Important Findings in C difficile Infection

The Role of Infection Control

Standard teaching is that Clostridium difficile infection (CDI) is a hospital-acquired infection that reflects a failure of infection control, but it may be more closely related to antibiotic control. A recent report from the Centers for Disease Control and Prevention (CDC), based on an analysis of 10,342 cases of CDI in 111 hospitals and 310 nursing homes, showed that 75% of the patients were already colonized with C difficile at the time of admission.[1] Nearly all (94%) of these cases were “healthcare-associated,” meaning that acquisition occurred during an outpatient visit, a nursing home stay, the current hospitalization, or a previous hospitalization. Only 25% of patients actually acquired the pathogen in the same hospital where clinical expression of CDI occurred.

Clinical relevance. The CDC study suggests that infection control personnel and physicians need to be aware of this association, because this may require changes in infection control practice. The implication is that to prevent CDI, clinicians need to find ways to identify patients who are already colonized to protect them from obvious risks, and also to consider them to be potential sources of infection to others. This could substantially change infection control practice for prevention of CDI.

5 Important Developments in C difficile Management.
5 Important Developments in C difficile Management.

Fidaxomicin- Fidaxomicin is the second drug approved by the US Food and Drug Administration (FDA) for the treatment of CDI. The first was oral vancomycin, which was approved in 1978 on the basis of a 16-patient randomized controlled trial.[2] The fidaxomicin trials included approximately 1200 patients randomly assigned to receive fidaxomicin vs oral vancomycin.[3,4] Results showed similar initial response rates (88% vs 86%), but a significantly reduced rate of relapse in fidaxomicin recipients (15% vs 25%).[3] A subsequent trial showed that fidaxomicin was also superior to vancomycin in prevention of a second relapse in patients who had already experienced a relapse of CDI (36% vs 20%).[5] The presumed mechanism for reduced rates of relapse is a less pronounced alteration of the colonic microbiome with fidaxomicin,[6] which is presumed to be the ultimate control of C difficiletoxin production.

Clinical relevance. It appears that fidaxomicin is a good drug for CDI because it is FDA-approved; similar to oral vancomycin with respect to cure rates; and clearly superior in terms of “global cure” rates, which include initial responses without relapses. Nevertheless, the cost of fidaxomicin (which reflects the high cost of FDA trials) is intimidating.

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Increased Iron in Brain Associated With Alzheimer’s Disease

A recent UCLA study has shown that individuals with Alzheimer’s disease (AD) have increased ferritin iron levels in the hippocampus, but not the thalamus, and this iron accumulation occurs in conjunction with hippocampus damage.

These findings, along with prior observations, suggest that “increased brain iron may be contributing to the process that leads to AD,” said senior study author George Bartzokis, MD, Department of Psychiatry and Biobehavioral Sciences, The David Geffen School of Medicine at UCLA, Laboratory of Neuroimaging, Department of Neurology, Division of Brain Mapping, UCLA, and Department of Psychiatry, Greater Los Angeles VA Healthcare System, West Los Angeles, CA.


The study noted that iron accumulates in gray matter regions of the brain as one ages, which may contribute to the risk of developing AD and other age-related diseases. Although previous magnetic resonance imaging (MRI) studies have demonstrated increased iron deposits in basal ganglia regions, the hippocampus (a region of the brain associated with memory and one of the first regions of the brain to suffer damage in persons with AD) and the thalamus (a region that is generally not affected until the later stages of AD) have rarely been examined.

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Nurse Training Program Boosts Quality

Administrators are caught between a rock and a hard place. Among the rubs are reimbursement rate reductions of up to 15 percent, constant pressure to reduce hospital admissions, new battles to attract and retain core nursing staff in a shallow pool of nurses, and possible further cutbacks in Medicare and Medicaid payments, just to name a few.

Like many since the 2008 economic crash, facility administrators have no choice. They must do more with less.
At risk is care quality, which triggers a domino chain. Less quality equals less satisfaction. Eventually, this means fewer patients; fewer residents; and fewer referrals from hospitals, families, and from happy clients.

At issue is prosperity—a survival of the fittest—in a rapidly changing, super-competitive, viselike marketplace.

What’s A Provider To Do?

