Clostridium difficileassociated disease CDAD

1
Clostridium difficile-associated disease (CDAD)

• Public Reporting
• Outbreak Management

August, 2008
2
Acknowledgements

• Dr. Mary Vearncombe, Chair, PIDAC Infection
  Prevention and Control Sub-committee
• Ms. Sandra Callery, Chair, PIDAC Surveillance
  Sub-committee
• For permission to reproduce their slides from the
  OHA/MOHLTC C. difficile videoconference June 26,
  2008

3
Overview

• Overview of Clostridium difficile associated
  disease (CDAD) in hospitals
• Surveillance for CDAD
• Public reporting for patient safety indicator
• Outbreak reporting and management

4
General Principles for Infection Prevention and
Control

• Each facility should establish a surveillance
  program for C. difficile and maintain a summary
  record
• Infection Prevention and Control should review
  and analyze these data on an ongoing basis
• The report should be submitted to the Infection
  Prevention and Control Committee and facility
  administration on a regular basis
• An antibiotic stewardship program should be in
  place in the facility and regular reports made to
  Pharmacy Therapeutics Committee and then to
  Infection Prevention Control Committee

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Overview of CDAD
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Clostridium difficile What is it?

• Gram positive, anaerobic, spore-forming bacillus
• Widely distributed in environment colonizes 3-5
  adults
• Commonest cause of infectious diarrhea in
  hospitalized patients
• Range of C. difficile associated disease
• Diarrhea, pseudomembranous colitis, toxic
  megacolon
• Incidence and severity of illness appear to be
  increasing
• Presence of NAP1 strain does not change IPC Best
  Practices

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Clostridium difficile Who gets it?

• Risk factors include
• History of antibiotic usage
• Bowel surgery
• Chemotherapy
• Prolonged hospitalization
• Additional risk factors predisposing to more
  severe disease include
• Increased age
• Serious underlying illness or debilitation

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Epidemiology

• Known cause of healthcare and community
  associated diarrhea for about 30 years.
• Can cause mild diarrhea or life-threatening
  disease
• C. difficile produces spores that survive for
  long periods and are resistant to destruction by
  many environmental factors (e.g. temperature,
  humidity)
• Inadequate hand hygiene and inadequate
  environmental cleaning contribute to the spread
  of C.difficile.

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Infection Prevention and Control (IPC)

• Infection prevention and control programs for
  Clostridium difficile associated disease (CDAD)
  are important to
• Assist staff to promptly identify clusters of
  CDAD
• Infection prevention and control practice for
  Clostridium difficile associated disease is
  important to
• Prevent the transmission of CDAD to other
  patients

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Prompt identification and Implementation of
Contact Precautions

• Initiate contact precautions at onset of
  diarrhea. Obtain laboratory specimens. Do not
  wait for 24 hours of loose stool and do not wait
  for laboratory results
• Contact precautions should be initiated by the
  health care professional who first identifies new
  onset diarrhea. Single room with toilet
  preferred. Gown and gloves for room entry
• Notify IPC of case
• Contact precautions remain in place until C.
  difficile is ruled out, or if C. difficile
  confirmed until at least 48 hours after symptoms
  resolved
• Only IPC should discontinue precautions

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Laboratory testing for C. difficile

• Detection of cytotoxins A and B
• Point of care assays do not have sufficient
  sensitivity and are not recommended
• Stool specimen collection should be done ASAP
  after onset of watery diarrhea
• Quick turn around time, e.g. within 24 hours,
  should be available and pre-arranged with the
  microbiology laboratory
• All positive tests should be reported to IPC
  immediately
• Do not test formed stools
• Do not test infants (normal flora)
• Do not do test of cure

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Repeat tests, Relapse, Recurrences

• If results are negative but symptoms persist,
  then perform a second test.
• Screening all patients for C.difficile? There is
  no evidence to support toxin assay testing on
  asymptomatic individuals.
• The duration to determine relapse is unknown.
  Expert opinion is that If symptoms recur within 8
  weeks consider this a relapse and do not record
  as a new case.
• Recurrence is Common occurs in about 30 of
  cases

