Annex C: - CDI What’s the diff?

4th Annual Outbreak Management Workshop

September 19, 2013

Naideen Bailey & Grace Volkening

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There’s an updated Annex C

• Annex C is an extension to the PIDAC – Infection Prevention and Control ‘Routine Practices and Additional Precautions in All Health Care Settings’ November 2012

• Appropriate for but not limited to: acute care, long-term care, chronic (including mental health) care and home health care

• Incorporates Ministry of Health and Long-Term Care. Control of Clostridium difficile Infection (CDI) Outbreaks in Hospitals, A Guide for Hospital and Health Unit Staff. 2009

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Background

• Mandatory public reporting of nosocomial CDI began in Ontario public hospitals in Sept. 2008

• Between 2009 and 2011, rates of CDI increased 13% in Acute Teaching and Large Community Hospitals (from 0.30/1000 patient days in 2009 to 0.34/1000 patient days in 2011)

• Current rate as of July 2013 is 0.29/1000 patient days

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Emerging CDI knowledge

• Data is starting to accumulate regarding community-associated C. diff

• Role of community environments, food, water sources and animal sources of C. diff may need to be considered – more research is currently underway

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Outbreak investigations

• Number of strains identified per outbreak ranged from 1 to 41, with a median of 3 distinct strains

• Is it an outbreak?

• Is community acquisition/carriage and antibiotic use contributing to the burden and expression of CDI in hospital?

• NAP1 Strain represented 60% of all C. difficile outbreak strains as tested by PHO laboratories.

• All isolates were susceptible to metronizadole and vancomycin (still preferred treatment options)

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So what’s changed in this Annex? A number of updates including:

• IPAC measures

• CDI testing and surveillance (addition to the case definition and removal of 80th percentile as an outbreak threshold)

• Management of CDI outbreaks

• Overall, stronger positions on patient accommodations, enhanced cleaning practices, baseline rate determination, surveillance and treatments

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“There are two major components to successful control of CDI – effective infection prevention and control (IPAC) measures and antibiotic stewardship” Annex C, 2013 p.5

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IPAC Measures Sustained control of CDI may be achieved with a bundle of IPAC measures directed at interrupting the horizontal spread

• A system for identification and prompt isolation of suspected or known CDI cases

• Appropriate environmental services policies and procedures for rooms/bathrooms of CDI cases, including use of sporicides

• A hand hygiene program

• A system for disposal of human waste that prevents environmental contamination

• Access to appropriate and timely laboratory testing

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Treatment • New antibiotic option – Fidaxomicin

• Similar to vancomycin for curing CDI and is superior for reducing CDI recurrences

• New prevention and treatment modalities that are being explored include;

• probiotics

• faecal microbiota transplantation

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• Discontinuation of precautions for CDI

• Relapse of symptoms

• Occupational Health

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Other IPAC measures covered are:

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• Ideally laboratory testing turnaround should be less than 24 hours and the test should be available 7 days per week

• Testing by molecular methods (PCR) is more sensitive and is now considered testing method of choice

• If the first molecular test is negative there is no need for a second test

• Re-testing for test of cure is not indicated

• Testing should not be carried out on formed stools

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CDI Testing and Surveillance

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• Laboratory confirmation of C.difficile together with diarrhea* or

• Visualization of pseudomembranes on sigmoidoscopy or colonoscopy or • Histological/pathological diagnosis of pseudomembranous colitis or • Diagnosis of toxic megacolon

PLUS (newly added to the case definition)

• For the purpose of defining a case of CDI, there should be 3 or more episodes of diarrhea within a 24 hour period

*Remember to initiate contact precautions at onset of diarrhea without waiting for further episodes

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Case Definition of Clostridium difficile Infection (CDI)

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Case Definition

• Testing can detect C. difficile colonization or disease

• Results of laboratory testing must be correlated with the clinical condition of the patient/resident

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• Cases of CDI occurring at a rate exceeding the normally expected baseline rate for the health care setting during a specified period of time should be investigated as a possible outbreak

• CDI outbreak definitions incorporate the concept of notification thresholds – points that trigger action and dialogue between local public health unit and the facility

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CDI Outbreak identification and thresholds

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For wards/units with ≥20 beds,

• three (3) new cases of nosocomial CDI identified on one ward/unit within a seven-day period

OR

• five (5) new cases of nosocomial CDI within a four-week period,

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CDI Notification thresholds:

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CDI Notification Thresholds

For wards/units with <20 beds,

• two (2) new cases of nosocomial CDI identified on one ward/unit within a seven-day period

OR

• four (4) new cases of nosocomial CDI within a four-week period,

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CDI attribution: Yours? Ours? Their’s?

• Annex C provides surveillance guidance and this differs from public reporting requirements, which has three levels of attribution

• Careful and full review of the case clinical information and past history is needed when determining attribution

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CDI Outbreaks (cont’d)

Facilities that have a facility nosocomial CDI rate that exceeds their annual nosocomial baseline rate for a period of two consecutive months

NOTE: This is not valid for a small community hospital, where a single case of nosocomial CDI can artificially elevate the facility rate

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Note: exceeding a threshold does not necessarily imply that an outbreak will be declared

Consultation with local public health unit and/or with the local regional infection control network is available for facilities with limited experience in managing CDI outbreaks

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CLEANING UP ON CDI

And now over to Grace Volkening

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