In tough economic times, three administrators—in Alaska, Massachusetts, and Nebraska—took a counterintuitive approach. They spent money on registered nurse (RN) training. They enrolled their nurses in a unique gerontological certification course based at the University of Nebraska Medical Center.

Bill Bogdanovich

Among facility operators who became involved in the course—known as Gero Nurse Prep (GNP)—early were Alaska’s Charlie Franz, Massachusetts’ Bill Bogdanovich, and Nebraska’s Roger Biens. What intrigued them? That higher-care quality also fosters lower costs.

GNP was born with one purpose: improve quality in long term and post-acute care centers. It was created by the University of Nebraska Medical Center (UNMC) College of Nursing.

“RN degree programs historically gave little attention to geriatric nursing,” says Catherine Bevil, RN, EdD, director of continuing nursing education at UNMC. “While that’s changing as the biggest generation in U.S. history ages, the fact remains that most RNs today—about two-thirds—have zero geriatric training.”

GNP, she said, is solely focused on current, evidence-based clinical nursing skills for seniors. “The nursing profession has always been about health promotion, disease prevention, and symptom management. We take that to a new level for geriatrics. It’s niche nursing for long term and post-acute care.”

Advanced geriatric knowledge and skills, says Bevil, mean measurably better care. Ten interactive learning modules train RNs to:

  • Manage physical and mental aspects of aging;
  • Quickly recognize symptoms, changes, and problems;
  • Keep physicians, administrators, and the nursing team well informed; and
  • Be attentive and compassionate in talking to residents and their families.

Training Promotes Patient-Centered Care

“Many seniors say they feel invisible,” says Bevil. “This course puts them front and center.”

The learning program emphasizes prevention of adverse events, especially those with potential for lingering, time-intensive, and costly consequences.

For example, falls, medication errors, and pressure ulcers are serious health risks for seniors in long term and post-acute care. “Proper nursing practice cuts risk substantially,” Bevil says. “In geriatric nursing especially, an ounce of prevention is better than a pound of cure—but RNs need sharper awareness and preemptive action steps.”

Catherine Bevil, RN, EdD

Higher-quality care yields other benefits, she explains. It means happier residents and families, and that means happier nurses. Not only do RNs feel more competent, confident, and empowered, they also get more positive feedback and recognition, she says.

That in turn feeds staff stability, with lower RN churn, which means fewer temp nurses, less recruiting time and expense, less new staff orientation, and less disruption of nursing care teams, Bevil says.

GNP prepares RNs to pass the certification exam in gerontological nursing administered by the American Nurses Credentialing Center. To date, GNP alums have a 98 percent pass rate.

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Get Recognized for Your Achievement!

Calling all Gero Nurse Prep Grads!

We need your help! Provider magazine, published by the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL), the major associations for the long term and post-acute care industry, would like to honor nurses who have become board certified after completing Gero Nurse Prep. AHCA/NCAL would also like to recognize you in other print and online advertisements related to Gero Nurse Prep.

To take advantage of this opportunity for public recognition of your achievement, call Anji Wittman at 402-559-6565 by June 7!

Dementia Care Conference

Heidi Keeler, Gero Nurse Prep faculty, is presenting a breakout session on how to increase quality of care in the long term setting at the annual Dementia Care Conference on March 22, 2013 in La Vista, NE. The conference is sponsored by the Midlands Chapter of the Alzheimer’s Association, and will be attended by area experts, health care providers, facility administrators, and family interested in how to care for older adults with cognitive decline. Take a look at the following link to learn more about the conference: Dementia Care Confrence

A Forecast: Long Term And Post-Acute Care

As President Obama prepared to give his State of the Union address on Tuesday evening, Provider asked Gov. Mark Parkinson, president and chief executive officer of the American Health Care Association, to draw upon his experience as both a long term care owner/operator, and as a former policymaker, to assess the state of long term and post-acute care today.

In this eight-minute video, Parkinson answers five questions from Managing Editor Meg LaPorte that frame the pressing issues facing the nation as they impact nursing homes.

From the impending cuts to Medicare rates, how providers are working to improve quality care, to what his organization is doing to avert further cuts to Medicare and Medicaid funding, Parkinson is pragmatic and succinct in his forecast as he forecasts the near future in his approach.