Week 11 - Topic 4: C difficile Flashcards
What is C difficile (CD)?
Spore-forming gram + anaerobic bacillus
When is CD a spore vs in its vegetative state?
Spore: in the environment
Vegetative: in the GI tract
What causes disease from CD?
The toxin secreted by CD
What % of CD organisms produce toxins?
80%
5-20% don’t produce toxin and thus don’t cause colitis
What are the two toxins produced by CD?
Toxin A enterotoxin: fluid secretion, mucosal damage and intestinal inflammation
Toxin B cytotoxin: cellular damage
Lead to colon damage
How is CD stool set apart from other poops?
It has a notable odour
You have been colonized with CD and have symptoms. What illness do you have?
Clostridium difficile infection (CDI)
True or False: If you have CD in the gut, you will most likely develop symptoms.
True, only 1-15% are asymptomatic
What colonized age group is usually asymptomatic and why?
Newborns (30-80%) bc they lack the receptors for toxins
Why do CD spores germinate?
They germinate (usually in the large intestine) because of the imbalance of normal fecal flora
What causes imbalances to normal fecal flora?
1) Abx **
2) Surgery (stomach/bowels) –> exposure to Abx and spores
3) Old age –> exposure to hospitals, LTC
4) Chemo, laxatives –> change in bowel flora
What are the 5 manifestations of the CDI spectrum (going from mild to bad)?
1) Asymptomatic carrier (subclinical)
2) Mild self-limited diarrhea
3) Colitis w/o pseudomembranes
4) Pseudomembranous colitis
5) Fulminant colitis, toxic megacolon, intestine rupture (high mortality)
When do people with CDI produce symptoms?
80% within 4-9 days of antimicrobial therapy
20% within 8-10 weeks after cessation of therapy
(Monitor sx during and after abx therapy)
What are common symptoms of CDI?
Mucoid, green, foul-smelling diarrhea***
Abdominal cramps
What are the 5 characteristics of pseudomembranous colitis?
1) Rapid elevation of peripheral WBC
2) Hypoalbuminemia of 3.0 g/dL
3) Hemodynamic instability
4) Blood diarrhea
5) Development of multi-organ dysfunction
Is pseudomembranous colitis dangerous?
Yes, death rate of 40-80%
If you were to observe a colon with pseudomembranous colitis what would you see?
Slime, blisters, ulcers, necrosis
Why do pts with fulminant CD have little diarrhea?
Their large intestine is so enlarged/distended that it won’t let out diarrhea = toxic megacolon
What are the 4 characteristics of culminant CD?
1) Preceded by hemodynamic instability
2) Multi-organ dysfunction
3) Toxic megacolon
4) Colonic perforation
When imaging toxic colitis for diagnosis, what do you see?
Damage to the intestinal wall:
- No contraction of ileus
- Loss of muscle tone = abdo distention
- Gas buildup in intestines = “thumbprint”
What are the sx of fulminant CD?
- Severe lower quadrant or diffuse abdo pain
- Distention
- Bloody diarrhea
- High fever, chills, leukocytosis
How do you diagnose CD?
1) Culture of bacteria (rare)
2) Toxin detection by PCR (24-48h)
3) Endoscopic visualization of gut (if pt has sx but tests come back negative)
How do you collect specimen for CD diagnosis?
Place freshly passed (1-2h ago) watery, unformed stool (10-20 mL) in clean container
How do you collect specimen for CD diagnosis for those who wear diapers?
Place a bag in diaper to collect it while you make sure the person doesn’t develop a rash or urinate in it
True or False: You can’t send stool mixed with urine out for analysis.
True, dilute stool can produce false negatives
True or False: 25% of hospitalized pts on antibiotics have CDI.
False, they carry CD without symptoms
What can you modify with regards to antibiotics to reduce CDI risks?
1) Type of Abx (avoid cephalosporin)
2) Duration of Abx treatment (avoid more than 7 days)
3) Use of multiple Abx
4) Use of broad spectrum Abx (narrow spectrum preferred)
Why do stool softeners increase risk of CDI?
Softened stool = more risk it goes on your hands = touch contamination
Why do nasogastric tubes increase risk of CDI?
It is used for feeding and touched a lot = touch contamination
Why shouldn’t you clean surfaces contaminated with CD using disinfectants?
It increases sporulation
With what should you clean surfaces contaminated with CD?
Bleach
What is the most effective management of CDI?
