m


 „

Guidelines for the prevention and

management in the older adult.

Sandrina Rodrigues
Gerontological Nursing I
April 13, 2006
Yivision of Healthcare Quality Promotion
Mission includes:

Healthcare outcomes
Outbreaks in healthcare settings
Emerging antimicrobial-resistant infections
Promotion of implementation and
evaluation of prevention interventions
Yevelopment of infection control guidelines
and policies
www.cdc.gov/ncidad/dhqp/about.html
Scope of Practice of GNP
Yeveloping and implementing evidence based
strategies regarding health promotion, evaluation
and treatment of C. Yifficile infections in the older
adult.
Assisting older adults in minimizing health risks.
Recognizing and addressing specific characteristics and
atypical responses of older adults to disease and its
treatment.
Providing information, education, and resources to older
adults, considering factors related to safety,
effectiveness, and cost in planning and delivering care.
Collaborating with the older adult, caregiver, and
healthcare team to provide comprehensive care.

American Nurses Association, 2001

 Clostridium Yifficile
Yiscovered in 1935 by
Hall & O¶Toole.

Anaerobic gram-positive
spore forming bacillus.

Named ³difficult clostridium´

due to its resistance in isolation and growth.

In 1978 C. difficile produced toxin was found in patients with

antibiotic-associated pseudomembranous colitis.

Today, known as the major cause of diarrhea and colitis in

patients exposed to antibiotics.
LaMont, 2006
http://news.bbc.co.uk/health/4612779.stm
ÿ Prevalence
NHYS data using ICY-9-CM code specific for
³intestinal infection due to m
 

 ´ as a
discharge diagnosis between 1996 - 2003.

C. difficile on discharge summary

1996-2003 - estimated 978,000 discharges

Primary diagnosis VS Secondary diagnosis

2000 = 25,000 1996 = 98,000
2003 = 54,000 2003 = 178,000

McYonald, Owings, & Jernigan, 2006

Yemographics Per 100,000 discharges

Sex
Male 0.38%
Female 0.38%

Age group

 228
 
 40
   11

Geographic region
Northeast 68
Midwest 49
South 36
West 31

McYonald, Owings, & Jernigan, 2006

Community-acquired C. difficile

According to the UK General Practice Research

Yatabase:
1994 = <1 case per 100,000
2004 = 22 cases per 100,000

70% had not been admitted to a hospital within the last

12 months
< 50% had taken antibiotics three months prior to
developing C. difficile
www.medicalnewstoday.com
ÿ 
 
Accountable for 15-25% of antibiotic-associated
diarrhea.

Fecal-oral route transmission.

Three steps to C. Yifficile diarrhea:

Alteration of the normal fecal flora

Ļ
Colonic colonization of C. difficile
Ļ
Growth and production of its toxins
LaMont, 2006
Poutanen & Simor, 2004
Toxins A (enterotoxin) and B (cytotoxin)
Ļ
activate inflammatory mediators
Ļ
increase mucosal permeability,
fluid secretion & hemorrhage
Ļ
colonic inflammation (colitis)
Ļ
progression may lead to formation of
pseudomembranous colitis, fulminant
colitis, or toxic megacolon
LaMont, 2006
Poutanen & Simor, 2004
Schroeder, 2005
www.nursingspectrum.com
Neither the organism or its toxins are
believed to enter the bloodstream.

Asymptomatic patients:
Not all strains are toxigenic
Good IgG antibody immune response to
toxin A

LaMont, 2006
×
 
 

 



Uncolonized patient
Ļ
Antibiotic exposure
Ļ
Yisruption of colinic microflora
Ļ
C. Yifficile ingestion & colonization
Ļ Ļ
Good IgG Poor IgG
Ļ Ļ
Asymptomatic carrier Production of toxins
Ļ
Colonic mucosal damage
Ļ
Clinical Yisease

Schroeder, 2005
ÿ  

Antibiotics ± fluoroquinolones, cephalosporins,
clindamycins, penicillins
Medications:
Proton pump inhibitor
Histamine-2 receptor blockers
Non-steroidal anti-inflammatories (except aspirin)
Laxatives
Narcotics
Antiperistaltic drugs
Advanced age ( 
)
Chemotherapy
Medical/Surgical procedures
Gastrointestinal surgery
Enemas
Enteral tube feedings
Endoscopy
Underlying illness and its severity
Inflammatory bowel disease
Yiabetes mellitus/Hyperthyroidism
Leukemia/Lymphoma
Liver/Renal failure
History of C. difficile associated diarrhea
Prolonged hospital stay/Nursing home resident
Louie & Meddings, 2004
McYonald, Owings, & Jernigan, 2006
Melillo, 1998
Poutanon & Simor, 2004
ÿ    

Type of Yiarrhea Other Physical
infection symptoms Examination
6 
 Absent Absent Normal

6

 Mild to Crampy Slight lower
 moderate lower abd abdominal

 
 discomfort tenderness
6

 10+ loose Nausea, Abdominal

 
 bm/day; anorexia, distention,


fecal fever, tenderness
 leukocytes; malaise,
occult dehydration,
blood leukocytosis
Cont.

