Clostridium difficile

Transcription

1 Clostridium difficile

2 C difficle

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4 Oral Metronidazole and Oral Vancomycin Promote Persistent Overgrowth of VRE during treatment of Clostridium difficile-associated Disease. (Al-Nassir, W.N. et al, 2008)

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6 Wet hands transport pathogens much more readily than dry hands OR hands not washed at all.

7 Residual moisture determines the level of bacterial and viral transfer to skin, food, and environmental surface. Need for an adequate supply of paper towels. Towels rough? Absorbent? (Marx, J.(2013 )FADONA)

8 Soap & Water vs. Gel for CDI OughtonM. ICAAC Meeting 2007 Abstract K-1376a

9 OUTBREAK One case of an infection that is highly communicable; Trends that are 10 percent higher than the historical rate of infection for the facility that may reflect an outbreak or seasonal variation and therefore warrant further investigation; or Occurrence of three or more cases of the same infection over a specified length of time on the same unit or other defined areas. (CMS, Interpretive Guideline, 2009)

10 CMS Requirements It is appropriate to use the least restrictive approach possible that adequately protects the resident and others

11 Transmission-based Precautions Maintained for as long as necessary to prevent the transmission of infection (CMS, Interpretive Guideline, 2009)

12 Maintaining isolation longer than necessary may adversely affect psychosocial well-being of residents Document in the medical record the rationale for the selected transmission-based precautions (CMS, Interpretive Guideance, 2009)

13 Role of Antibiotic Stewardship Not Treating Aymptomatic Bacturia Reduce C difficle Infections

14 Inservice +Verify Competence

15 Prevention Extend use of Contact Precautions beyond duration of diarrhea (e.g., 48 hours) Presumptive isolation for symptomatic patients pending confirmation of CDI Evaluate and optimize testing for CDI

16 Implement soap and water for hand hygiene before exiting room of a patient with CDI Implement universal glove use on units with high CDI rates Use sodium hypochlorite (bleach) or Sporocidal products agents for environmental cleaning with Correct Dilutions. (Competency Housekeeping?)

17 Intra-facility Transport Resident should perform hand hygiene prior to movement from their room. The transporter should remove and discard contaminated personal protective equipment (PPE) and perform hand hygiene prior to transporting patients on contact precautions.

18 Clean PPE should be available to use at the next destination to handle resident/patient The resident/patient s isolation status should be communicated to the receiving unit/therapy prior to transport In room therapy as needed.

19 Education Family and Residents Competition and Contests? Handwashing and Sanitizing Engage Activities and Rehabilitation Services and other Departments

20 Resident Door Signage

21 After removing PPE including gloves( Soap and Water Before eating After using bathroom Soiled with visible dirt, blood, moist or dry body fluids Contact with any patient with diarrhea Alcohol-based Product Entering/exiting patient occupied area Before moving between patients in same room Before putting on sterile gloves

22 Hand washing Wet hands with water, apply soap, rub hands together for 15 to 20 seconds. Rinse and dry with disposable towel. Use towel to turn off faucet.(doesn t have to be a clean towel) The entire procedure should take 40 to 60 Seconds

23 Areas of the Hands Most Frequently Missed Least frequently missed Less frequently missed Most frequently missed

24 Hand Rubs Apply to palm of one hand Rub hands together covering all surfaces until dry approx 15 sec. ***Except for when your hands are visibly dirty/contaminated.

25 McGeer Definitions Long term care published 1991 Updated and revised 2012 Accepted standardized definitions of infection Used for internal process improvement Not validated; expert opinion

26 Time period for infection (after day 2) New fever definitions Added leukocytosis to criteria Criteria for change in mental status Criteria for change in functional status UTI requires a positive urine culture Bloodstream infections and unexplained febrile episodes were deleted Expanded section on gastroenteritis

27 Creative Engagement of Staff

28 1. Hand Hygiene Competency Contest Involve Activities, Housekeeping, Bookkeeping in independent observations

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30 High Touch Cleaning Areas

31 2. High touch cleaning records in room

32 Root Cause Rates CDI/Unit

33 Process Guide 1. Has facility defined this as an outbreak? 2. If yes, have all staff been informed of mandatory handwashing? 3. Have you decided to cohort by organism? Roommate of patient with MDRO should be low acquisition risk. 4. Roommates (First patient with C diff and the other without C diff) Is the C diff patient using the toilet in the room and the non- C diff using the commode? 5. ** Was initial stool specimen taken and immediately refrigerated for lab pick-up? Did the stool take the shape of container? Watery and loose?? Staff informed of no re-culture after ABT therapy required.

34 6. Single use equipment in room or designated C diff only. Leave in room; glucometer, BP, disposable thermometer, extra PPE. 7. Have you contacted CSR and Environmental Services about need for specific cleaning protocol for room? Specific directional cleaning. What is most dirty in the room? Clean floor toward this area. Hall is clean, bed and toilet are dirty. 8. Transport out of room necessary? Use a containment sheet with flowers? 9. Do staff have a donning and doffing competency completed within last 6 months?

35 10. Has a Nurse verified competence in the use of Alcohol Sanitizer and in Handwashing within the last 6 months? 11. Do nurses practice High Touch Environmental in room cleaning. 12. Have you initiated Terminal Cleaning of room to include cubicles and curtains, walls, all surfaces and floors. 13. Consider wearing gloves at all times in outbreak and non-outbreak situations with hand hygiene after removal. (Removal to prevent spore dispersal).

36 ROOM CONTAMINATION?? Prior room occupant with CDI is a significant risk factor for CDI acquisition, independent of established CDI risk factors. ***Regardless of advanced age, underlying illness, immunosuppression, and other risk factors, that being placed in a room previously occupied by someone who had a CDI infection increased the new patients risk of getting CDI by 110%.

37 Bedside table handle Light/lamp knob Chair Room sink Room light switch Room inner door knob Environmental High Touch Cleaning Bed rails / controls Tray table IV pole (grab area) Call box / button Telephone TV Remote

38 Bathroom light switch Environmental High Touch Bathroom handrails by toilet Bathroom sink Toilet seat Toilet flush handle Wheelchair Gerichair/ other equipment

39 Al-Nassir, W. N., Sethi, A. K., Li, Y., Pultz, Y., Riggs, M.,& Donskey, C. (2008) Both oral Metronidazole and oral Vancomycin promote persistent overgrowth of Vancomycin- Resistant Enterococci during treatment of Clostridium difficile-associated Disease Antimicrobial Agents and Chemotherapy. pp Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) (2013) Guide to preventing Clostridium difficile infections. Author:Washington: DC Marx, J. (2013,April). Are You Prepared To Lead An Effective Infection Prevention Program In 2013 And Beyond? Presentation at the FADONA conference, Daytona Beach, Florida. Shaughnessy, M. K., Micielli, L. R., DePestel, D. D., Arndt, J., Strachan, K. L., Welch, K. B., & Chenoweth, C. B (2011). Evaluation of hospital room assignment and acquisition of Clostridium difficile infection. Infection Control and Hospital Epidemiology, 32, Stone, N. D, Ashraf, M. S., Calder, J., Crnich, C. J., Crossley, K., Drinka, P. J., Society for Healthcare Epidemiology Long-Term Care Special Interest Group (2012). Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infection Control and Hospital Epidemiology, 33, doi: /667743