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Contact Precautions

• Post Contact Precautions sign at patient room.
• Gown, gloves readily accessible and used by all
  health care staff entering room
• Dedicate patient care equipment if must be
  shared, clean and disinfect after each use
• No rectal temperatures
• No special handling of trays, linen or waste
• Handle bedpans and commodes carefully

15
Hand Hygiene

• All health care facilities should follow best
  practices and have a hand hygiene program in
  place, i.e. PIDAC Best Practices for Hand Hygiene
  and Just Clean Your Hands
• Observe meticulous hand hygiene with either
  alcohol-based hand rub (ABHR) or soap and water

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Hand Hygiene

• Soap and water is theoretically more effective in
  removing spores than ABHR
• When a dedicated hand washing sink is immediately
  available, wash hands with soap and water after
  glove removal
• When a dedicated hand washing sink is not
  immediately available, clean hands with ABHR
  after glove removal use of ABHR has not
  contributed to spread of CDAD
• Do not use patient sink for hand hygiene
• Educate and assist patients in hand hygiene

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Environmental Cleaning

• Advise Environmental Services of cases
• Cleaning must be thorough and adequately
  resourced
• All horizontal surfaces and items within reach
  must be cleaned twice daily with a hospital grade
  disinfectant

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Environmental Cleaning

• Pay particular attention to high touch items
• Cleaning must be thorough
• Clean to dirty
• Do not spray apply directly saturate ensure
  sufficient contact time
• Change cloths and mops frequently no
  double-dipping
• Use dedicated disposable toilet brushes may
  remain in patients room until discharge/transfer

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Environmental Cleaning

• If ongoing transmission of C. difficile, consider
  use of hypochlorite-based products after
  hospital-grade disinfectant, or other product
  with sporicidal claim, e.g. higher concentration
  accelerated hydrogen peroxide
• Discharge/transfer cleaning must be done at
  resolution of CDAD symptoms or when patient moved
  from the room (e.g. moved from multi-bed room to
  single room) maintain Contact Precautions until
  cleaning complete
• Launder all privacy, shower and window curtains
• Thoroughly clean patient bathroom
• Discard all disposable items
• Discard toilet brush
• If patient is transferred from a multi-bed room
  to another room the entire toilet/bathroom in
  the multi-bed room must be cleaned

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Accommodations

• All patients with suspect or confirmed CDAD
  should be placed in a single room with dedicated
  toilet facilities
• When single room not available
• Consult with IPC professional
• Cohort patients with confirmed CDAD
• If multi-bed room temporarily required ensure
  patient space has visible Contact Precautions
  sign, dedicated toileting facilities and
  accessible laundry and supply cart

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Patient Transfer

• Receiving department/facility and transportation
  services must be notified of precautions required
  before transfer
• If transferring to another facility, inform IPC
  of the receiving facility
• Does not preclude transfer within healthcare
  system!
• Receiving department/facility must be able to
  comply with accommodations and Contact Precautions

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Discontinuation of Precautions

• Consult with IPC
• Contact Precautions may usually be discontinued
  when patient has at least 48 hours symptom free
• Retesting for C. difficile cytotoxin is not
  necessary to discontinue precautions and should
  not be done

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Patient Discharge

• After discharge home, no additional precautions
  are required for family members however...
• Hand hygiene should always be practiced by
  patient and by their family, before and after
  performing any care for the patient.
• Education on hand hygiene should be provided

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Treatment Recommendations

• Treatment recommendations outlined in PIDAC best
  practice document.
• The physician may start treatment for CDAD before
  the laboratory results are available
• Should include
• Cessation of antibiotic(s) if possible
• Rehydration of patient
• Avoidance of antimotility agents

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Recurrence of symptoms

• Common occurs in about 30 of cases
• If diarrhea recurs
• Place patient on Contact Precautions
• Re-test for C. difficile
• Physician may re-start therapy before test
  results available
• Patients with recurrent CDAD consider leaving in
  single room accommodation