Type of Yiarrhea Other Physical

infection symptoms Examination
×

>10 loose Nausea, Marked

 bm/day, anorexia, abdominal

 fecal fever, tenderness,
leukocytes, malaise, distention
occult blood dehydration,
electrolyte
imbalance,
leukocytosis

LaMont, 2006
Mahan-Butarro, Aznavorian, & Yick, 2006
Melillo, 1998
Poutanen & Simon, 2004
 Pseudomembranes:

Irregular yellow plaques of necrotic debris (black arrow) with

intervening edematous bowel mucosa (white arrow) in an 87-year-old
woman. These findings are consistent with pseudomembranes
caused by Clostridium difficile infection.
Schroeder, 2005
 Type of Yiarrhea Other Physical
infection symptoms Examination
Ñ  May be Lethargy, Severe lower

 severe or high fever, or diffuse
decreased chills, abdominal
due to tachycardia, tenderness,
colonic abdominal distention
dilation pain,
(toxic hypotension,
megacolon) dehydration,
&/or marked
paralytic leukocytosis,
ileus electrolyte
imbalance

LaMont, 2006
Mahan-Butarro, Aznavorian, & Yick, 2006
Melillo, 1998
Poutanen & Simon, 2004
Toxic Megacolon

LaMont, 2006
ÿ   

Infectious enteritis or colitis (diarrhea not
associated with C. difficile): bacterial
gastroenteritis, viral gastroenteritis, amebic
dysentery.
History of travel, camping, infectious contacts, or day
care attendance; associated with nausea and vomiting

Inflammatory bowel disease: Crohn's disease,

ulcerative colitis
Bloody diarrhea, abdominal pain, nausea, vomiting, loss
of appetite, family history

Ischemic colitis
History of vascular disease; pain associated with eating

Schroeder, 2005
ÿ 
 

Clinical Presentation:
Antibiotics in the past 3 months
Onset occurring after 72 hours of admission
Risk factors
Characteristics of diarrhea:
Watery
Foul smelling
Bloody, green, or yellow appearance
Quantity
Physical Exam:
Vital signs
Labs
Weight
Input/Output
Skin
HEENT
Cardiac
Respiratory
Abdomen
Rectal

Mahan-Butarro, Aznavorian, & Yick, 2006

ÿÿ 
  

LaMont, 2006
Cytotoxicity Assay ± ³Gold Standard´
High specificity (99%-100%)
Yetects toxin B
Sensitivity rate of 80%-90%
Results not available for at least 48 hours

Culture
High sensitivity (>90%) & specificity (>98%)
Yetermines typing of strain for outbreak
investigation
Results not available for at least 72-96 hrs
Labor intensive
Poutanen & Simon, 2004
http://www.cha.state.md.us/edcp/guidelines/clostdiff
Immunologic assays
High specificity (95%-100%)
Results available within 4 hours
Reduced sensitivity (65%-85%)

Endoscopy
Yiarrhea persists
Rapid diagnosis is needed
Asymptomatic carrier -

Antibiotic-associated diarrhea without colitis -

Antibiotic-associated colitis without pseudomembrane
formation - !  " !" #
Pseudomembranous colitis - !" !  " 
$
%&
 '() !
LaMont, 2006
Poutanen & Simor, 2004
ÿ  

Yiscontinue the offending agent

If unable:
Choose an antibiotic less frequently
associated with antibiotic-associated
diarrhea (aminoglycosides, sulfonamides,
macrolides, vancomycin, tetracyclines)
Prescribe Metronidazole 500mg PO TIY
throughout the needed course of antibiotic
therapy and for 7 days after.

LaMont, 2006
Schroeder, 2005
Antibiotic therapy management:
Evidence of colitis
Severe diarrhea
Persistent diarrhea despite cessation of
offending antibiotic
A need to continue the antibiotic therapy
to treat underlying infection.

LaMont, 2006
 Metronidazole 250mg PO QIY or
500mg PO TIY x 10-14 days/
500mg IV q8 hours x 10-14 days

NOTE: Metronidazole ± use cautiously in patients

with severe liver impairment and severe renal
failure. If creatinine clearance < 10mL/minute,
administer 50% of the dose or q12hrs.

LaMont, 2006
Schroeder, 2005
Semla, Beizer, & Higbee, 2006
 Vancomycin 125mg PO QIY x 10-14
days

NOTE: Vancomycin ± use cautiously in patients with

renal impairment. Monitor serum concentration
levels.

LaMont, 2006
Semla, Beizer, & Higbee, 2006
Non-antibiotic management:
Correction of fluid losses and electrolyte
imbalances.
Monitor weight.
Avoid antiperistaltic drugs.
Implementation of infection control
policies.

