand Hygiene – The “5 Moments of Hand Hygiene”.
    • Soap and water
    • Not alcohol-based hand rubs (don’t kill the spores) 
  • Contact Precautions.
    • Gown and glove.
  • Environmental cleaning and disinfection.
    • Ammonium-based disinfectants are not sporicidal
    • Solutions must include unbuffered hypochlorite (bleach), which is sporicidal. In other words, chlorine-based solutions.
  • Restriction of antimicrobial use.
• Education, via a widespread campaign, and audit, of staff and compliance will be important.
• Consider the introduction of a formal CDI Team which would help educate, raise awareness, implement and audit your policy
• Consider the introduction of CDI Bundles similar to other hospitals 
  • Education Bundle
  • Prevention Bundle
  • Treatment Bundle
• Introduction of an Antibiotic Stewardship Program would help monitor appropriate antibiotic use and cessation etc.
• Consider restricting the use of gastric acid suppressive agents. Multiple large trials now support the association between CDI and PPI use. One would have to weigh up the riskbenefit on a patient-to-patient basis though.
• Finally there are ongoing trials looking at the use of probiotics for the prevention of CDI. Their role is unclear at present.

Discussion

Approach to specific patient treatment:

Mild-moderate C.difficile infection:

• Treat empirically in the absence of positive results, if the pre-test suspicion is strong.
• Stop the inciting antibiotics
• Give oral metronidazole for 10 days
  • Change metronidazole to vancomycin if there is no response in 5-7 days
• For severe infection, just give oral vancomycin straight away(125mg qid for 10 days)
• Vancomycin enemas are an option
• Avoid anti-diarrhoea medications

Severe and complicated C.difficile infection:

• CT of the abdomen is indicated
• Oral vacomycin PLUS intravenous metronidazole are indicated
• If there is significant abdominal distension, the vancomycin should be given as an enema

Recurrent C.difficile infection:

• First recurrence: treat in the same way as the first episode
• Second recurrence: change to vancomycin
• Third recurrence: consider a faecal microbiota transplant

When to consider surgery:

• Hypotension requiring vasopressor therapy
• Clinical signs of sepsis and organ dysfunction
• WCC in excess of 50
• Lactate in excess of 5mmol/L
• Failure to improve on medical therapy after 5 days

Supportive management:

• Manage the diarrhoea
  • This includes stool management systems, rectal tubes etc.
• Manage the symptoms of colitis
  • Adequate pain relief
• Restore fluid and electrolyte imbalance 

Infection control:

Active surveillance cultures

• Identifies the "reservoir" for spread
• Allows precautions to be cost-effectively focused on the reservoir.
• The health care workers themselves may become colonised reservoirs.
• Performed on all patients, on admission, and then peridoically (eg. weekly).
• In facilities found to have a high prevalence on initial sampling, a facility-wide culture survey is indicated.

Contact precautions

• Hand hygiene
  • Soap and water for visibly contaminated hands
  • Alcohol-based rub for routine pre-and-post-contact hygiene
  • Monitoring of compliance should be performed
• Disposable gloves
• Disposable gowns
• Patients colonised by C.difficile may be cohorted together.
• Contaminated areas should be identified by obvious cautonary signs

Eradication of existing colonies

• Effective treatment of existing cases
• Decontamination of colonised health care workers
• Environmental disinfection
• Routine disinfection of equipment between patient contacts
• Wherever possible, individualised equipment for every patient

Prevention of C.difficile outbreaks

Barrier methods:

• Isolation of affected patients, at least until 48 hours after the resolution of diarrhoea
• Gowns and gloves
• Traditional soap-and-water handwashing rather than alcohol rub
• Individualised equipment in single rooms (turns out it is more cost-effective to buy new thermometers than to treat additional C.difficile cases)
• Sporicidal bleaching agents should be used to disinfect rooms after patient departure: specifically, unbuffered hypochlorite bleach

A change in prescribing culture:

• Antibotic stewardship is strongly recommended: incidence may reduce by 60%
• The prescribing of PPIs should be rationalised, as the use of PPIs is associated with a 2-fold increase in the risk of C.difficile infection (Deshpande et al, 2012)

Organisation-level changes to improve infection control

Organisation

• Infection control specialty team, composed of ICU specialists, infectious diseases specialists, senior nursing staff, laboratory staff and administration staff.
• Allocated resources to MRO surveillance, compliance monitoring and education
• "Champions" - staff allocated to promote the existing policies and monitor adherence

Education

• "Widespread campaign", as recommended by the SAQ model answer
• Awareness-rasing posters
• Lunchtime meetings
• Promulgated reading material
• Education bundle as a part of mandatory employee training

Data collection and audit

• Data collection and MRO colonisation record
  • Records of MRO results allow colonised patients to be identified early
• Regular review of collected information, resistance and transmission patterns
• Regular audit of the efficacy of implemented strategies
• Regular comparison of policies to those of peer hospitals
• Regular reevaluation and amendment of infection control policies

Oh's Manual: Chapter 70  (pp. 724)  Nosocomial  infections by James  Hatcher  and  Rishi  H-P  Dhillon - totally useless; there is literally just one paragraph devoted to it here.

Surawicz, Christina M., et al. "Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections." The American journal of gastroenterology 108.4 (2013): 478-498.

Lawrence, Steven J., et al. "Clostridium difficile in the intensive care unit: epidemiology, costs, and colonization pressure." Infection Control 28.02 (2007): 123-130.

Deshpande, Abhishek, et al. "Association between proton pump inhibitor therapy and Clostridium difficile infection in a meta-analysis." Clinical Gastroenterology and Hepatology 10.3 (2012): 225-233.