Long term Care Pharmacy Update: Clostridium Difficile

At Grane Rx, we’re committed to providing the highest-quality LTC pharmacy services. As part of that commitment, we share an ongoing series of pharmacy updates from our Chief Clinical Officer, designed to keep you in the know on clinical topics related to long term care pharmacy and PACE pharmacy. Clostridium difficile, or C. diff, is a type of Gram-positive spore-forming bacteria that develops in about half a million people each year. C. diff infection is an extremely serious healthcare complication that can result in increased frailty, malnutrition, sepsis, pseudomembranous colitis and even death. C. diff is responsible for more than 10,000 deaths each year.   Residents of a long term care facility are considered to be a vulnerable population due to close contact and constant exposure to bacteria; therefore, healthcare providers have a responsibility to ensure the safety of these residents while receiving care.

What Long term Care Pharmacy and Other Providers Should Know

What are the causes of C. diff? The residents who will be most likely to contract C. diff are the residents who:
  • Are taking proton pump inhibitors
  • Are immunocompromised
  • Have had gastrointestinal surgery
  • Have come into contact with contaminated feces
  • Have had antibiotic exposure
Antibiotic use causes a 7–10 times increase in probability of contracting C. diff during use and for one month following discontinuation. Cefixime (Suprax), erythromycin, amoxicillin-clavulanate (Augmentin) and clindamycin (Cleocin) are examples of antibiotics that are associated with a higher incidence of C. diff infection. What are the symptoms of C. difficile? Symptoms for C. diff are most commonly seen within the first 10 days of starting antibiotic treatment; however, C. diff may be seen up to two months follow discontinuation of antibiotics. Symptoms include:
  • Abdominal cramping
  • Fever
  • Peripheral leukocytosis/pseudomembranes seen on lower gastrointestinal endoscopy
  • Nausea
  • Loss of appetite
  • Diarrhea (watery stool that occurs ≥3 times a day for at least 2 days)
How can C. difficile be prevented?
  • Keep hands clean and wash regularly. (Use soap and warm water. Alcohol does not kill C. difficile spores.)
  • Identify residents who are suspected of having C. diff as early as possible.
  • Implement contact precautions for residents who are suspected of having C. diff in order to prevent transmission.
  • Assign residents who are infected to isolation.
  • Maintain clean medical supplies and equipment.
If a resident is considered to be an asymptomatic carrier, should antibiotic therapy be initiated prophylactically? Unfortunately, while a resident is being tested and awaiting a symptomatic state, it is not currently recommended to begin prophylactic antibiotic therapy. There has not been conclusive data to show that it is beneficial to the resident’s quality of life, nor does it show any decrease in occurrence. In fact, prematurely starting an antibiotic while the resident’s gastrointestinal flora combats and prevents the colonization and infection of Clostridium difficile may cause collateral damage by altering the gastrointestinal flora. [Tweet “Close contact with others is one risk factor for C. diff transmission in #SkilledNursing Facilities”]

Long term Care Pharmacy Treatment of C. diff

Clinical Classification Therapy Duration
Simple Metronidazole, 3x500mg orally 10 days
Vancomycin, 4×125 (to 250)mg orally 10 days
Severe Vancomycin, 4×125 (to 250)mg orally 10 days
Severe, complicated Vancomycin, 4×125 (to 500)mg orally 10 days
(plus) metronidazole, 3x500mg IV 10 days
First recurrence Vancomycin, 4×125 (to 250)mg orally 10 days
Fidaxomicin, 2x200mg orally 10 days
Multiple recurrence Vancomycin, 4x500mg orally (4 days), followed by stool transplantation in an experience facility <7 days

Elements of an Antibiotic Stewardship Program

Because of the potential impact of C. diff infection in the long term care population, many antibiotic stewardship programs are specifically focusing on managing C. diff. As a refresher, there are seven key components to antibiotic stewardship programs, which include:
  1. Leadership commitment. Creating a culture which promotes antibiotic stewardship throughout the facility is a key starting point.
  2. Accountability. Empowering team members such as the medical director, director of nursing, consultant pharmacist and infection control team members to have ownership for antibiotic stewardship efforts.
  3. Medication Expertise. Tapping into available resources such as your consultant pharmacist and infectious disease consultants to assist in developing and supporting your program.
  4. Action. Creating and implementing necessary policies and procedures to support the antibiotic stewardship program.
  5. Tracking. Tracking the outcomes of all new interventions will enable the facility to determine successes and areas that may need additional attention.
  6. Reporting. Reporting will enable on-going analysis of program successes and outcomes while providing the team with information to identify potentially new areas of focus.
  7. Education. Engaging all parties, including residents, facility staff, prescribers and family members, will ensure optimal and continuous success of the program.
Grane Rx long term care pharmacy providers stay ahead of the latest clinical information and pass those details along to our partner facilities. Learn how your center can benefit by filling out this quick form or calling (866) 824-MEDS (6337).]]>

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