1. 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

2. 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

3. 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

4. C difficile: The Changing Epidemiology 1990-2004

5. 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

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

7. “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

8. Antibiotic stewardship

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

10. 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

11. Impact in Primary care

12. E.Coli bacteraemias 2006-2011 Antibiotic resistance (%)

13. C difficile cases

14. National decline in CDI cases
All CDI reports
- 2009/
- 2010/ (down 17%)
- 2011/ (down 15%)
Trust apportioned
- 2009/
- 2010/ (down 26%)
- 2011/ (down 21%)

15. Total C.diff rates (aged 2+)

16. Performance against 2012-13 target

17. 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

18. Clostridium difficile BY PATIENT DEMOGRAPHICS

19. REVIEW OF TRENDS
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

20. 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

21. Antimicrobial stewardship is a clinical priority for 3 years

22. 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

23. 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

24. 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

25. Antibiotic Management Guidance

27. 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