Jane Stockley Chris Catchpole Carole Clive November 2012

 Clostridium difficile disease  Local & National epidemiology – mandatory reporting and targets – not just a hospital problem  ‘Dealing with the problem’ February 2009 – preventing avoidable infection  Changes to the C difficile testing algorithm April 2012  Antibiotic Stewardship in Primary Care

 Important healthcare associated infection, occurs across the healthcare economy  Sporadic cases and outbreaks  Disease: can lead to colitis and perforation  Predisposing factors: age, invasive procedures, antibiotic therapy, malignant disease  Case definition:  Type 5 – 7 stool, not attributable to other causes PLUS  a positive C. difficile toxin assay  Spores not killed by alcohol gel – handwashing required  Risk from environment and other patients

 ? Emergence of hypervirulence/toxin production  Newly recognised 027 strain – outbreaks, association with different antibiotics. Other new strains also emerging  Greater diversity of strains in community, typing can be useful to identify clusters or links between cases  Most cases continue to affect elderly, but disease may also occur in young people

 Any antibiotic (3-15X risk)  Increasing age  Surgery  Proton pump inhibitors?  Cancer  Chemotherapy  Environment for acquisition  ? diclofenac

 All Trusts should have an antibiotic management team  All Trusts should have a restricted antibiotic formulary  There should be clear guidelines on when to use broad spectrum antibiotics, and these should be reviewed when results available  Antibiotics should only be prescribed when there is clear evidence of infection, this evidence should be documented in the patient notes  Antibiotics started inappropriately or without sufficient evidence of infection should be stopped. Antibiotics should be stopped if results do not support the diagnosis of infection. Antibiotics that depart from the policy without justification should be stopped or change  Clinical directors should ensure that good antimicrobial prescribing is embedded in individual patient care by …..  AMT ward rounds, changing prescriptions and giving feedback to teams

Dial, CMAJ, 2008

 Revised primary and secondary care prescribing guidelines  Removal of ‘high risk’ antibiotics – notably cephalosporins and quinolones – from empirical prescribing guidance  Educational events to promote antibiotic stewardship, prompt recognition of CDI and optimal management of individual cases  Infection prevention and control training  Audit

Impact in Primary care

E.Coli bacteraemias Antibiotic resistance (%)

C difficile cases

 All CDI reports / / (down 17%) / (down 15%)  Trust apportioned / / (down 26%) / (down 21%)

 Rate nationally continues to fall but in Worcestershire this has plateaued  Targets set across the healthcare economy  Current rates are above trajectory for both primary and secondary care  Rate high in Worcestershire in July to Sept for the last 3 years ?why – coincidence or seasonal pattern  Need to understand trends and find solutions

Clostridium difficile BY PATIENT DEMOGRAPHICS

TREND % of cases that have had a recent hospital stay 6975 % of cases that have had a recent course of antibiotics 86 % of cases that have recently had or were on PPIs 5946 % of cases that have had a course of antibiotics and on PPIs 4846 % of cases on either/or antibiotics/PPIs 8892 % of cases recently had cytotoxic drugs 87 % of cases with recent or continued use of laxatives 2829

 Development of more sophisticated tests - recognition that single testing result not suitable for C. difficile disease  Understanding that both organism and toxin expression required for disease  GDH antigen – screening test (organism Ag)  Toxin EIA – expression of toxin  Toxin PCR – indicates gene presence, not necessarily toxin expression

Antimicrobial stewardship is a clinical priority for 3 years

 Do not prescribe antibiotics unnecessarily  Do not delay treatment of critically ill patients  Do not overuse broad spectrum antibiotics  Use appropriate dose, and timing schedule, for individual patients  Ensure duration of treatment is correct – not too long, or too short  Streamline antibiotic treatment according to microbiology results  Focus on making a correct diagnosis

 Total antibiotic use measured in items (STAR PU). Target National 25 th percentile on set date. Analyse by age group and seasonal use.  Compliance with local antibiotic guidance OR ciprofloxacin, cephalosporins under 5% of total  Particular focus on ciprofloxacin & other quinolones. Also cephalosporins, co-amoxiclav & clarithromycin

 Flu and pneumococcal vaccine uptake rates  UTI – 80% prescribed trimethoprim or nitrofurantoin, and under 5% prescribed quinolone.  Use of diagnostic tests by practices in line with National guidance (eg HPA lab use or CKS)  Antibiotic susceptibility reporting by laboratories in line with local antibiotic guidance

Antibiotic Management Guidance

 Clostridium difficile disease is a serious healthcare-associated infection which affects both primary and secondary care  We need to work together to eliminate avoidable infection  We can do this through optimal case management, good infection control within healthcare settings, and good antimicrobial prescribing