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Doctor, consultant, microbiologist. Um so today, um hopefully you can see full screen here. Today. We're gonna talk about c difficile infection, a deadly health care associated infection. So we'll run through. What is C diff, who's at risk? Why does it happen? How you can help reduce the risk? The Southern trust perspective, look at the outbreaks and what's on the horizon. So, Clostridia difficile is a gram positives, anaerobic bacteria that be can be found in the gut and when it starts to produce toxin, this leads to the symptoms of abdominal pain, diarrhea, temperatures, colitis, dehydration, kidney failure, and in severe cases, toxic megacolon sepsis and death. C difficile infection is defined um in Europe as one episode of diarrhea, either defined as stool loose enough to take the shape of the container or Bristol stool charts type 5 to 7, that's not attributable to another cause. And it happens at the same time as a toxin positive test or where you don't have a test where there's endoscopic evidence of pseudomembranous colitis and no patient should be harmed by their health care. And C diff is a healthcare associated infection that causes significant morbidity and mortality and outbreaks amongst hospitalized patients. So on an individual patient level, it's bad for the care experience. It ranges from unpleasant to disabling, deadly diarrhea. On a population level, it's not good either with increased length of stays and increased costs to the health care system. The CDC recognizes C diff as one of the top five urgent antibiotic resistance threats worldwide and that's resistance not only to the antibiotics that you use to treat CD, but also to non CD antibiotics, which leads to the emergence of novel strains that are more virulent with more multidrug resistance and different types of resistance have been found throughout the world in Israel, Texas and the US. Um thankfully in Europe, most of our strains, 96.8% remain susceptible to Vancomycin. 100% susceptible to fida. But metroNIDAZOLE is no longer recommended as treatment because resistance rates are just too high. CDI can be thought of as a zoonosis. And there is documented spread from animals into humans through the environment and food. And there are reservoirs found in the natural environment, soil water and whole genome sequencing has evidenced bidirectional spread between pigs and farmers. And it's further driven by antibiotic use, particularly tetracycline in animal husbandry who is at risk. So um anyone can get CDI. Um those most at risk are the older patients over 65. The average age for us in the Southern Trust is 72. Um recent antibiotic treatment. So, one of the main points from today is CDI happens almost exclusively in patients that have had antibiotics in the past three months. So if we don't give antibiotics, we will see a lot less CDI. Recent healthcare contact is also a risk comorbidities, frailty, immunosuppression, chemotherapy G I surgery patients taking PPIs um inflammatory bowel disease. Those with a history of CD and females are more susceptible due to alterations in the microbiota. And that's what we see in the Southern Trust with 58% being female. So why does it happen? Well, we know c difficile is present in the gut of 5% of the population, the general population that increases to about 20% in hospitalized patients and up to 70% of infants. So you get CDI in two ways, either you have interruption of the normal complement of boil flora, usually from antibiotic exposure, which selectively promotes the C difficile already in the gut and you get CDI or you don't have CDI in your gut already and you acquire it from someone else via the feca oral route, either directly or through a contaminated intermediate person or the contaminated environment, um or contaminated equipment in that environment. Um The environment and the people in it, the equipment in it gets heavily contaminated as a result of the c difficile spores being expelled conveniently and heavily by the diarrheal symptoms it causes. So a large amount of liquid stools and fecal incontinence. That's a very effective way for c difficile to spread itself. You'll find heavy contamination on floors, toilets, sinks, commodes, curtains, surfaces, beds, clothing and hands and these spores can survive for months to years unless removed by aid cleaning with a spor product. Unfortunately, once a patient has CDI, once, um, they're at 20% chance of getting it again and that further increases following a second episode to between 45 to 60%. And with each episode, their chance of recurrence increases again. So what can you do to help reduce the risk? So the number one thing and the number one take home message is reduce antibiotic use. People will not get C uh D I in the same um way if we weren't using antibiotics in the Southern Trust, 22% of the patients with CDI had six or more courses of antibiotics in the previous three months. And that really is quite startling numbers. The most frequent antibiotic is tazo. Now, sometimes people need antibiotics. They have an infection that requires an antibiotic. But the message here is if you're going to give IV antibiotics to a patient, you must take blood cultures and other relevant samples before starting them. And you want to choose the narrowest spectrum agent for the shortest duration that's appropriate and discuss with microbiology as required. The second thing we can do is reduce the environmental presence of C diff. So that includes promptly isolating patients with diarrhea ideally within two hours. This is happening 63% of the time in the Southern Trust. And secondly, early sampling of diarrhea. So this is happening um 62% of the time in the Southern Trust. Uh Another important point here is that toxin negative patients are equally likely as toxin positives patients to transmit C diff. So all the IPC measures are the same. However, toxin negative patients are usually described as carriers and don't require active treatment. We know the Southern Trust