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1 Thank You for Joining! Session 5 Prevention and Management of C. difficile and Other Healthcare Associated Infections Webinar Will Begin Shortly. Call-In Number: (888) Access Code:

2 How to Get an A+ on Your Report Card Prevention and Management of C. difficile and Other Healthcare Associated Infections Shira Doron, MD and Kirthana Beaulac, PharmD

3 3 Polling Question 1 With respect to antimicrobial stewardship, I feel that my facility: A. Has a program in place B. Has a feasible plan to implement a program C. Has little if any program or plan

4 Objectives Understand the current landscape of NHSN (CDC) tracking and reporting Evaluate antimicrobial stewardship strategies for preventing C. difficile Identify interventions to avoid and treat other resistant healthcare-associated infections

5 The National Healthcare Safety Network CDC s healthcare-associated infection tracking system Collects and feeds back data to facilities, states, regions and the nation It s goals: Identify infection prevention problems Benchmark progress of infection prevention efforts Drive progress toward elimination of HAIs

6 NHSN reporting and long term care Currently a voluntary pilot project Expected to become mandatory in the not-too-distant future (probably starting with CDI) Quality measures: CDI, MRSA, UTI, HCP influenza vaccination, hand hygiene, gown/glove compliance, HCP blood/body fluid exposure In Massachusetts, currently there are 62 LTCFs that are enrolled and not quite all of these are entering data into NHSN One facility is entering staff influenza vaccination data DPH goal is to enroll an additional 50 LTCFs this year for CDI data entry

7 Requirements for Submitting Number of positive LabID Events An unformed/loose stool that tests positive for C. difficile toxin A and/or B, (includes molecular assays [PCR] and/or toxin assays) OR A toxin-producing C. difficile organism detected in an unformed/loose stool sample by culture or other laboratory means Each positive should be recorded on the Laboratory-identified MDRO or CDI Event for LTCF Form (CDC ) Blank form: ww.cdc.gov/nhsn/forms/57.138_labidevent_ltcf_blank.pdf Form instructions: Denominator information should include number of resident admissions, number of resident-days, and number of admissions on C. difficile treatment

8 Attributable Categorization NHSN will further categorize CDI LabID Events based on date of current admission to the facility and date of specimen collection Community-onset (CO) LabID Event: Date specimen collected 3 calendar days after current admission to the facility (i.e., days 1, 2, or 3 of admission) Long-term Care Facility-onset (LO) LabID Event :Date specimen collected > 3 calendar days after current admission to the facility (i.e., on or after day 4) Acute Care Transfer-Long-term Care Facility-onset (ACT-LO): LTCFonset (LO) LabID event with specimen collection date 4 weeks following date of last transfer from an Acute Care Facility (hospital, long-term acute care hospital, or acute inpatient rehabilitation facility only) Both Community-Onset and LTCF-Onset LabID Events must be submitted to the NHSN

9 More Information NHSN LTCF website: NHSN LTCF Surveillance for C. difficile, MRSA, and other Drug-resistant Infections website: Training Protocols Data collection forms Tables of instructions for completing all forms Key terms

10 NHSN reports

11 NHSN reports Number of expected infections

12 NHSN reports Number of actual infections

13 NHSN reports Standardized infection ratio (risk adjusted)

14 NHSN reports Default goal is HHS goal of 30% improvement (you can set your own)

15 NHSN reports Your facility s secret number

16 NHSN reports Your facility s rank (with 1 being the worst)

17 NHSN reports Cumulative attributable difference (# of infections needed to avoid to be at goal)

18 NHSN reports Statistically significant?

19 This Sounds Horrible! Why would anyone voluntarily report CDI? Allows benchmarking internally and with other facilities Forces evaluation of current practice and action plans Will eventually be required More historical data = better ability to use the system and accurately risk adjust

20 20 Polling Question 2 The CDC currently collects information about C. difficile, MRSA, and device-related infection rates from acute care hospitals through the NHSN and benchmarks performance. CDI data reporting for long term care is currently in a voluntary pilot phase. Which of the following elements do you think it would be feasible for your facility to report to the CDC database? (Check all that apply) a) C. difficile rate b) UTI rate c) Hand Hygiene compliance rate d) Gowning and gloving compliance rate e) MRSA acquisition rate f) None of these