- Early detection
- Contact precautions
- Early treatment if sx
- Hand hygiene with soap and water
- Thorough environmental cleaning
- Proper Abx management
- Education on prevention
How do you manage CDI?
1) Early recognition and treatment of symptomatic cases
2) Adequate supportive therapy (fluids and electrolytes)
3) Challenge drugs that inhibit bowel motility and broad spectrum abx
What happens when you stop abx in symptomatic pts?
10-20% of mild cases will stop having sx
What abx is used for CDI therapy?
1) Metronidazole (MTZ)
2) Vancomycin, +++ $
ORAL not IV
True or False: 20-25% of pts have reccurences within 8-10 weeks after treatment stops.
False, within 2 weeks
Who (3) are at the highest risk for recurrence of CDI after treatment stops?
1) Older > 65 y.o.
2) Cancer pts
3) Frequent abx
What (6) treatments do we use for CDI?
1) Vancomycin for 4-6 wk and taper
2) Pulse vancomycin: 7 days on, 7 off
3) Vanco with Rifampin
4) Alternate vanco with Cholestyramine (binds to toxins)
5) IV gamma globulin
6) Fecal transplant
True or False: There is a vaccine for toxin A and B.
True, but only used in severe cases
True or False: Probiotics can be used as a treatment for C diff.
True, but they give mixed results and are expensive
Saccharomyces boulardii (Florastor) seems promising Lactobacillus seems to have no effect
When do you initiate contact precautions with a CDI patient?
On first diarrhea
–> validate if a laxative was given and do not wait for culture results
When do you send a diarrhea for culture?
After the 3 stool (bc some people will have 1-2 diarrheas and then stop)
When should treatment be given to CD pts?
If symptomatic and culture is positive
What must you document with CDI pts?
of stools per shift
Consistency
Efficacy of tx
Who can you cohort a CD pt with?
Another positive CD pt
Group together on to one side of the unit
Where should you place a CD sign on the unit?
PT’s bedside and on entry to room
How do you perform hand hygiene when coming into contact with CD?
Soap and water
Alcohol does not kill spores as much!!!
True or False: You can clean surfaces with quaternary ammonium compounds.
False!!!
They increase sporulation
Clean with bleach
For people with CD (regardless if they are asymptomatic), where do you find CD on their body the most?
Skin > groin > chest/abdomen
Your PT with CDI needs to be cleaned. How do you proceed to do so?
If possible, shower is ideal
After he uses the shower, make sure it is blocked until housekeeping arrives
True or False: You should bathe CDI pts in CHG.
False, may help but not required
Daily showers are preferred
What are 3 CD containment measures?
1) Daily showers
2) Fresh linen and clean cloths daily
3) Assign the same nurse to care for a cohort of C diff cases
What are some environmental control measures for CD?
1) Disinfect with sporicidal agent all reusable equipment (BP cuff, oxymeter, stethoscope) and touched surfaces
2) Do not overstock supplies or linen in the room
3) Do not reuse supplies once a PT has been discharged
4) Dedicate equipment (thermometers and bedside commodes)
How do you manage feces in Cdiff pts? (name 5-6 points)
1) Use of disposable bedpans
2) Dispose feces in dirty utility flush-sink/macerator
3) Do not rinse feces in sink or pt bathroom
4) Dispose of ostomy bags
5) Do not use toilette spray to wash bedpan
6) Do not leave diapers on the floor
7) Only use rectal tubes for immobile pts
8) Remove gloves before touching bed rail
9) Hand hygiene with soap+water
When should PTs do hand hygiene (5)?
1) Before meals
2) After using toilet
3) Before touching face
4) Before leaving room
5) Before entering room
What are the 7 procedures when transporting a CDI pt out of the room?
1) Alert receiving unit of CD status
2) Ensure Pt has clean cloths and perianal area covered
3) Make pt wash hands before placing on transport vehicle
4) Wrap the pt and the transport wheelchair/stretcher
5) Disinfect the area on the vehicle that will be pushed.
6) Remove PPE, hand hygiene
7) Carry extra supplies of PPE
True or False: A visitor can bring their personal items to a CD pt room.
True, if it is contained in the bag
True or False: A visitor can touch the belongings of a CD pt
False
When are contact precautions discontinued for a CD pt?
When they are discharged
What must you discuss with a CD PT before they go home (4)?
1) Regular bathroom cleaning with bleach
2) Monitor for reccurence
3) Hand hygiene + short nails
4) Proper laundering of clothes (store off the floor and use warm water+detergent for underwear)