has um is an old estate. We don't have the number of side dreams that we would like to isolate all the patients. And this is probably more from a nursing and patient perspective. But where side dream is not available for a patient who needs one a day should be completed because that's the way that it's formally fed back into the department of health that the estate isn't fit for purpose. The next thing you can do is suspect CDC D and you can use this site pneumonic. So um this means suspect if you have a patient with diarrhea with no um known cause isolate them in a single side room. G is for gloves and aprons for all contact with the patient and their environment. H for hand washing with soap and water for, for the patient themselves as well as the healthcare worker. Because alcohol gel does not kill CD spores and T is for test, send a stool to microbiology Now, in severe cases of CDI, um it can present in the absence of any bile motions um due to IES and toxic megacolon. So where you can't actually get a stool sample because the patient is so severe, you need to consider diagnostic imaging to help you with that. Number four, what you can do is consider empirical treatment. So when you spec CDI um consider starting the CD treatment and then reviewing when the result of the stool is back. Um CD treatment is a critical medicine and it should be started within two hours with no missed doses. This is happening in the Southern trust 66% of the time. The main treatment which is oral vancomycin, sometimes patients can't take oral. So other routes should be utilized. Um G peg or intraco nic IV administration is not effective for CD. So when you get your result back, um you'll get one of either of these results. So PCR negative toxin negative, this means there's no lab evidence of CDI PCR positive toxin negative. So this means that um there's C diff CD carriage but the toxin protein is not detected. Um So this doesn't usually require treatment, but with any test, you can get false negatives. So if there's a high clinical suspicion of C diff you might want to continue empathic therapy until you get a second sample. Result back. If you're getting multiple toxin negative samples, it's unlikely that the patient has C diff infection and you should consider other causes for their diarrhea. The PCR positive toxin positive, this is toxic c diff infection. The toxin protein is detected and the patient must be treated as per the trust guidelines. So whenever you're considering treatment, you first need to establish if this is the first or subsequent episode of CDI need to establish the severity. And we'll come on to a table to show you how to work out how severe it is. Need to review any prescription, uh antibiotic prescriptions, the patient is on and stop them unless they're essential. If you think they need continued, I would highly suggest discussing with microbiology to help you pick the Naro spec agent for the shortest duration. Review. The need to conti to continue any PPI the patient is on stop any antimotility or prokinetic agents. Think about medications the patients on that will cause problems if they're dehydrated, such as nsaids Ace inhibitors diuretics. Um I've said already about utilizing other routes when oral is not available. Um and you want to be keeping a close eye on their stool chart, their fluid balance, their electrolytes. And um they should be referred to the dietician when a patient is treated, you should notice improvement by day seven and please speak to us if they don't improve or worsen significantly at, at any point. So this is your severity assessment. So mild would be someone with a normal white cell count and less than three stools per day. Moderate would be a raised white cell count but still below 15 with 3 to 5 stools per day, severe would be a white cell count over 15 or a serum creatinine rise over 50% above the baseline or a temperature above 38 5 or evidence of severe colitis on examination or radiologically, life-threatening signs that you should really be worried about and looking out for hypotension, ileus, toxic megacolon and ct evidence of severe disease. So the treatment then if it's the first episode, it's your oral vancomycin for 10 days. Like I've already said IV, vancomycin is not effective, but the IV preparation can be given orally for a second episode. It's the Doxycin for 10 days for a third or subsequent uh episode and speak to the microbiologist. So um as per nice guidance, these patients should be considered for fecal microbiota transplant and they're not always available, not available in, in real time. So talk that through with us. Um The only time you wouldn't do the treatment of 1st, 2nd or third is where there's lifethreatening. So, lifethreatening epi any episode number, you want to give high dose oral vancomycin plus IV Metronidazol, it's important to note if the patient has ile S. So if you were giving orals, it wouldn't actually get to the colon, you need to give the Vancomycin via rectal installation. And there's guidelines on how to do that on the uh internet, they also need an urgent urgent surgical review and a lactate because sometimes colectomy is required and it's better done before the lactate is above five. Ivig used to be in the guidance. It's no longer recommended for C diff in terms of reporting, all cases should have a data completed. Um pr stands for postinfection review. So uh cases that lead to death or colectomy, there is a trust uh governance around doing a post infection review to look at everything that went on with that case. There are also um trigger points for discussion um of a death or CDI has occurred um in the M and M. So the consultant reviews the case and presents at M and M and if there's any issues arising, they're forwarded from the chair of the M and M to the medical director and also all toxin positive cases are reported to the PH A and on to the Department of Health. It's really important to have good care documentation around the CD diagnosis and it should be reviewed daily as a diagnosis on