abbreviated C.diff COCA presentation (long)

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Information about abbreviated C.diff COCA presentation (long)
Health & Medicine

Published on September 17, 2008

Author: CxLxMx

Source: slideshare.net

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Abbreviated version of the CDC's Sept 16 COCA conference call. I am also uploading an even shorter version. Check out the document to see the web address of the original.

This is an abbreviated version of the PowerPoint presentation that accompanied the CDC's Sept 16, 2008 COCA Conference Call. For the full presentation, visit http://www.emergency.cdc.gov/coca/callinfo.asp (This version should not be used as a basis for making decisions about diagnosis or infection control.)‏

Changing Epidemiology and Prevention of Clostridium difficile Carolyn Gould, MD, MS Division of Healthcare Quality Promotion Clinician Outreach and Communication Activity September 16, 2008 The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention No Conflicts of Interest to Disclose

Prerequisites for CDI Advanced age Underlying illness CDI CDI due to recent (re)acquisition of C. difficile Incubation period unknown <7 days to several weeks? Antimicrobial exposure may or may not precede acquisition The two appear to be in proximity Antimicrobial therapy Disturbed colonic microflora Acquisition of toxigenic C. difficile Toxin A & Toxin B production

Advanced age

Underlying illness

CDI due to recent (re)acquisition of C. difficile

Incubation period unknown

<7 days to several weeks?

Antimicrobial exposure may or may not precede acquisition

The two appear to be in proximity

Changing Epidemiology of CDI Increasing incidence and severity Based on NNIS, national hospital discharge data, reports from healthcare systems, death certificate data Recent outbreaks of severe disease caused by epidemic strain of C. difficile with increased virulence, antibiotic resistance Although elderly are still most greatly affected, more disease reported in “low-risk” persons Healthy persons in community, peripartum women

Increasing incidence and severity

Based on NNIS, national hospital discharge data, reports from healthcare systems, death certificate data

Recent outbreaks of severe disease caused by epidemic strain of C. difficile with increased virulence, antibiotic resistance

Although elderly are still most greatly affected, more disease reported in “low-risk” persons

Healthy persons in community, peripartum women

Outcomes of CDI in Setting of Endemic Disease Dubberke ER, et al. Clin Infect Dis. 2008;46:497-504. Dubberke ER, et al. 17th Annual Meeting of The Society for Healthcare Epidemiology of America (SHEA), April 14-17, 2007; Baltimore, MD. Unpublished data. Excess costs $2,380 to $3,240 per index hospitalization $3,797 to $7,179 inpatient costs over 180 days of follow-up Other outcomes 2.8 days attributable excess length of stay 19.3% attributable readmission (180 days)‏ 5.7% attributable mortality (180 days)‏ More likely discharged to long-term care

Excess costs

$2,380 to $3,240 per index hospitalization

$3,797 to $7,179 inpatient costs over 180 days of follow-up

Other outcomes

2.8 days attributable excess length of stay

19.3% attributable readmission (180 days)‏

5.7% attributable mortality (180 days)‏

More likely discharged to long-term care

Current Epidemic Strain of C. difficile BI/NAP1/027, toxinotype III Historically uncommon, now epidemic Current strain more resistant to fluoroquinolones Carries extra toxin known as binary toxin Polymorphism in toxins A and B regulatory gene ( tcdC ) and increased toxin production in vitro

BI/NAP1/027, toxinotype III

Historically uncommon, now epidemic

Current strain more resistant to fluoroquinolones

Carries extra toxin known as binary toxin

Polymorphism in toxins A and B regulatory gene ( tcdC ) and increased toxin production in vitro

How important are asymptomatic carriers in transmission? Riggs MM et al. Clin Infect Dis 2007; 45:992–8

Rationale to consider extending isolation beyond duration of diarrhea Bobulsky GS et al. Clin Infect Dis 2008; 46:447–50

Environmental control: Effect of hypochlorite in highly endemic ward Mayfield JL. Clin Infect Dis 2000;31:995–1000

Novel Risk Factors, Washington University Prevention Epicenter (n=36,086)‏ CI=confidence interval; IV=intravenous; OR=odds ratio. Dubberke ER, et al. Clin Infect Dis. 2007;45:1543-1549. 0.5 (0.3–0.6)‏ Metronidazole 1.9 (1.3–2.7)‏ IV vancomycin, >7 days 2.5 (1.8–3.5)‏ Fluoroquinolones, >7 days 1.6 (1.3–2.1)‏ Proton pump inhibitors 2.0 (1.6–2.5)‏ Histamine-2 blockers Medications 4.0 (2.9–5.6)‏ >1.4 2.9 (2.1–4.2)‏ 0.3–1.4 Reference <0.03 C. difficile -associated disease pressure OR (95% CI)‏ Risk Factor by Multivariable Analysis

Quinolone Restriction Period Nimber of Defined Daily Doses 2005 2006 2007 Month and Year Impact that Restricting Fluoroquinolones can Have on Reducing Unnecessary Antimicrobial Use 0 500 1000 1500 2000 2500 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Aminoglycosides Cephalosporins (1st gen.)‏ Cephalosporins (2nd gen.)‏ Cephalosporins (3rd and 4th gen.)‏ Quinolones Vancomycin Piperacillin/Tazobactam Ampicillin/Sulbactam Azithromycin Carbapenems Aztreonam Clindamycin Kallen, et al. 18th Annual Meeting of The Society for Healthcare Epidemiology of America (SHEA), April 6, 2008; Orlando, FL.

