antibiotic stewardship and the relationship to c.difficile resources/april 2016/pdf...
TRANSCRIPT
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Antibiotic Stewardship and the Relationship to
C.Difficile
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CDCs Core Elements of Hospital Antibiotic Stewardship Programs
Leadership Support
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CDCs Core Elements of Hospital Antibiotic Stewardship Programs
Accountability
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CDCs Core Elements of Hospital Antibiotic Stewardship Programs
Drug Expertise
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CDCs Core Elements of Hospital Antibiotic Stewardship Programs
Actions to Support Optimal Antibiotic Use
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CDCs Core Elements of Hospital Antibiotic Stewardship Programs
Tracking: Monitoring Antibiotic Prescribing, Use and Resistance
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CDCs Core Elements of Hospital Antibiotic Stewardship Programs
Reporting Information to Staff on Improving Antibiotic Use and
Resistance
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CDCs Core Elements of Hospital Antibiotic Stewardship Programs
Education
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Clostridium difficile
C
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Clostridium difficile Colonization vs. Clostridium difficile Infection
Clostridium difficile colonization patient exhibits NO clinical symptoms patient tests positive for Clostridium difficile organism
and/or its toxin more common than Clostridium difficile infection Clostridium difficile infection patient exhibits clinical symptoms patient tests positive for the Clostridium difficile organism
and/or its toxin
http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html
http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html
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Patients at Greatest Risk for CDI
The risk for CDI increases in patients with:
Antibiotic exposure
Proton pump inhibitors
Gastrointestinal surgery/manipulation
Long length of stay in healthcare settings
A serious underlying illness
Immunocompromising conditions
Advanced age http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html#a4
http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html#a4http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html#a4http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html#a4
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Proper Use of Handwashing and PPE
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Proper Use of Handwashing and PPE
http://www.safecarecampaign.org/cdifficile.html
http://www.bing.com/videos/search?q=understanding+CDiff+video&view=deta
il&mid=F37443F6DF9F6A93E2ADF37443F6DF9F6A93E2AD&FORM=VIRE
http://www.safecarecampaign.org/cdifficile.htmlhttp://www.safecarecampaign.org/cdifficile.htmlhttp://www.bing.com/videos/search?q=understanding+CDiff+video&view=detail&mid=F37443F6DF9F6A93E2ADF37443F6DF9F6A93E2AD&FORM=VIREhttp://www.bing.com/videos/search?q=understanding+CDiff+video&view=detail&mid=F37443F6DF9F6A93E2ADF37443F6DF9F6A93E2AD&FORM=VIREhttp://www.bing.com/videos/search?q=understanding+CDiff+video&view=detail&mid=F37443F6DF9F6A93E2ADF37443F6DF9F6A93E2AD&FORM=VIRE
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Appropriateness of Diagnostic Testing
Testing procedures at your facility
Who has authorization to send specimen?
What type of tracking is in place to insure appropriate stool testing for CDI?
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Staff Education/Competencies
Mechanism in place to determine staff training related to CDI, isolation, PPE?
What does that look like at your facility?
At what point does education and re-education occur?
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Proper Environmental Cleaning
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CDI Team Composition
Do you have a CDI team in place at your institution?
Is it a multi-disciplinary team?
Which departments are represented?
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Patient and Family Education
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Patient and Family Education
http://www.safecarecampaign.org/cdifficile.html
http://www.safecarecampaign.org/cdifficile.html
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Discharge from the Hospital Communication of diagnosis is key
whether unit to unit or facility to agency/facility
Testing for cure?
Treatment plans
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Environmental Cleaning
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C difficile and Environmental Service Case #1
Name: WG Admission: 12/10 HPI: 66yoF initially admitted for encephalopathy d/t CVA vs SNS infection vs sepsis. D/t
pacemaker no MRI. Patient received 48hours of meningitis combo 12/14-12/16 12/17 started empiric high dose steroids for empiric treatment of possibility of
autoimmune CNS vasculitis, initially patient improved 12/20 condition worsened, was found to have a large L-sided retroperitoneal hematoma
(in Coumadin INR 4.1), not a surgical candidate, ->hemorrhagic shock-> on 4 pressors and continued to be hypotensive
PMH: (1) COPD Acute and chronic respiratory failure with hypercapnia (2) Pseudomonas pneumonia
(3) Clostridium difficile diarrhea (4) Atrial fibrillation, chronic (5) Toxic metabolic encephalopathy (6) Chronic systolic CHF (congestive heart failure) (7) On mechanically assisted ventilation for which she ultimately required tracheostomy with subsequent decannulation (8) Acute renal failure superimposed on stage 3 chronic kidney disease (9) Pulmonary hypertension assoc with unclear multi-factorial mechanisms (10) CAD (coronary artery disease)
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C difficile and Environmental Service cont.
Cultures: all no growth, viral panel negative Antibiotics:
acyclovir 555mg Q 12H 12/14-12/16 ampicillin 2gQ4 hours 12/14-12/16 cefepime 2gQ12 hours 12/14-12/16 vancomycin 12/12-12/16
Laxatives: docusate 100mg BID 12/14-12/15 Bowel Movement: 12/10-12/14 No symptoms, 12/15 (liquid brown Q3-6h)
12/16 (green liq Q1-2h)12/17 (liq brown Q3-6h, then 1-2h) 12/18 no GI sxs, 12/19-12/20 (liq brown Q 1-2 h, bloating)
12/20 diagnosed with C diff Initial assessment: She had C diff Hx, received antibitics,
very poor prognosis, very complicated patient...