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Visitors

• Should receive instruction on hand hygiene and
  personal protective equipment.
• If visitor providing care, or significant contact
  with patient, they should wear gown and gloves
• Printed information sheets are helpful
• Should not use patient bathroom or enter other
  patients rooms or bedspace

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Education and Empowerment

• All direct care providers should receive
  education on C. difficile, including measures to
  control spread and their responsibility to
  identify and act on new onset diarrhea
• Reinforce that staff are not at risk with
  consistent use of Routine Practices and safe work
  practices, e.g., no eating or drinking in patient
  care areas

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Program Evaluation

• The facility C. difficile IPAC program should be
  evaluated on a regular basis
• Make improvements based on new literature,
  standards, facility trends
• Periodic audits of hand hygiene and environmental
  cleaning should be done. (e.g. Environmental
  cleaning audits should be done by Environmental
  Services in collaboration with IPC)

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Prevention is always preferable over control

• Early identification of patients, i.e. syndromic
  surveillance
• Empowering front-line staff to institute Contact
  Precautions at onset of symptoms
• Daily surveillance reporting to Infection
  Prevention Control (IPC)
• IPC resources appropriate to the facility

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Surveillance 101
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Objectives of surveillance

• A tool for improvement of patient outcomes..
• Quality assurance/Risk Management
• To benchmark
• To evaluate the effectiveness of our
  interventions
• To know when you have a problem..
• Outbreak Detection

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Plan

• Who will collect the data?
• What will be collected?
• Where will we find the data (sources)?
• How will rates be calculated?

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Who will Collect the Data?

• Each facility should be conducting surveillance
  for CDAD.
• Those collecting the data should be managed by
  trained and experienced professionals skilled in
  data collection procedures (e.g. Infection
  Prevention and Control).

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Case Definition of CDAD

• The case definition of CDAD is
• Diarrhea with laboratory confirmation of a
  positive toxin assay (A/B) for C. difficile
• OR
• Visualization of pseudomembranes on sigmoidoscopy
  or colonoscopy
• OR
• Histological/pathological diagnosis of
  pseudomembranous colitis.

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What is diarrhea?

• Diarrhea is defined as
• Loose/watery bowel movements (conform to the
  shape of the container)
• AND
• The bowel movements are unusual or different
  for the patient
• AND
• There is no other recognized etiology for the
  diarrhea (for example, laxative use)

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Surveillance Case Definitions

• New nosocomial case of CDAD associated with
  reporting facility
• A case that meets the case definition for CDAD
• AND
• CDAD was not present on admission (i.e., onset of
  symptoms 72 hours after admission)
• OR
• the infection was present at time of admission
  and patient was admitted to the same facility
  within the last 4 weeks.
• AND
• the case has not had CDAD in the past 8 weeks.

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Surveillance Case Definitions

• New nosocomial case of CDAD associated with other
  health care facilities
• A case that meets the case definition for CDAD
• AND
• CDAD was present on admission
• OR
• the case had symptom onset admission
• AND
• the case was exposed to any other health care
  facility (including LTC) other than the reporting
  facility within the last 4 weeks
• AND
• the case has not had CDAD in the past 8 weeks.

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Surveillance Case Definitions

• New case of CDAD associated with source other
  than a health care facility or indeterminate
  source
• A case that meets the case definition for CDAD
• AND
• CDAD was present on admission
• OR
• the case had symptom onset admission
• AND
• there was no exposure to any health care facility
  within the last 4 weeks
• OR
• the source of infection cannot be determined
• AND
• the case has not had CDAD in the past 8 weeks.

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Case Finding for Clostridium difficile Infection

• Use the following Data Sources
• Sentinel reports
• Daily syndromic surveillance
• Laboratory reports to Infection Prevention
  Control

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Data Collection What to collect

• Name
• Medical Record
• Date of Admission
• Previous Admission in last 4 weeks?