21 Clostridium difficile infection (CDI) prevention and management

22 CDI risk Antibiotic exposure (susceptible host) Organism exposure (fecal-oral route)

23 Antibiotics Cause C. difficile Rupnik M, Wilcox M, Gerding DN. Nature Reviews Microbiol. 2009; 7:

24 Antibiotic Use Is a Key Cause of C. difficile Dingle KE, Didelot X, Quan TP, et al. Lancet Inf Dis. 2017; 17(4):

25 Brown KA, Khanafer N, Daneman N, Fisman DN. Antimicrob Agents Chemother. 2013; 57(5):

26 26 Oral Vancomycin Impact on Gut Flora Vancomycin decreases both the colony count of gut bacteria (OTUs), but also the diversity (Shannon index) Isaac S, Scher JU, Djukovic A, et al. J Antimicrob Chemother. 2017; 72(1):

27 Other factors that increase the risk of CDI: patient related Advanced age Intestinal surgery Obesity Inflammatory bowel disease Chemotherapy/stem cell transplantation Gastric acid suppression (Proton pump inhibitors and H2 blockers)

28 PPIs Increase Risk and Severity of CDI Lewis PO, et al. Pharmacotherapy. 2016; 36(9):

29 PPI Stewardship Contributes to Antibiotic Stewardship Kandel CE, Gill S, McCready J, et al. BMC Infect Dis. 2016; 16:355.

30 Other factors that increase the risk of CDI: environmental Poor hand hygiene Adequacy of room cleaning Prior patient in room received antibiotics

31 Risk of CDI according to receipt of antibiotics by prior bed occupant Freedberg et al. JAMA Intern Med. 2016;176(12):

32 Probiotics Living microorganisms which upon ingestion in certain numbers exert health benefits beyond inherent general nutrition

33 Can probiotics help prevent C. diff from developing in patients taking antibiotics? Cochrane systematic review 2013: 1871 studies, 31 met criteria to be included, 4492 subjects Probiotics reduced risk of C. diff associated diarrhea by 64% (2% in probiotic group versus 5.5% in placebo/no treatment group) Goldenberg et al. Cochrane Database of Systematic Reviews 2013, Issue 5.

34 Authors conclusions: Based on this systematic review and meta-analysis of 23 randomized controlled trials including 4213 patients, moderate quality evidence suggests that probiotics are both safe and effective for preventing Clostridium difficile-associated diarrhea.

35 Caveat: each probiotic strain behaves differently. One cannot extrapolate results from a study using one strain to the efficacy of another.

36 Probiotics The most well studied probiotics are Lactobacillus GG and Saccharomyces boulardii Adverse events have been seen Bacteremia, endocarditis, liver abscess

37 CDI diagnosis

38 Cdiff PCR testing PCR test

39 Cdiff PCR testing Patients who have positive PCR only may have colonization rather than infection Treat only if: Patient has true diarrhea (sample conforms to shape of container) Clinically significant diarrhea (>3 loose stools in 24 hours) unless ileus Diarrhea is a change from baseline Diarrhea cannot be explained by other causes (e.g. laxatives, tube feeds, lactulose) Remember, antibiotics for CDI can increase the risk of CDI Do not do test of cure!

40 40 Polling Question 3 Which of the following strategies is your facility using to minimize the risk of C. difficile acquisition in your residents? (Check all that apply) a) Antimicrobial Stewardship b) Enhanced cleaning of rooms housing residents with C. difficile c) Enhanced cleaning of beds/mattresses used by residents with C. difficile d) Contact precautions upon entering rooms of residents with C. difficile e) Private rooms for residents with C. difficile f) Bedside commodes (prohibited use of toilets) for residents with C. difficile g) Residents with C. difficile use gowns and/or gloves when leaving their rooms h) Routine use of probiotics in all or certain residents (e.g. those receiving antibiotics) i) Prophylaxis against C. difficile using oral vancomycin for certain residents (e.g. those receiving antibiotics who have a history of C. difficile ) j) Prolonged (more than 10 days) C. difficile treatment regimens k) None of these

