梭状芽孢杆菌（英文ppt）clostridiumdifficilea new

Clostridiumdifficile anewDisease DrMikeCooperConsultantMicrobiologistandDIPCNewCrossHospitalWolverhampton OxoidInfectionControlTeamoftheYearAwards 2006 2007WinnersAnnounced BASINGSTOKE UK 26April2007 Oxoid aworldleaderinmicrobiology ispleasedtoannouncethewinnersofthe2006 2007OxoidInfectionControlTeamoftheYearAwards 1stPrize RoyalWolverhamptonHospitalsNHSTrust UK2ndPrize ChoRayHospital VietnamJoint3rdPrize SouthamptonUniversityHospitalsNHSTrust UKandAminuKanoTeachingHospital Nigeria C difficile 1935 discoveredObligateanaerobeMotileGrampositivebacillusOval sub terminalsporesOccasionalcasereports infectedwounds 1960s C difficile 1977 C difficileidentifiedascauseBirminghamGeneralHospitalAAD 20 30 AAC 50 75 90 pseudomembranouscolitis C difficileToxins Toxigenicstrainsproduce2majortoxins toxinA enterotoxin toxinB cytotoxin NeutralisedbyC sordelliiantitoxin ToxinA BindstospecificCHOreceptorsonintestinalepitheliumToxininducedinflammatoryprocess neutrophilsinflammatorymediatorsfluidsecretionalteredmembranepermeabilityhaemorrhagicnecrosis ToxinB BindingsitenotyetidentifiedDepolymerizationoffilamentousactindestructionofcellcytoskeletonroundingofcells ClinicalManifestations Asymptomaticcarriage neonates Diarrhoea5 10daysafterstartingantibioticsmaybebe1dayafterstartingmaybeupto10weeksafterstoppingmaybeaftersingledosespectrumofdisease brief selflimitingcholera like 20X day waterystool ClinicalManifestations Additionalsymptoms abdominalpain fever nausea malaise anorexia hypoalbuminaemia colonicbleeding dehydrationAcutetoxicmegacolonacutedilatationofcolonsystemictoxicitysignsofobstructionhighmortality 64 Colonicperforation Pathogenesis DisruptionofnormalcolonicfloraColonisationwithC difficileProductionoftoxinA BMucosalinjuryandinflammation Pathogenesis Microfloraofgut 1012bacteria gram400 500speciescolonisationresistanceTransmission faecal oralsporesLatelog earlystationaryphasetoxinproduction Pathology Colonicmucosa raisedyellow whiteplaquesinitiallysmallenlargeandcoalesceInflamedmucosa Mortality Allcause28 7mortalityforCDTpositive 1 12 03 31 3 0418 6030 0 1 12 05 31 3 0671 18338 8 RR1 29 CI0 84 1 98 WhatChanged Handhygiene Environmentalcleanliness Antimicrobialprescribing Otherfactors WhatChanged Differentorganism Independent6 8thJune2005 PCRRibotype027 InNorthAmerica PFGETypeNAP1International NAP1 027MajorproblemsinMontrealandseveralstatesintheUS PCRRibotype027 Montreal 30 7mortalityincreased4 7 in1991 28 6 in200213 8 in2003Incidenceper100 000individualsaged 65102 1991 2 866 2003 PCRRibotype027 FirstUKisolate Preston1999SecondUKisolate Birmingham2002Nextseen March2004 StokeMandevilleWolverhampton 8isolatesfromOct Dec2005sentfortypingall027 PCRRibotype027 NorthAmericanoutbreakstrain 8to16XproductionoftoxinsAandBin vitroHyper toxinproduction 18bpdeletionintheTcdCgeneregulatestoxinproductionStrongassociationwithfluoroquinoloneuseTheLancet24thSept2005 Warny Pepin Fang Killgore Thompson Brazier FrostandMcDonald ToxinproductionbyanemergingstrainofC difficileassociatedwithoutbreaksofseverediseaseinNorthAmericaandEurope RWHTResponse AlsomajorproblemswithMRSAbacteraemias RWHTResponse DoHMRSAHCAIImprovementProgrammeDisbandICCFormIPB chairedbyChiefExecutiveperformancemanagementforDivisionsandWards RWHTResponsetoC difficile RegularcommodeauditingReplacementof100old