• Symptoms and date of onset.
• Laboratory results
• Treatment
• Date symptoms resolved

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Data collection

• Numerator number of new nosocomial cases of
  CDAD associated with reporting facility by month.
• Denominator number of patient days for that
  month

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Calculation of Rates

• Rates are calculated by month
• of new nosocomial cases of CDAD associated
  with reporting facility of patient days x
  1000
• This represents the incidence rate of nosocomial
  cases of CDAD per 1000 patient days.
• (e.g., 5 cases9865 pt.days 5.068 x 1000 0.5
  per 1000 patient days)

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Interpretation of Data

• Regular reporting to IPC Committee, Medical
  Advisory Committee.
• IPC should review and analyze information to
  identify trends and clusters and direct
  interventions as required.
• Benchmarking internal versus external.
• Flag the patients electronic record? No
  benefit.

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Tools for Surveillance

• MOHLTC is developing an Excel based tool to
  assist hospitals that do not have an electronic
  surveillance system in place to capture CDAD data
• The tool will allow the hospital to enter CDAD
  surveillance information and produce monthly
  reports for IPC committee as well as public
  reporting

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Public Patient Safety Indicator Reporting
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What?

• All new nosocomial cases of CDAD attributable to
  the reporting facility
• All new CDAD cases attributable to other
  facilities
• All new unknown/indeterminate CDAD cases
• Patient days
• The rate of new nosocomial cases of CDAD
  associated with the reporting facility will be
  included.

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Who?

• All public hospitals
• This includes all mental health facilities,
  rehabilitation facilities and complex continuing
  care facilities that are funded as public
  hospitals

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When?

• Reports sent to Ministry of Health and Long-Term
  Care (MOHLTC) by 15th of each month
• First report due September 15, 2008

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How?

• CDAD Patient Safety Indicator data to be entered
  by hospital using Web Enabled Reporting System
  (WERS) template
• Determine who in your facility is responsible for
  entering the WERS data
• Provide them with the data elements using the
  MOHLTC WERS form

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Data

• Data are to be provided by site
• Hospitals that have more than one site will be
  required to report separately for each site
• Patient days for the reporting period will also
  be required infants excluded from patient days

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Draft Data Elements for Public Reporting on WERS
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Calculating rates for public reporting

• Use the same formula
• Nosocomial your facility new nosocomial
  cases of CDAD of patient days x 1000
• Rates cannot be calculated for
• Nosocomial CDAD cases associated with other
  health care facilities or
• CDAD cases associated with a source other than
  health care facilities or indeterminate source

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Outbreak Management
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Systems and Tools in OB Management

• Relevance Support the needs of prevention,
  detection, investigation, monitoring, management,
  analysis, and reporting of an OB
• Surveillance related
• Data collection system
• Standardization case definitions
• Established reporting channels
• Program related
• IPAC Program (well designed, sustainable, systems
  supported)
• AB review Program

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Who is included?

• Requirement to report is for all public hospitals
  including acute care, mental health,
  rehabilitation, and complex continuing care

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Outbreak Management - definitions

• Ward or Unit-level thresholds
• Three or more new nosocomial cases of CDAD
  associated with the reporting facility within a 7
  day period on a single ward/unit shall be treated
  as cluster.
• investigation and review should be actively
  undertaken and IPAC team must notify and liaise
  with the local public health unit to determine if
  this represents an outbreak.
• Six or more new nosocomial cases of CDAD
  associated with the reporting facility within a
  30 day period on a single ward/unit constitutes
  an outbreak.
• Outbreak reporting is mandatory immediately to
  the local public health unit when this level is
  reached.

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Outbreak Management - definitions

• Facility-level outbreak
• Baseline CDAD rate is the cumulative number of
  new nosocomial cases of CDAD associated with the
  reporting facility divided by the of patient
  days and expressed as a rate per 1,000 patient
  days
• Facility-level outbreak must be declared when
  baseline CDAD rate is at or above the 80th
  percentile of the average rate for comparator
  facilities calculated on a quarterly basis
• Facilities that are under the 80th percentile for
  their category but have experienced a doubling of
  their new nosocomial cases of CDAD for 2
  consecutive months should trigger investigation
  and notification of their local public health unit

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Additional Data Collection Elements - Outbreaks