LaMont, 2006
Mahan-Butarro, Aznavorian, & Yick, 2006
ÿ  
Occurs in 20-30% of successfully treated
patients.
Onset is 1 week to 2 months after completion
of treatment.
Risk Factors:
Failure to mount an immune response to C. Yifficile
toxins
Advanced age (>65yrs)
Severity of underlying illness
Prolonged antibiotic use

LaMont, 2006
www.nursingspectrum.com
ÿÿ  %

1- Confirm diagnosis

2- Metronidazole 250mg PO QIY or

500mg PO TIY x 10-14 days
Or
Vancomycin 125mg PO QIY x 10-14
days

LaMont, 2006
ÿÿ *
! %

1- Confirm diagnosis
2- Vancomycin taper:
125mg PO QIY x 7 days
125mg PO BIY x 7 days
125mg PO daily x 7 days
125mg PO every other day x 7 days
125mg PO every 3 days x 14 days

LaMont, 2006
ÿÿ   %
1- Confirm diagnosis
2-
a) Saccharomyces boulardii 250mg PO QIY in
combination with previous Metronidazole or
Vancomycin orders
or
b) Cholestyramine 4g PO BIY in combination
with previous Vancomycin taper
or
c) Vancomycin 125mg PO QIY in combination
with Rifampin 600mg PO BIY x 7 days

LaMont, 2006
ÿ 

Avoid antibiotics associated with high rates
of C. difficile infection
Private room or cohort with other infectious
patient
Utilize protective equipment before
entering the room and remove prior to
leaving
Wash hands with soap and water
Patient care equipment should remain in
the room
Yesinfect room with hypochlorite-based
desinfectants
Patient should remain in contact
precautions until 72 hours of no loose
stools

www.nursingspectrum.com
www.guideline.gov
ÿ  
Enhance previous research:
Efficacy of vaccination
Administration of IV IgG anti-toxin A antibodies
Vancomycin based enemas

Explore the types of strains seen in regions

with higher incidence of C. Yifficile
infection.

Staff knowledge on C. Yifficile contact

precautions and incidence of nosocomial
infections.
 References
American Nurses Association. (2001). Ú
  Ú




  × (2nd edition). Washington, Y.C.:

American Nurses Publishing.
BBC News (2005). ×        Retrieved
March 30, 2006, from
http://news.bbc.co.uk/1/hi/health/4612779.stm
Centers for Yisease Control and Prevention (2004). m



  




   
 Retrieved March 30,
2006, from http://cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html
Centers for Yisease Control and Prevention (2005). 



     


 Retrieved April 3, 2006, from
„


Community Health Administration (2001).  

 

  



m
 

  
  

  Retrieved April 6, 2006, from
https://www.cha.state.md.us/edcp/guidelines/clostdiff.html
LaMont, J. (2006). m  

  



m
 

  

 Retrieved March 31, 2006, from
http://uptodateonline.com
LaMont, J. (2006). ×
 

  



 


  


m
 

  


Retrieved March 31, 2006, from http://uptodateonline.com
LaMont, J. (2006). 




 
  m
 

  Retrieved March 31, 2006, from

http://uptodateonline.com
LaMont, J. (2006). 

 m
 

 
Retrieved March 31, 2006, from http://uptodateonline.com
Louie, T. & Meddings, J. (2004). Clostridium difficile infection in
hospitals: risk factors and responses. m 
6

 
 !"!(1), 45-46.
Mahan-Butarro, T., Aznavorian, S. & Yick, K. (2006).
Gastrointestinal disorders. In m  

 
 

   (pp.136-144). St. Louis:
Elsevier, Inc.
McYonald, L., Owings, M. & Jernigan, Y. (2006). Clostridium
difficile infection in patients discharged from US short-stay
hospitals, 1996-2003.  #

  !$(3),
409-415.
Medical News Today (2006). % 
„ 6 






 m 

  Retrieved April 4, 2006, from

http://www.medicalnewstoday.com/medicalnews
Melillo, K.Y. (1998). Clostridium difficile and older adults: What
primary providers should know.   ×
 $&(7),
25-45.
National Guideline Clearinghouse (2005). m   




 
  Retrieved March 30, 2006, from
www.guideline.gov
Nursing Spectrum (2005). m 

   
 '

 Retrieved April 11, 2005, from
http://nursingspectrum.com
Poutanen, S. & Simor, A. (2004). Clostridium difficile-associated
diarrhea in adults. m  6

 

!"!(1), 51-58.
Schroeder, M. (2005). Clostridium difficile associated diarrhea.
6 Ñ ×  "!(5), 921-929.
Semla, T., Beizer, J. & Higbee, M. (2006).  



 (11th edition). Hudson, OH: Lexi-Comp, Inc.

Ú (