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C difficile and Environmental Service Case #2
Name: JM Admission: 12/9 HPI:
12/9 The patient is a 79-year-old female who was admitted on for AMS change and malignant hypertension. She was initially treated with anti-hypertensives in the ER and then had severe hypotension requiring ICU transfer and epinephrine. She was also found to have Escherichia coli urinary tract infection, pan-sensitive was treated with ceftriaxone x3 days.
PMH: HTN, DM, hyperlipidemia, diabetic neuropathy, anxiety Antibiotics:
Ceftriaxone 6/15-6/18
Laxatives: none Bowell Movement: 12/12: per note: at 1800 pt had one large
loose stool 12/21: 4 loose stools, pt remained hypotensive 12/21 Diagnosed with C diff
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C difficile and Environmental Service Case #3
Name JP Admission 12/15 PMH: cancer with metastasis to liver, chronic non-ischemic cardiomyopathy,
ejection fraction of 30 percent per record, osteoarthritis, hypertension, rosacea, history of peptic ulcer disease
HPI: 12/15 admitted to Maury Regional Medical Center per cardiology for worsening of bilateral lower extremity edema and social displacement concerns due to being bedridden and unable to care for herself. Was found to have a upper extremity DVT.
Bowel Movement: 12/16 no mention of any of GI sxs or diarrhea in progress notes. 12/17 (soft formed Q3-6h), 12/18 (soft x3) 5/30(soft brown x9), 12/19 (soft brown 6), 12/20(soft brown 9), 12/21(soft liquid 8), 12/22 (soft liq 2)
Medications: No antibiotics Laxatives: Docusate/senna PRN not given
12/22 C diff positive
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C difficile and Environmental Service
Problem: 3 cases of C diff happened with 48 hours of each other 2/3 patients received short antibiotic courses x48-72 hours, all for
appropriate indications. 1 patient had no antibiotics. WG had a Hx of C diff, JM and JP were located on the same floor. Even though WG and JM received antibiotics it was felt that there
was more to this then just antibiotic associate C diff, especially after JP, patient who did not receive any antibiotics was diagnosed.
Suspected horizontal spread. After in depth review, it was found that the patents did not share physicians, RNs, therapists, or dietary workers. The positive finding was possibly cleaning personnel.
Action Taken: Cleaning procedures updated, training provided to environmental workers, especially recently hired employees.
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Proper Diagnostics
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Proper Diagnosis Name BB
Admission 12/17
PMH: DM, CAD, obese, schizophrenia, bipolar disorder, recent hospitalization for A fib.
HPI: 12/17 - 51 yo F initially admitted to floor for HCAP treated with azithro/piptazo-> got worse -> 12/19 transferred to ICU with septic shock, intubated, re-cultured, PCR done-> 12/23 cxc NGx2 and PCR (+) for Human Metapneumovirus antibiotics discontinued
CXC:
12/17 Blood NGx5
12/19 BAL NGx2
12/19 PCR + for Human Metapneumovirus
ABX:
piperacillin/tazobactam 12/17-12/20
vancomycin 12/19-12/20
azithromycin 12/17-12/20
Laxatives:
docusate BID 12/19-12/30
Bowel description: 12/16-12/17 (nothing), 12/18 (constipation No BM), 12/19 -12/20 (No BM), 12/21 (soft brown large #3), 12/22-12/30 (Brown, liquid Q1-2hrs->continuous), 12/31(soft brown Q3-6H), 1/1-1/3 (soft brown Q7-12H)
1/1 C diff ordered - positive
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Proper Diagnosis
Problem: Diarrhea was most likely caused by scheduled
laxatives, not C diff. Patient was likely colonized. Diarrhea resolved after laxatives were
discontinued. However, since the test was ordered and patient was diagnosed with C diff he had to be treated and the incident recorded as hospital acquired C diff.
Action Taken: After several repeated cases, nursing order for C diff was removed. Presently, C diff has to be ordered by an MD.
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Antibiotic Stewardship
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C difficile and Antibiotic Stewardship
Name: DN Admission: Date 9/8/14 Diagnosis: Community Acquired Pneumonia PMH: CHF, pace maker, HTN, CVA, CAD, A fib, no risk factors for resistant pathogens SH: lives at home Antibiotics:
Piperazillin/ tazobactam 9/8-9/15 levofloxacin 9/8-9/15 vancomycin 9/11-9/15 linezolid 9/8-9/11
Culture data:
9/8 Sputum norm flora 9/8 Blood NGx5
9/14 Patient started having diarrhea 9/15 C diff positive
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C difficile and Antibiotic Stewardship
Problem: Inappropriate antibiotics were used. Too many, too broad, not deescalated
Action taken: Antibiotic Stewardship Implemented. Leadership support Accountability Drug Expertise Action to support optimal antibiotic use Tracking antibiotic use Reporting Educaiton
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A Patients Story
http://www.bing.com/videos/search?q=c+diff+patient+experience+videos&qpvt=c+diff+patient+experience+videos&view=detail&mid=8B705EE069564D0116C58B705EE069564D0116C5&FORM=VRDGAR
http://www.bing.com/videos/search?q=c+diff+patient+experience+videos&qpvt=c+diff+patient+experience+videos&view=detail&mid=8B705EE069564D0116C58B705EE069564D0116C5&FORM=VRDGARhttp://www.bing.com/videos/search?q=c+diff+patient+experience+videos&qpvt=c+diff+patient+experience+videos&view=detail&mid=8B705EE069564D0116C58B705EE069564D0116C5&FORM=VRDGARhttp://www.bing.com/videos/search?q=c+diff+patient+experience+videos&qpvt=c+diff+patient+experience+videos&view=detail&mid=8B705EE069564D0116C58B705EE069564D0116C5&FORM=VRDGAR
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Wrap-up and Questions