CDAD and Antibiotics

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CDAD and Antibiotics

• Niketa Platt
• Antimicrobial Pharmacist
• NHS Fife

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Four main groups of bacteria

• Gram positive
• Gram negative
• Anaerobes
• Atypical

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Bacteria Structural Differences
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• Gram ve Cocci (spherical)
• Staphylococci
• Streptococci
• Enterococci
• Peptococci/Peptostreptococci

• Gram -ve Cocci
• Neisseria meningitidis
• Neisseria gonorrhoea
• Moraxella catarrhalis
• Acinetobacter (coccobacillus)

• Gram ve Rods
• Clostridia
• Corynebacteria (diphtheroids)
• Listeria
• Bacillus
• Anaerobes

• Gram -ve Rods
• Bacteroides
• Lactose-fermenting coliforms
• E coli, Klebsiella, Enterobacter
• Non lactose-fermenting coliforms
• Proteus, Salmonella, Shigella
• Pseudomonas
• Haemophilus
• Helicobacter, Campylobacter
• Legionella

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Generally Found..
Anaerobes Mouth, teeth, throat, sinuses and lower
bowel
Atypicals Chest and genito-urinary
Pneumonia Urethritis PID
Abscesses Dental infections Peritonitis Appendicit
is
Gram positive Skin and mucous membranes
Gram negative Gastro-intestinal tract
UTI Peritonitis Biliary infection Pancreatitis PID
Pneumonia Sinusitis Cellulitis Osteomyelitis Wound
infection Line infection
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Clostridium difficile

• Gram positive, spore forming anaerobic bacillus
• Produces 2 main toxins, A and B
• 2 adults carry as part of normal large bowel
  flora
• Carriage increase with age, elderly can have
  colonisation rates of up to 30

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Signs and Symptoms

• Diarrhoea with characteristic foul odour
• Abdominal pain
• Pyrexia
• Raised WCC
• Raised serum creatinine

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Complications

• Dehydration
• Hypotension
• Hypokalaemia
• Hypoalbuminaemia
• Pseudomembranous colitis (PMC)
• Toxic megacolon
• Death

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Risk Factors

• Patient gt65 years of age
• Increased asymptomatic carriage
• Immunosuppressed / co-morbidities
• Antibiotic exposure
• Prolonged hospital stay
• ? Other drugs e.g. PPIs
• NG tube
• Environmental
• Inadequate isolation facilities
• Inadequate cleaning of ward facilities and
  equipment
• Poor Hand Hygiene by patients and staff
• Increased movement of patients in hospitals
• More virulent strains emerging e.g. type 027

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Bacteria and the Bowel

• In an Healthy adult the colon can contain 1012
  bacteria per gram of contents therefore
  constituting 10-30 of the faecal mass.
• 96-99 of the bowel flora are anaerobes
• Other residents include gram negative coliforms,
  enterococci, and other organisms.
• These bacteria can provide a service e.g. vitamin
  K synthesis
• They also prevent the growth of pathogenic
  bacteria e.g. Clostridium difficile.

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CDAD and the Role of Antibiotics

• Broad spectrum antibiotics disrupt the natural
  bowel flora allowing pathogenic organisms such as
  C. difficile to flourish.
• However, some broad spectrum antibiotics may have
  activity against C. difficile e.g. tazocin
• Narrow spectrum antibiotics that cause little
  disruption to the bowel flora are less likely to
  cause CDAD, but there have still been reports.
• There have been a number of patients reported
  with CDAD that had not been exposed to any
  antibiotics.

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Antibiotics and risk of CDAD
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CDAD and Antibiotics cont.
Owens et al CID 200846 (supp 1). S19
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Recap

• Risk of developing CDAD as a complication of
  antimicrobial use depends on
• Disturbance of natural flora
• Exposure to toxigenic C. difficile or its spores
• 3. Patient health and immune response

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Treatment of CDAD

• Treatment of CDAD will depend on the severity
• If the patient has any ONE of the following they
  should be managed as having severe CDAD
• Admitted to ITU for treatment of CDAD or its
  complications
• Suspicion of/confirmed pseudomembranous colitis,
  toxic megacolon, ileus
• Temperature gt38.5oC
• White cell count lt1.5 or gt15 X109/L
• Serum albumin lt25g/l
• Acutely rising serum creatinine or creatinine
  gt1.5 times baseline
• Colonic dilatation on CT scan gt6cm
• Patient immunocompromised (e.g. neutropenic, on
  immunosuppressive therapy)

