Clostridium difficile infection

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Clostridium difficile infection
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Case definition of CDI

• Toxin positive symptomatic patient
• Diarrhoea (gt 3 loose stools per day) for at least
  48 hours
• (be aware of occasional severe cases without
  diarrhoea)

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Case definition of CDI (ii)

• Lab issues
• When to re-test
• Repeat toxin positive cases 28 days
• Positive, negative predictive values
• Clinical issues
• Accuracy of diarrhoea history
• Faecal incontinence
• Severity

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ingest excreteasymptomatic carriagediarrhoea
colitispseudomembranous colitisdeathonly 20
of cases of antibiotic associated diarrhoea are
caused by CDI
Consequences of C. difficile acquisition
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Laboratory reports of Clostridium difficile
England, Wales NI 1982-2006
Data for NI only included from 2001. Data for
2005 and 2006 are for England only (mandatory HPA
surveillance, gt65 year olds only).
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Number of death certificates mentioning
Clostridium difficileEngland Wales, 1999-2005
69?
number of deaths
National Statisitics Online http//www.statistics.
gov.uk/cci/nugget.asp?id1735
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C. difficile 027

• Outbreak of hypervirulent strain since 2001/02
• Numerous US states have also been affected
• Europe wide, 90 NHS hospitals
• In one Canadian hospital the incidence of CDI
  increased 5-fold 1991 to 2003 (8-fold in
  patients aged gt65)
• Measured complications at 1 month
• Colectomy 1.9
• ICU admission 6.5
• Crude mortality 24.8
• Attrib mortality 12

Pepin et al. CMAJ 2004171466-72.
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C. difficile 027/other virulent strains
cannot reliably detect CD 027 cases clinically
i.e. many cases are indistinguishable from
normals high index of suspicion when to
review control measures when to escalate therapy
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UK epidemic strains

• Up until 2003/4 CD 001 was responsible for 60
  of cases
• 2006 sentinel data 2007
• CD 001 25 of cases ?
• CD 106 25 of cases ?
• CD 027 25 of cases ?

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Antibiotics and risk of CDi
Need to minimise all antibiotic use -
polypharmacy and duration
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CDI risk factor studies

• Most are flawed
• Inappropriate controls
• Failure to control for key confounders
• Antibiotic duration
• Antibiotic polypharmacy
• Exposure to C. difficile
• Outbreak based studies
• Multiple interventions

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Number of antibiotics received by 027 cases and
controls in 30 days prior to CDi diagnosis
n35
n35
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CDI key control measures

• Early warning system to identify changes in local
  epidemiology
• Reduce risk of transmission
• Isolation/cohorting of cases
• Environmental cleaning, chlorine
• Hand hygiene soap water
• Examine/optimise/reduce overall antibiotic use
• Limit high risk agents in high risk patients
• Feedback CDI and antibiotic data on a regular
  basis

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Effect of viral gastroenteritis on incidence of
CDi
0.036 CD toxin ve cases per ward day
2.75x increase in faecal sample testing (P0.001)
0.076 CD toxin ve per day that ward has
confirmed cases of viral gastroenteritis (P0.02)
Wilcox MH, Fawley WN. J Hosp Infect 2007 in
press.
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Clostridium difficile Ribotyping Network for
England (CDRNE)
Established (2007) by the Health Protection
Agency. With a roll out programme increasing
ribotyping for hospitals in England, from a
network of 6 laboratories.
Leeds (reference laboratory), Birmingham, London,
Manchester, Newcastle, Southampton.
Mark.Wilcox_at_Leedsth.nhs.uk
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When to consider CDRNE

• Increase in frequency or severity of cases of CDI
• or
• Increase in mortality
• or
• Increase in the recurrence rate
• If in doubt please discuss with Regional
  Microbiologist
• Must routinely store faecal samples/aliquots
  (-20oC) to enable enhanced surveillance
•  

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