its own right. So most patients are in hospital for another reason and they acquired developed C diff but the C diff needs considered daily. And the medical daily assessment sheet is meant to be a helpful way to remind you what to look at. And it also includes a section to say that the patient has been informed. There's also um things uh for the nurses to complete the initial checklist and car bundle. So the southern trust perspective then um we have had 79 toxin positive cases since April 2023. So these are counted kind of in financial years, 54 of these have been healthcare associated. So that is the person was in hospital for more than 48 hours or they were an inpatient for more than 48 hours in the preceding 12 weeks, 15 patients had more than one episode. So 15 patients accounted for more than one of these numbers. In the 79 11% of the patients died within 30 days. This is split um per month. So cases per month, this was refreshed on the fourth of October. So that's why October looks quite low whenever we looked closer at the numbers. So we break down the numbers um to the place they're attributed to. So the place they were in for the previous 48 hours or for more than 48 hours in the previous 12 weeks. So most of them are still attributed to the community. Um But secondly, they're attributed then to medicine as a whole and surgery and going deeper into that data when you break it down per ward, most cases um attributed to One South followed by Neil medical and female medical in Daisy Hill, remove ward three. and so on, this is the same broken down for surgery. So most cases attributed to four North and second to trauma and then female surgical ward in the Southern Trust, we use uh the definition of a period of increased incidence. So this is where you have two cases. Um hospital acquired cases um in the same ward in a 28 day period. And this results in a number of actions that the I PC team put in place really to try and prevent any further cases and to await the typing results to see. Was this transmission or was this just coincidence when you have a whole genome sequencing results back of the two cases? If they were the same strain, that's whenever it changes from a period of increased incidence to an outbreak. So um trigger wards, these are wards that have a period of increased incidence and have those actions put in place. So we have a number of wards on the trigger at the moment. One, Daisy Hill, female surgical ward, Pre Gavan and Daisy Hill, Ed two South stroke trauma and Lurgan ward one, we've also had a number of recent outbreaks. Again, these are since April 2023. In each case, it's one patient transmitting to another patient. So the transmissions when they happen are identified relatively quickly and the the outbreaks um don't extend. Um three of them were in van um whenever you have periods of um being over capacity, um you know, that really doesn't lend itself well to good I PC practices. So it's kind of what you expect. And we know that our Ed has been working overcapacity and our wards working overcapacity for quite some time. Two of the outbreaks were in one South, there was one in two South and one in D Hill Ed. I'm not going to go into interpreting whole genome sequencing results. Um But if anyone's interested in that and they can speak to me at another time, what I would say is that in each of the outbreaks, um the hypothesis of transmission, um we find that the patients are mostly bedbound and full nursing care. So the C diff C was brought to them, they didn't go and get it from the environment. So the transmission was likely via the hands or clothing of an intermediate person or environmental contamination or contaminated equipment that was brought between patients. So things that we find in previous outbreak meetings is that, you know, the same glucose monitor was was used between patients. So that was the vector of the spores going from one patient to another machines, hosts, you know, used with the same patient commodes. Um So really reducing the burden um of sports and the environment through good cleaning um through good practices in terms of um hand hygiene, appropriate use of PPE are all really important. Um One thing that we found was for example, hand wash basins in a patient's room and having face cloths on. So handwash, things are for handwashing only if you think about it. If you see a patient with C diff, you might have spores on your hands. So if you wash your hands in their sink and it goes on to the face cloth, and the patient then uses that face cloth to clean their face, then they can reinfect themselves. And we know that once they've had c diff, once the chances are already are higher of them getting it again. So it's really important to reduce the environmental burden. Um I touched on the point that fecal microbiota transplant is um relatively difficult to get. And the gastro head of service is following that up commissioners because it has been in C CD I Guidance since 2021. Um But on the horizon, um the FDA in April has approved the first orally administered uh fecal microbiota product for prevention of recurrence of CDI. It's called VO it's four capsules taken orally once daily for three consecutive days. So it doesn't require um fecal microbiota transplant as we have now requires an NJ tube. So not an NG tube but NJ tube. So only certain people that can do it requires uh you know, being booked on the endoscopy list. Um So this would be much easier if we had access to this. Um Voice contains live bacteria. It's manufactured from human fecal matter that has been donated by screened and qualified individuals. Um It was test the efficacy study that um led to FDA approval there were 89 participants um blinded to have and 93 blinded to have placebo and eight weeks after treatment, treated participants um had lower recurrence. So 12.4% compared to 39.8%. This is a previous educational video that I did. I put the link here, but um I appreciate this one's now going to be recorded and some references. So I hope you find that useful.