• Patient Data
• Complications toxic megacolon, colectomy, death
• Deaths date and cause of death
• IPC measures implemented

• Facility Data
• Outbreak
• Date of onset for index case
• Date of onset for last case
• Total of cases
• patient days in outbreak affected area during
  the outbreak

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Steps in the Outbreak Management Process

• IPAC Measures
• Contact Precautions for all patients with
  diarrhea as soon as symptoms identified
  appropriate PPE available
• Hand Hygiene
• Dedicated equipment
• Environmental cleaning protocols reviewed with
  housekeeping
• Education staff, patients, visitors

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Steps in the Outbreak Management Process

• Assessment
• Review data based on the surveillance definition
• Ensure all cases are on line list include lab
  results
• Ensure IPAC measures implemented
• Determine whether a cluster or possible outbreak
  exists
• Notify Senior Management Team
• Contact local public health unit to discuss
  findings

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Steps in the Outbreak Management Process

• Consult with local Public Health Unit
• Notify local MOH/designate and provide line list
• Obtain outbreak
• Share contact information for ICP and PH staff
  member responsible for outbreak
• Outbreak declared
• Outbreak Management Team (OMT) established
• Outbreak declared in consultation with local MOH

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Steps in the Outbreak Management Process

• Outbreak Management Team
• Initial meeting held with representatives from
  hospital IPAC program, Senior Management,
  appropriate hospital departments and local public
  health unit
• Define roles and responsibilities including
  communication channels
• Develop communication to hospital departments and
  stakeholders including other health care
  facilities, LHINs, RICNs
• Review line list and IPAC measures implemented
• Confirm PIDAC case definition being used
• Identify any additional measures required

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Steps in the Outbreak Management Process

• Ongoing Outbreak Management
• OMT to meet regularly during outbreak frequency
  will depend on activity in the outbreak
• Surveillance for new cases daily. Review the
  line list daily with public health
• Identify and implement any additional IPAC
  measures and communication strategies required

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Steps in the Outbreak Management Process

• Declare Outbreak Over
• Declaration made in consultation with public
  health and hospital based on
• of cases decreased to baseline level
• IPAC measures to prevent transmission are
  sustained
• Review of Outbreak
• OMT debriefs
• Report prepared jointly by hospital and public
  health on outbreak including lessons learned,
  recommendations to prevent future outbreaks
• Report distributed to IPAC Committee and Senior
  Management

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Case Studies
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Case Study 1

• Mrs. Smith is admitted to Hospital A on June
  10th. She is then transferred to Hospital B on
  the 15th where she is prescribed antibiotics. She
  is transferred back to Hospital A on the 19th. On
  the 23rd, she develops diarrhea and subsequently
  tests positive for CDAD.
• Questions
• The patient was admitted to 2 facilities within 4
  weeks and the patient tested positive after her
  second stay at the first facility after 72 hours.
  Which hospital reports the case?
• Do you need to review the chart for more clinical
  data prior to determining is she is a nosocomial
  case or not?
• Does the use of antibiotic in one facility mean
  it is their case?

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Case Study 2

• M. Louis Pasteur is a 45 year old male
  construction worker admitted to your facility
  with a diagnosis of dehydration on July 2nd. He
  reports that he has been experiencing at least 6
  watery foul smelling bowel movements every day
  for the last week. He just finished taking
  antibiotics for a dental abscess. This is the
  first time he has been admitted to a hospital.
• Questions
• Should a stool specimen be sent?
• Should additional precautions be initiated? If
  yes, which type?
• How should this case be classified?

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Case Study 3

• Ms. Florence Nightingale is an 82 year old female
  who fell at home and broke her hip on July 4th.
  She was admitted to your facility on the same
  day, and had a hip replacement on July 5th. She
  received appropriate pre-op prophylactic
  antibiotics. On July 9th she became incontinent
  of loose stools. A stool specimen was sent and is
  positive for C. difficile toxin.
• Questions
• What type of accommodation would you suggest?
• How would you classify this case?
• Does the patient meet the case definition for
  CDAD?
• When should Contact Precautions be initiated?
• Are visitors allowed to visit with Ms.
  Nightingale? What education should be provided to
  them?

