C.Difficile update – what you need to know in Primary Care Jane Stockley Chris Catchpole Carole Clive C.Difficile update – what you need to know in Primary Care November 2012

Clostridium difficile disease update 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

Clostridium difficile 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

C difficile: The Changing Epidemiology 1990-2004

The changing epidemiology ? 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

Risk Factors for C. difficile Any antibiotic (3-15X risk) Increasing age Surgery Proton pump inhibitors? Cancer Chemotherapy Environment for acquisition ? diclofenac

“Clostridium difficile infection – How to Deal With the Problem” Feb 09 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

Antibiotic stewardship

Risk of C. difficile related to recent antibiotic exposure in the community Dial, CMAJ, 2008

Action taken in Worcestershire 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 2006-2011 Antibiotic resistance (%)

C difficile cases

National decline in CDI cases All CDI reports - 2009/10 25615 - 2010/11 21721 (down 17%) - 2011/12 18025 (down 15%) Trust apportioned - 2009/10 13224 - 2010/11 10418 (down 26%) - 2011/12 7676 (down 21%)

Total C.diff rates (aged 2+)

Performance against 2012-13 target

What is happening to C diff locally? 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 2011-2012 2012 - 2013

REVIEW OF TRENDS 2011-2012 2012-2013 TREND % of cases that have had a recent hospital stay 69 75 % of cases that have had a recent course of antibiotics 86 % of cases that have recently had or were on PPIs 59 46 % of cases that have had a course of antibiotics and on PPIs 48 % of cases on either/or antibiotics/PPIs 88 92 % of cases recently had cytotoxic drugs 8 7 % of cases with recent or continued use of laxatives 28 29

April 2012 – DH new testing algorithm 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

Avoiding misuse of antibiotics 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

2010: Indicators of antimicrobial usage Total antibiotic use measured in items (STAR PU). Target National 25th 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

Other indicators 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

Summary 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