damagedcommodesReplacementof300mattressesIntroductionof SavingLives HIINumber6followingeverycaseofCDADRootcauseanalysisoneverycaseIntroductionofhotelstylebedspacechecklistsfollowingdischargeofeverypatient RWHTResponsetoC difficile Matronledwardde clutterprogrammeIntroductionofmonthlycluttercollection200domesticstrainedinCDADandtheroleoftheenvironmentMedicaldivisionnursetrainingonCDAD spreadandroleofequipmentGrandRoundpresentationofcasestudiesandactiononCDAD Mandatoryattendanceofatleastonememberofeveryclinicalteam 250attended RWHTResponsetoC difficile Slidecard forinfectionpreventionforallstaffC difficilemanagement treatmentguidelinesNewantimicrobialguidelinesAntimicrobialprescribingpolicyMonitoringandantimicrobialprescribingperformancemanagementofDivisionsWardrefurbishmentprogramme C difficile AntibioticRisk HighRiskAntibiotics CefotaximeCeftriaxoneCefalexinCefuroximeCeftazidimeCiprofloxacinMoxifloxacinClindamycin lowdose MediumRiskAntibiotics MeropenemErtapenemClindamycin highdose Co amoxiclavTazocinErythromycinClarithromycin C difficile AntibioticRisk LowRiskAntibiotics BenzylpenicillinGentamicinAmoxicillinMetronidazoleFlucloxacillinVancomycinTetracyclinesTeicoplaninTrimethoprimSynercidNitrofurantoinLinezolidFusidicacidTigecyclineRifampicinDaptomycin SymptomaticProvenorSuspectedC diffinfection AssessPatient AXR CRP U E s FBCStoolChartStoolforC diff culture ifnotdone ConsiderFlexiSigifdiagnosisindoubtReviewAntibiotics TreatmentAlgorithmForNewCasesofC difficileDiarrhoea ModerateDiseaseWellWCC 20CRP 150NormalAXR SevereDiseaseUnwellWC 20 CRP 150 AbnormalAXR DistendedAbdomen severeifanyofthesefeatures IfDeterioratestoSevere Starttreatmentwithoutdelay Vancomycin500mgQDSPO Metronidazole500mgTDSIVor400mgTDSPO IVI ConsiderHDU ITUColorectalSurgicalReferralonday1DailySurgicalReviewuntilimproving iffailstoimproveconsidersurgery Starttreatmentwithoutdelay Metronidazole400mgTDSfor5days DailyReviewincludingstoolchart FBC CRP AXRifdeteriorates Moderate Severe IfDeterioratestoSevere ResponseComplete14daycourseofVancomycinCompletecourseofmetronidazole NoResponse ReferGastroenterologyforflexiblesigmoidoscopy advice ContinueVanc MetTreatasforsevereifdeteriorates ResponseComplete14daycourseofmetronidazole NoResponse AddVancomycin500mgQDSPOfor5daysComplete14daycourseofmetronidazole Canbedischargedonmetronidazoleandvancomycin 125mgQDS Recurrence re infectionAssess ifseveretreatasaboveModerate metronidazole400mgTDSandPOvancomycin500mgQDSIfrespondsbyday5 14daysofmetronidazole 500mgQDSvancomycin then6weekstaperingvancomycinIfnoresponseafter5daysofcombinedtherapyrefertogastroenterologyIfremainssymptomaticafter10daysandC diff PMCconfirmedonflexiblesigmoidoscopythenconsiderIVImmunoglobulin Ifthisisthethirdormorerecurrencethenconsiderimmunoglobulin 2weeksmetronidazole400mgTDSPO vancomycin500mgQDSattheoutsetfollowedby6weeksofvancomycin ThirdLineDrugRegimesforRecurrentDisease 6weeksTaperingVancomycin 125mgevery6hoursfor1week125mgevery12hrsfor1week125mgoncedailyfor1week125mgeveryotherdayfor1week125mgevery3rddayfor2weeksIVImmunoglobulin400mg kgsingledosewitharepeatat21daysifnecessaryYeastYeastpreparationsarecontraindicated PrebioticandProbiotics liveyoghurt Noprovenbenefitofprebioticsorprobiotics Cannotbeprescribedandshouldnotbeadvocated noqualitycontrolovertheagentsthatthepatientwillreceive MatronsleadWardDeclutterprogramme Domesticstrai