Week 11 - Topic 4: C difficile

Question 1

What is C difficile (CD)?

Answer 1

Spore-forming gram + anaerobic bacillus

Question 2

When is CD a spore vs in its vegetative state?

Answer 2

Spore: in the environment
Vegetative: in the GI tract

Question 3

What causes disease from CD?

Answer 3

The toxin secreted by CD

Question 4

What % of CD organisms produce toxins?

Answer 4

80%

5-20% don’t produce toxin and thus don’t cause colitis

Question 5

What are the two toxins produced by CD?

Answer 5

Toxin A enterotoxin: fluid secretion, mucosal damage and intestinal inflammation

Toxin B cytotoxin: cellular damage

Lead to colon damage

Question 6

How is CD stool set apart from other poops?

Answer 6

It has a notable odour

Question 7

You have been colonized with CD and have symptoms. What illness do you have?

Answer 7

Clostridium difficile infection (CDI)

Question 8

True or False: If you have CD in the gut, you will most likely develop symptoms.

Answer 8

True, only 1-15% are asymptomatic

Question 9

What colonized age group is usually asymptomatic and why?

Answer 9

Newborns (30-80%) bc they lack the receptors for toxins

Question 10

Why do CD spores germinate?

Answer 10

They germinate (usually in the large intestine) because of the imbalance of normal fecal flora

Question 11

What causes imbalances to normal fecal flora?

Answer 11

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

Question 12

What are the 5 manifestations of the CDI spectrum (going from mild to bad)?

Answer 12

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)

Question 13

When do people with CDI produce symptoms?

Answer 13

80% within 4-9 days of antimicrobial therapy

20% within 8-10 weeks after cessation of therapy

(Monitor sx during and after abx therapy)

Question 14

What are common symptoms of CDI?

Answer 14

Mucoid, green, foul-smelling diarrhea***

Abdominal cramps

Question 15

What are the 5 characteristics of pseudomembranous colitis?

Answer 15

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

Question 16

Is pseudomembranous colitis dangerous?

Answer 16

Yes, death rate of 40-80%

Question 17

If you were to observe a colon with pseudomembranous colitis what would you see?

Answer 17

Slime, blisters, ulcers, necrosis

Question 18

Why do pts with fulminant CD have little diarrhea?

Answer 18

Their large intestine is so enlarged/distended that it won’t let out diarrhea = toxic megacolon

Question 19

What are the 4 characteristics of culminant CD?

Answer 19

1) Preceded by hemodynamic instability
2) Multi-organ dysfunction
3) Toxic megacolon
4) Colonic perforation

Question 20

When imaging toxic colitis for diagnosis, what do you see?

Answer 20

Damage to the intestinal wall:

• No contraction of ileus
• Loss of muscle tone = abdo distention
• Gas buildup in intestines = “thumbprint”

Question 21

What are the sx of fulminant CD?

Answer 21

• Severe lower quadrant or diffuse abdo pain
• Distention
• Bloody diarrhea
• High fever, chills, leukocytosis

Question 22

How do you diagnose CD?

Answer 22

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)

Question 23

How do you collect specimen for CD diagnosis?

Answer 23

Place freshly passed (1-2h ago) watery, unformed stool (10-20 mL) in clean container

Question 24

How do you collect specimen for CD diagnosis for those who wear diapers?

Answer 24

Place a bag in diaper to collect it while you make sure the person doesn’t develop a rash or urinate in it

Question 25

True or False: You can't send stool mixed with urine out for analysis.

Answer 25

True, dilute stool can produce false negatives

Question 26

True or False: 25% of hospitalized pts on antibiotics have CDI.

Answer 26

False, they carry CD without symptoms

Question 27

What can you modify with regards to antibiotics to reduce CDI risks?

Answer 27

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)

Question 28

Why do stool softeners increase risk of CDI?

Answer 28

Softened stool = more risk it goes on your hands = touch contamination

Question 29

Why do nasogastric tubes increase risk of CDI?