41 Prevention and management of transmission of other healthcare associated infections

42 UTI Event Monitoring To calculate rates of UTI events among all residents in a facility Non-catheter associated UTI rates will be calculated among all residents without a catheter in the facility Catheter-associated UTI rates will be calculated among only those residents with indwelling urinary catheters To identify which residents get UTIs Events related to urinary catheters Organisms cause UTIs in a facility Based on McGeer s Criteria To monitor antibiotic use for UTIs To assess the impact of efforts to prevent UTI over time

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44 Lack of Symptoms Patients with asymptomatic bacteriuria should not be included Patients with asymptomatic bateremic UTI should be counted No signs or symptoms localizing to the urinary tract Blood cultures and urine cultures growing matching organisms Does not matter whether or not patient has a catheter

45 Altered Mental Status Altered mental status as the sole symptom will not count as a UTI

46 How Will This Help? By adding a metric to the diagnosis of UTI, prescribers will think more critically upon diagnosis Decrease number of urine cultures sent Decrease number of antibiotics started Decrease resistance and CDI

47 Don t Treat Colonization

48 48 Use of Isolation Precautions Standard Precautions All blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents Hand hygiene after touching blood, body fluids, secretions, or excretions Gloves, Gown, or Mask depending on contact and risk Contact Precautions Excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission Generally recommended for patients with MDROs Wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient s environment Droplet Precautions Prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions Special air handling and ventilation is not needed Healthcare personnel wear a mask (a respirator is not necessary) for close contact with infectious patient Airborne Precautions Precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air Requires special air handling (at least 12 air exchanges per hour) or at least use of a N95 respirator or mask when in public Healthcare workers should wear mask or respirator

49 49 Appropriate Isolation Full Guideline:

50 Appropriate Sequence of Gowning and Gloving 50

51 51 Weighing the Balance Dashiell-Earp CN, Bell DS, Ang AO, Uslan DZ. JAMA Intern Med. 2014; 174(5):

52 Use of Appropriate Precautions 52

53 53 Decolonization Patients who are colonized with MDROs may be decolonized Decolonization may include Intranasal mupirocin Antiseptic or antimicrobial bathing Oral antibiotics Gastric lavages with antimicrobials May be useful in an outbreak setting or pre-procedure Benefit is not durable, not good as management strategy Re-exposure from environment Recolonizatoin Antiseptic resistance

54 54 Summary There are reportable metrics that will be required for LTCFs in the near future CDI will be the first one Others will likely follow soon after It is a challenging but worthy battle to limit transmission of organisms between nursing home residents Antimicrobial Stewardship is a key piece of preventing transmission of multi-drug resistant organisms, in addition to other strategies

55 55 Polling Question 4 I feel that the strategies discussed in today s webinar are largely: A. Feasible in my facility B. Not feasible in my facility C. Already being used in my facility

56 Contact your Nursing Home CDI/ NHSN Initiative State Contacts Connecticut Cynthia Hayle Maine Danielle Watford Massachusetts Sarah Dereniuk New Hampshire Pamela Heckman Rhode Island Janet Robinson Vermont Gail Harbour This material was prepared by the New England QIN-QIO, the Medicare Quality Innovation Network-Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMSQINC

57 The NE QIN-QIO Outpatient Antibiotic Stewardship Collaborative No-cost opportunity for antibiotic stewardship support in physician offices and other outpatient settings Continues through at least July 2019 but limited time to sign up Includes: Resources and tools for patients and providers Webinars and direct assistance as desired Opportunities to connect with peers and highlight best practices 57

58 Interested in the NE QIN-QIO Antibiotic Stewardship Collaborative? Contact us... Connecticut Carol Dietz New Hampshire Margaret Crowley Massachusetts Alyssa DaCunha ext.3241 Rhode Island Maureen Marsella Maine Amanda Gagnon Vermont Regina-Anne Cooper Questions regarding CE status may be submitted to Ileizy Victor at 58

59 Connect with the New England QIN-QIO on Social Media! 59

60 Evaluation This material was prepared by the New England QIN-QIO, the Medicare Quality Innovation Network-Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMSMA_C2_062217_