IDSA and SHEA have new guidelines on clostridium difficile

Clostrdium difficult has gone from being just a nuisance or an everyday major problem today. Research has been ongoing to look for better treatment plans and strategies for dealing with relapses. The Infectious Disease Society of America (IDSA) and The Society for for Healthcare Epidemiology of America (SHEA) have released updated guidelines in the May 2010 issue of Infection Control and Hospital Epidemiology.

The guidelines are helpful in reviewing the current state of the art with regards to treating this problem. With the number of remedies and regimens it is important to decide what works and what does not have the science to back it up.
A few points to emphasize from this document that are relevant for day to day practice.

1. Stools should not be checked in asymptomatic patients: This sounds simple enough but unfortunately I get a call almost every week from the lab asking what they should do with a solid stool specimen sent to them for clostridium difficile assay. Stools will remain toxin positive and PCR positive in patients successfully treated for months. There is no value in retesting stools.

2. Repeat testing of stool for toxin during the same episode of diarrhea should not be done.

3. Gloves AND gowns are recommended for all healthcare workers and visitors. There is good evidence that this does reduce nosocomial transmission. This has remained standard practice but unfortunately is often the least adhered to.

4. Private rooms are preferred but if private rooms are not available, cohorting is acceptable with a dedicated commode for each patient.

5. Chlorine containing cleaning agents should be used to reduce spore transmission, there was no recommendations with regards to changing curtains etc.

6. Environmental culture for clostridium difficile is not recommended.

7. Probiotics: Primary use of probiotics to prevent clostridium difficile is not recommended. There are no trials that support the theory that it will prevent clostridium difficile.

8. Metronidazole still remains the first line of therapy it is also recommended for relapse. But should not be used for long term therapy due to risk of neurotoxicity.

9. Treatment of greater than two recurrences can be done with vancomycin with either tapering or pulse treatment. Jury still appears to be out with clear guidelines on what should be done with frequent relapsers.

10. Though is is still very frequently used there is no evidence that use of rifampin or cholestyramine reduces the risk of future recurrence. In fact cholestyramine may delay recovery as it bind to the antibiotics in addition to the toxin.

11. Some practitioners use rifaxamin for the treatment of clostridium difficile with PO vancomycin. The only study on this was small study of 8 patients, where rifaxamin was used immediately after finishing the course of vancomycin it reduced the number of future relapses in 7 of the patients. A very small study and difficult to base widespread use of the agent based on this alone.

12. There is no compelling evidence that use of probiotics are useful in prevention or treatment of clostridium difficile. These agents are widely used with the general feeling that it “cannot hurt”. I am not sure that there is any evidence of this either. In fact there are cases of fungemia due to this.

There is ongoing study in the area of use of immunoglobulin for the prevention and treatment of refractory clostridium difficile. Widespread use cannot still be advocated.

Clostridium difficile remains an important disease and there remains a need for better understanding of the treatment especially in those with frequent relapses and refractory disease.

Prevention of infections aboard cruise ships

Spring break is here many Americans will go on vacation and some will take a cruise.

Cruises have become increasingly popular over the years as a form of vacation. Cruise lines have responded to the increased demand by adding larger ships to meet the demand. On the darker side cruise ships have been plagues by risk of infection outbreaks due to the over crowding aboard ships. The cruise lines have appropriately responded to this fear of outbreaks by instituting appropriate precautions without interfering with the vacation mood. In fact we just got back from our own spring break cruise in the Caribbean sea on Royal Caribbean’s Oasis of the Seas, their newest and currently largest cruise ship. I noticed several precautions since the last time we took a cruise several years ago. (BTW:The cruise was fabulous. I highly recommend it!)

From an infectious disease perspective I not only have to congratulate the cruise line on a phenomenal job with the accommodations and entertainment but also the attention to infection control issues.

Most dreaded infection issues are the ones transmitted by either droplet leading to respiratory infections or by contact leading to diarrheal illnesses like norovirus outbreaks that often get media attention that the cruise lines dread.

With regard to respiratory infections the few obvious changes in newer ships is the larger airspaces in common areas. The dining halls, the theaters and the promenade all had higher ceilings than on older cruise ships allowing for greater air exchanges. There was information posted daily about respiratory infections, H1N1 precautions etc.