Answer 29

It is used for feeding and touched a lot = touch contamination

Question 30

Why shouldn't you clean surfaces contaminated with CD using disinfectants?

Answer 30

It increases sporulation

Question 31

With what should you clean surfaces contaminated with CD?

Answer 31

Bleach

Question 32

What is the most effective management of CDI?

Answer 32

- Early detection - Contact precautions - Early treatment if sx - Hand hygiene with soap and water - Thorough environmental cleaning - Proper Abx management - Education on prevention

Question 33

How do you manage CDI?

Answer 33

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

Question 34

What happens when you stop abx in symptomatic pts?

Answer 34

10-20% of mild cases will stop having sx

Question 35

What abx is used for CDI therapy?

Answer 35

1) Metronidazole (MTZ) 2) Vancomycin, +++ $ ORAL not IV

Question 36

True or False: 20-25% of pts have reccurences within 8-10 weeks after treatment stops.

Answer 36

False, within 2 weeks

Question 37

Who (3) are at the highest risk for recurrence of CDI after treatment stops?

Answer 37

1) Older > 65 y.o. 2) Cancer pts 3) Frequent abx

Question 38

What (6) treatments do we use for CDI?

Answer 38

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

Question 39

True or False: There is a vaccine for toxin A and B.

Answer 39

True, but only used in severe cases

Question 40

True or False: Probiotics can be used as a treatment for C diff.

Answer 40

True, but they give mixed results and are expensive ``` Saccharomyces boulardii (Florastor) seems promising Lactobacillus seems to have no effect ```

Question 41

When do you initiate contact precautions with a CDI patient?

Answer 41

On first diarrhea | --> validate if a laxative was given and do not wait for culture results

Question 42

When do you send a diarrhea for culture?

Answer 42

After the 3 stool (bc some people will have 1-2 diarrheas and then stop)

Question 43

When should treatment be given to CD pts?

Answer 43

If symptomatic and culture is positive

Question 44

What must you document with CDI pts?

Answer 44

of stools per shift Consistency Efficacy of tx

Question 45

Who can you cohort a CD pt with?

Answer 45

Another positive CD pt Group together on to one side of the unit

Question 46

Where should you place a CD sign on the unit?

Answer 46

PT's bedside and on entry to room

Question 47

How do you perform hand hygiene when coming into contact with CD?

Answer 47

Soap and water Alcohol does not kill spores as much!!!

Question 48

True or False: You can clean surfaces with quaternary ammonium compounds.

Answer 48

False!!! They increase sporulation Clean with bleach

Question 49

For people with CD (regardless if they are asymptomatic), where do you find CD on their body the most?

Answer 49

Skin > groin > chest/abdomen

Question 50

Your PT with CDI needs to be cleaned. How do you proceed to do so?

Answer 50

If possible, shower is ideal | After he uses the shower, make sure it is blocked until housekeeping arrives

Question 51

True or False: You should bathe CDI pts in CHG.

Answer 51

False, may help but not required | Daily showers are preferred

Question 52

What are 3 CD containment measures?

Answer 52

1) Daily showers 2) Fresh linen and clean cloths daily 3) Assign the same nurse to care for a cohort of C diff cases

Question 53

What are some environmental control measures for CD?

Answer 53

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)

Question 54

How do you manage feces in Cdiff pts? (name 5-6 points)

Answer 54

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

Question 55

When should PTs do hand hygiene (5)?

Answer 55

1) Before meals 2) After using toilet 3) Before touching face 4) Before leaving room 5) Before entering room

Question 56

What are the 7 procedures when transporting a CDI pt out of the room?

Answer 56

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

Question 57

True or False: A visitor can bring their personal items to a CD pt room.

Answer 57

True, if it is contained in the bag

Question 58

True or False: A visitor can touch the belongings of a CD pt

Answer 58

False

Question 59

When are contact precautions discontinued for a CD pt?

Answer 59

When they are discharged

Question 60

What must you discuss with a CD PT before they go home (4)?

Answer 60

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)