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Treatment of CDAD

• Mild/Moderate Disease
• If the patient has no severity markers
• Metronidazole 400mg TDS for 10-14 days
• If the patient does not respond within 5 days or
  develops any severity markers switch to oral
  vancomycin 125mg qds for 10-14 days
• Severe Disease
• If the patient has one or more severity markers
• Oral vancomycin 125mg QDS for 10-14 days
• in both cases stop antimotility agents and
  PPIs if possible

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Other Recommendations

• S uspect that a case may be infective where
  there is no clear alternative cause of diarrhoea
• I solate the patient in a side room, consult
  Infection Control Team
• G loves and aprons must be used for all contacts
  with the patient and their environment
• H and washing with soap before and after each
  contact with the patient and their environment
• T est the stool for toxin

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Recurrent Symptoms

• UK study showed 1/3 of patients required repeat
  courses of antibiotics.
• Relapses are often re-infections with the same or
  different strains not failed treatment.
• First recurrence should be treated the same drug
  i.e. metronidazole or vancomycin depending on
  severity.

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Discussion
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CEL 30 July 2008

• all Boards should immediately establish an AMT
  which covers primary and secondary care
  prescribing activities
• A key role for the AMT is the development,
  implementation and compliance monitoring of a
  local antimicrobial policy this should include
  restrictions on the use of broad spectrum
  antibiotics (particularly those associated with
  C.difficile disease)

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What do we consider when developing an
antimicrobial prescribing policy?

• Pathogen and site of infection
• Cause of infection
• Likely pathogens (epidemiology)
• Resistance
• Local / national resistance patterns
• Spectrum of activity
• Mechanism of action
• Penetration of antibiotic
• Site of infection
• Balance this against using the agent least likely
  to cause CDAD

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Community-Acquired Pneumonia
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Urinary Tract Infection
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Skin and soft tissue infection
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Co-amoxiclav use
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Ceftriaxone Use
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C difficile MQTs
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CEL 11 April 2009

• Confirmed HEAT target
• reduce the rate of Clostridium difficile
  Associated Disease among patients aged 65 and
  over by at least 30 by 31 March 2011. The target
  will measure the rate of CDAD reported from acute
  hospitals, non-acute hospitals, and community
  settings per 1000 occupied bed days in Scotland
• Introduced new antibiotic supporting indicators
• Hospital-based empirical prescribing antibiotic
  prescriptions are compliant with the local
  antimicrobial policy and the rationale for
  treatment is recorded in the clinical case note
  in gt95 of sampled cases
• Surgical antibiotic prophylaxis duration of
  surgical antibiotic prophylaxis is lt24 hours and
  compliant with local antimicrobial prescribing
  policy in gt 95 of sampled cases
• Primary Care empirical prescribing seasonal
  variation in quinolone use (summer months vs.
  winter months) is lt 5, calculated from PRISMS
  data held by NHS Boards.

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Advice for Non-Medical Prescribers

• Consider withholding therapy unless clear signs
  of infection
• Use the narrowest-spectrum agent appropriate to
  the infection
• Use the shortest duration needed to treat the
  infection
• Stop antibiotics if another diagnosis is found
  no need to complete the course
• Consider Delayed Prescribing
• Acute otitis media
• Acute sore throat/pharyngitis/tonsillitis
• Common cold
• Acute rhino sinusitis
• Acute cough
• Acute bronchitis

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Role for other HCPs in Antimicrobial Stewardship

• Ensure all prescriptions for antimicrobials are
  necessary, especially if CDAD is confirmed.
  Dont just finish the course
• Advise Prescribers to avoid clindamycin,
  cephalosporins, quinolones and broad spectrum
  agents e.g. co-amoxiclav where ever possible
  especially in the gt65 years
• Encourage Prescribers to document indication and
  specify duration on the prescription chart if
  possible.
• Check sensitivity reports and encourage
  Prescribers to avoid broad spectrum antibiotics
  and to switch to narrower spectrum agents
  wherever possible.
• Encourage early IV to oral switch. This may lead
  to an earlier discharge.