Desperate Measures for Desperate Times: Restricting all Fluoroquinolones to End an Outbreak Kallen, et al. 18th Annual Meeting of The Society for Healthcare Epidemiology of America (SHEA), April 6, 2008; Orlando, FL. Number of Cases Month and Year Beginning of outbreak period Quinolone restriction New housekeeping company Quinolone restriction partially lifted 2004 2005 2006 2007

Hospitals should conduct surveillance for CDI Track positive laboratory results Consider measures to track outcomes Early diagnosis and treatment important for reducing severe outcomes and reducing transmission Strict infection control: CDC Fact Sheet* Contact precautions for CDI patients An environmental cleaning and disinfection strategy Hand-washing with CDI patients in outbreak Antimicrobial management Recommendations for Hospitals *See CDC C. difficile Fact Sheets: http://www.cdc.gov/ncidod/dhqp/ .

Hospitals should conduct surveillance for CDI

Track positive laboratory results

Consider measures to track outcomes

Early diagnosis and treatment important for reducing severe outcomes and reducing transmission

Strict infection control: CDC Fact Sheet*

Contact precautions for CDI patients

An environmental cleaning and disinfection strategy

Hand-washing with CDI patients in outbreak

Antimicrobial management

CDI in Previously Low-Risk Populations 10 Pregnant women 23 Generally healthy persons in the community Cases without precedent antimicrobial use Centers for Disease Control and Prevention. MMWR Morbid Mortal Wkly Rep . 2005;54:1201-1205.

10 Pregnant women

23 Generally healthy persons in the community

Cases without precedent antimicrobial use

Recommendations for Surveillance of Clostridium difficile Infection Admission Discharge < 4 weeks 4-12 weeks HO-HCFA CO-HCFA Indeterminate CA-CDI Time 48 h > 12 weeks * HO: Hospital (Healthcare) onset CO-HA: Community Onset Healthcare-associated CA: Community Associated * Depending upon whether patient was discharged within previous 4 weeks, CO-HA vs. CA CDAD Surveillance Working Group. Infect Control Hosp Epidemiol 2007; 28:140-145

Clostridium difficile Infection (CDI) cases N = 1046 Healthcare facility–onset Healthcare facility-associated (HO-HCFA)‏ N=584 (56%)‏ (Including 142 with onset in another HCF)‏ Community Onset **Excluded: Prisoner: 8 Out of State:20 Bone Marrow Transplant: 17 Hemodialysis:29 Community Onset Healthcare facility-associated (CO-HCFA ) Indeterminate Community Associated (CA) N= 462 (44%)‏ 40 (4%)‏ 94 (9%)‏ 208 (20%)‏ Unknown Excluded** 46 (4%)‏ 74 (7%)‏ Adapted from Kutty PK, et al. Infect Control Hosp Epidemiol. 2007;29:197-202.

ToxV (BK/NAP7-8/078) Strains; Historically Rare, Recently More Common Tox V Isolates 10/6000 10/600 6/125 Jhung MA, et al. Second International Clostridium difficile Symposium, June 6-9, 2007; Maribor, Slovenia. Jhung MA et al. Emerg Infect Dis 2008;14:1039-45 Time Prior to 2001 2001-2005 2006

Tox V Isolates

10/6000

10/600

6/125

Time

Prior to 2001

2001-2005

2006

Human CDAD Caused by Strains Similar to Animal Epidemic Strains, 2001–2006 Jhung MA, et al. Second International Clostridium difficile Symposium, June 6-9, 2007; Maribor, Slovenia. Source Binary toxin Toxino type tcdC deletion Human Human Human Pig Pig Pig Pig Pig Pig Pig Pig Human Human Human Human Hosp Env V V V V V V V V V V V V V V V V + + + + + + + + + + + + + + + + + 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp

Summary Rates, mortality, and costs associated with CDI continue to increase Much of this increase may be due to emergence and spread of BI/NAP1/027 Hospital rates can be controlled through tiered implementation of existing and enhanced recommendations Disease becoming more notable in previously low-risk populations Community-associated disease appears associated with variant toxinotypes Circumstantial evidence for animal-to-human transmission of toxinotype V strains

Rates, mortality, and costs associated with CDI continue to increase

Much of this increase may be due to emergence and spread of BI/NAP1/027

Hospital rates can be controlled through tiered implementation of existing and enhanced recommendations

Disease becoming more notable in previously low-risk populations

Community-associated disease appears associated with variant toxinotypes

Circumstantial evidence for animal-to-human transmission of toxinotype V strains

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