Diarrheal outbreaks can quickly turn a vacation cruise into a nightmare adventure at sea, especially with the greater number of older persons on cruise ships who may be very susceptible to become very ill. If an effort to control this the cruise ships installed waterless hand sanitizer at the entry points to the ship and to the dining halls. They had staff reminding guests to use them. I was pleasantly surprised to see (non scientific observation) that the compliance rate among passengers was very high. I did not see the opposition from anyone that usually accompanies this kind of added inconvenience. Children, adults all seemed to participate and understand why this is needed. Of course the usual buffet controls were also in place such as sneeze guards, single use of plates and flatware etc.

It is very easy for corporations to go overboard (pun intended) with precautions in a knee jerk effort to control outbreaks at sea. These kind of measures prove to be counter productive in the long run. They create more inconvenience, greater cost, greater customer dissatisfaction without much hard science that they are getting anything for it. I did not see any of these problems on this particular cruise. Whoever is advising them is doing a good job.

All these precautions go a long way in making a successful vacation.
Hats off to Royal Caribbean cruise lines for the effort. We do appreciate it.

Successful vaccination season at our hospital

We have almost completed data collection from this years influenza vaccination season. participation has been higher among healthcare associates when compared to previous seasons at 68%. Despite the I
provements it is still too low to see the true benefit of herd immunity.
The most frequent reason to refuse inoculation is fear of complications. Of the 1900 doses given this year there were only 8 reported complication. Sounds like a lot at first but 7 of these were merely pain at the site of injection, yes we tracked even issues as minor as that. The remaining one felt faint and was taken to the ER only to be released back to work two hours later. No one called in sick in the subsequent weeks related to the vaccination. And there was no Gullian barre either!
Overall a successful vaccination season but hope to do better next year.

CDC releases H1N1 2009 Monovalent safety data

The Centers for disease control (CDC) released safety data on the current season H1N1 monovalent vaccine. Based on data collected a total of 82 adverse events were reported per million doses. This is in comparison to 47 cases per million doses seen in the seasonal influenza vaccine. At first this may seem much higher but the proportion of serious adverse effects was about the same.

Of the 3,783 adverse events reported in the 438,376 doses monitored, 204 adverse effects were categorized as serious (ending in death, hospitalization, disability) similarly 283 serious events were reported for seasonal influenza vaccination.

Of the 13 deaths that were reported nine had underlying illneses. One death occurred after a motor vehicle accident. There were no common conditions or causes of death in the 13 deaths.

With regards to Guillain Barre there were a total of twelve possible cases were reported. Of these only 4 actually met the definition of Guillain Barre.

Overall the number of adverse effects appear to be few and most of them of minor consequences. This is similar to the data published in the New England Journal of Medicine earlier. There are of course limitations in the data especially not being able to detect very rare associations but they will be after all “very rare”.

The healthcare community especially has done a remarkable job with H1N1 given the short time available to mount a response to the impending threat.

source MMWR

Influenza cases finally dropping- an update

The past few weeks are finally beginning to show a declining trend in the number of cases with influenza like illness (ILI) presenting to the ER . The last wave appears to have peaked the week of Oct 12-18 when we saw about 17% of visits to the ER having an ILI. The week of Nov 9-15 had 6% of visits with ILI. This week may be even lower. This is a welcome relief from the peak levels of mid Oct.

Nationally the same declining trend appears to be taking place with fewer states reporting active H1N1.

Does this mean that the season is over or that vaccination is not necessary? The answer is no to both.

Influenza does come in “waves”. We had a wave over spring break and another in Oct. We may get another wave in the next month or so. Having enough herd immunity through vaccination can minimize the wave by decreasing the number of susceptible individuals in the community. Remember the vaccination is of greater benefit for the community than for the individual. We all go a long way in protecting those who cannot protect themselves. So those who have not gotten their vaccinations should still do so.

On a side note; We are continuing to have intensive care hospitalizations due to influenza related complications. This week we have two otherwise healthy individuals between the ages of 45-50 with severe pneumonia related complication in the ICU. Both cases have been ill for over a month before seeking medical help. Both would have been infected during the last wave of influenza. Neither of them were vaccinated.

Remember even though the wave may have past. There are still people that may still be suffering from delayed complications.

Influenza activity Aug 30 to Oct 31 2009- a summary

Updates from the CDC show.

1. H1N1-2009 is the dominant influenza in circulation
2. Most isolates appear to be sensitive to Oseltamivir (tamiflu)
3. Outpatient visits for influenza like illnesses is higher than expected for this time of year (7.7% instead of 2.3%)
4. 672 deaths occurred due to lab confirmed H1N1 related illness in this time frame.

What is the effectiveness of seasonal influenza vaccination in preventing H1N1?