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Case Study 4

• Mr. Robert Koch is a 78 year old male admitted to
  your facility from a long term care home on July
  8th with a diagnosis of pneumonia. He has been
  experiencing fever, cough, and shortness of
  breath for the past week. He has lost his
  appetite and sleeps most of the time. Mr. Koch
  has been taking antibiotics prescribed by the
  LTCH physician since July 2nd. On July 9th he
  develops loose watery stools. He is having
  difficulty getting to the bathroom in time and
  his environment is heavily soiled. He is
  currently in a semi-private room with a bedridden
  dementia patient. July 12th a stool specimen was
  sent and CDAD confirmed.
• Questions
• There are no private rooms available on the unit.
  Can you leave Mr. Koch in his current room?
• Should additional precautions be initiated?
• How would you classify this CDAD?
• What type of environmental cleaning protocols
  would you suggest?
• Should the LTCH be notified of the CDAD
  diagnosis?
• When can Mr. Koch be transferred back to the LTCH?

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Case Study 5

• Ignaz Semmelweis is a 10 month old male who has
  been transferred to your facility from another
  hospital on July 10th. He has had numerous
  surgeries to correct his bilateral cleft lip and
  palate and is to remain at your facility until he
  establishes good sucking/feeding habits. He
  received pre-op prophylactic antibiotics prior to
  his surgeries and all wounds appear to be healing
  well. On July 14th he begins to have loose watery
  stools, up to 10x per day. There has been a
  change in his feeds from breast milk to formula.
  The physician orders stool specimens for CS,
  OP, and C. difficile toxin. The stool samples
  are all negative except that C. difficile toxin
  is detected.
• Questions
• Is this a significant result?
• How would you classify this?

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Case Study 6

• Mr. John Snow is an 88 year old male who has been
  admitted from home to your facility on July 15th
  with a diagnosis of diarrhea. He has not been
  admitted to any healthcare facility within the
  past 3 years although he did spend 3 days in the
  emergency department (July 8 11) to receive IV
  antibiotics for a cellulitis. His stool is
  positive for C. difficile toxin and he continues
  to have 6-8 loose stools/day. He has been started
  on Metronidazole 500 mg po q8h for 10 days.
• Questions
• How would you classify this?
• It is now July 22nd and Mr. Snow has not had
  diarrhea for 2 days. Can Contact Precautions be
  discontinued?

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Case Study 7

• You have been asked to report the incidence
  density rate/1000 patient days of nosocomial
  infections of C. difficile in your facility for
  the past 3 months. You have been using the PIDAC
  case definition and have a comprehensive database
  established. In May you had 5 cases, with 3 cases
  in each of June and July. Your patient days for
  these months were May 4500, June 4650, July
  4580.
• Questions
• How are incidence density rates calculated?
• What information do they convey?
• What is the purpose of C. difficile surveillance?
• What resources do you require to assist with your
  surveillance?

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Case Study 8

• Mr. Lister is a 56 year old male patient in your
  haemodialysis unit. He attends haemodialysis
  three times a week for approximately 4 hours each
  visit. On July 15th Mr. Lister received a dose of
  antibiotic post dialysis for a possible line
  infection. When he attends the clinic for his
  dialysis on July 24th he reports that he has been
  having 8-10 episodes of diarrhea each day for the
  past 2 days. A stool specimen is sent and the
  laboratory report states that it is positive for
  C. difficile toxin.
• Questions
• How would you classify this?
• Should additional precautions be implemented?

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Next Steps

• Draft education information has already been
  shared with hospital CEOs and MOHs. Tom Closson,
  OHA, has already spoken to CEOs in a
  teleconference and these will be ongoing. Dr.
  David Williams has addressed with MOHs in a
  teleconference on July 29th.
• Training and support provided by Regional
  Infection Control Networks to hospitals and
  public health units
• Public Health staff will receive additional
  training, from MOHLTC, on iPHIS components in
  August stay tuned for more information

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RICN Contact Information

• insert RICN specific contact information