Data published from the CDC suggests that the seasonal vaccine is about 10% effective against H1N1, further underlining the need for specific 2009-H1N1 specific vaccination for this season.

In our local community the public response to vaccine clinics has been very good. We hope to increase the vaccination rate as the supply of vaccine improves in the coming week.

What about the risk of Guillain barre syndrome?

What Gullian barre? Guillain barre sydrome is a neurologic condition where the body immune systems antibodies misrecognizes parts of the nervous system as foreign and attacks it. The host can develop muscle weakness and even paralysis. This can be a serious condition. Fortunately it is very rare. This is NOT caused directly by a vaccine but by the immune system itself. This can therefore happen with anything that stimulates the immune system to produce more antibodies. In other words infection itself can produce GBS. Most GBS is caused by viral infections and by a common bacteria that causes food poisoning called Campylobacter.

There are about 10-20 cases of GBS per million population in any given year, this is known as the “background rate” of occurrence. This has been closely watched since the initial cases of GBS were reported in the 1970s and does not appear to have changed that much with subsequent influenza seasons. (Roper AH. The Guillain barre syndrome. N Engl J Med 1992 326:1130-6)

The first series of GBS related to vaccination was reported in JAMA in 1980. This was based on data collected from the 1976 influenza vaccination season where it was believed that people were getting GBS from the vaccination. In this study they cite an attributable risk of 13 cases of GBS per 100,000 population vaccinated (an alarmingly high number) based on a collection of 32 cases with a history of vaccination. They needed a background rate for comparison. Due to the lack of public health records for GBS at that time they called local neurologists on the roster of the local medical associations in the state of Ohio and asked them about all the cases they had seen in the studied time interval. With this information they arrived at a background prevalence of 2.6 cases per 100,000. Of course this data was met with appropriate alarm, it turned out to be a public relations fiasco.

More detailed studies of the initial finding were later published regarding the 1976 swine flu vaccination where 40 million people were vaccinated and possible 532 cases of Guillian Barre were reported and 32 people died. This gives a rate of
about 13 cases per million. One tenth the number originally cited in the smaller study and a number more in the middle of the expected background rate. Definitely less alarming.

Data collected prospectively in subsequent years have failed to demonstrate any increased risk.

The risk from vaccination therefore may add an additional risk of perhaps up to 1 additional case per 1,000,000 administered doses of influenza vaccine this is a very small number compared with the original 130 cases per 1,000,000 that was reported in the 1980 article. This is rare enough to go so far as to say that there is probably no causal relationship influenza vaccination and GBS.

Pregnancy and H1N1 vaccination

The question of vaccination for H1N1 in pregnancy is frequently asked. A small study published by NIH does provide some answers around this.

Why all the concern about pregnancy?
To date there have been 100 pregnant women hospitalized with H1N1 in the US this season. 28 deaths have occurred in this group. This is an alarmingly high proportion for this healthy group (28% of admissions!). Though the total numbers seem very small it is the proportion of deaths in this important group that is high. Why is this group more important than other? To say the obvious; too many other lives depend on these women. A pregnant women is likely to have other children at home, those children are not only at risk for illness from mother but if mother is incapacitated or worse dies can changes the social structure of the home and future lives of her young children. Loss of life in other groups of people as traumatic as it may be does not carry as great a social burden as losses in this group can. This group is therefore at highest priority to be vaccinated.

Do pregnant women have adequate response to vaccination?
The study does show that pregnant women do mount an adequate response to a single dose of inactivated injectable vaccine and it is well tolerated. The 15mcgm dose appears to provide adequate response in 92% of recipients and 30mcgm in 96% of recipients. the pool sizes were very small at 25 women in each group.

The H1N1 2009 vaccine is made in an identical process to the existing seasonal influenza vaccine. It is a killed vaccine, therefore cannot cause H1N1. It is also thiomersol free.

How fast does the vaccine work?

“I got sick the day after I got vaccinated, the vaccine does not work!” is a common statement of alarm that frequently comes to me. Please understand that this is neither a failure of the vaccine nor caused be the vaccination itself.

Remember that the vaccine itself does not kill influenza. The vaccine stimulates your immune system to be ready for influenza if it were to encounter it in the future. This preparation or training takes about 2 to 4 weeks. Therefore there is some potential to get the “real” illness early after vaccination, though even that should be milder than if one was not vaccinated.

So if someone at home gets ill in the days after you got your vaccination, do not blame the vaccine. We are in the depths of flu season it is more likely than not that little johnny got infected at school than from your dead vaccination.