Annex C: - CDI What s the diff? 4 th Annual Outbreak Management Workshop September 19, 2013 Naideen Bailey & Grace Volkening

Transcription

1 Annex C: - CDI What s the diff? 4 th Annual Outbreak Management Workshop September 19, 2013 Naideen Bailey & Grace Volkening

2 There s an updated Annex C Annex C is an extension to the PIDAC Infection Prevention and Control Routine Practices and Additional Precautions in All Health Care Settings November 2012 Appropriate for but not limited to: acute care, long-term care, chronic (including mental health) care and home health care Incorporates Ministry of Health and Long-Term Care. Control of Clostridium difficile Infection (CDI) Outbreaks in Hospitals, A Guide for Hospital and Health Unit Staff

3 Background Mandatory public reporting of nosocomial CDI began in Ontario public hospitals in Sept Between 2009 and 2011, rates of CDI increased 13% in Acute Teaching and Large Community Hospitals (from 0.30/1000 patient days in 2009 to 0.34/1000 patient days in 2011) Current rate as of July 2013 is 0.29/1000 patient days 3

4 Emerging CDI knowledge Data is starting to accumulate regarding communityassociated C. diff Role of community environments, food, water sources and animal sources of C. diff may need to be considered more research is currently underway 4

5 Outbreak investigations Number of strains identified per outbreak ranged from 1 to 41, with a median of 3 distinct strains Is it an outbreak? Is community acquisition/carriage and antibiotic use contributing to the burden and expression of CDI in hospital? NAP1 Strain represented 60% of all C. difficile outbreak strains as tested by PHO laboratories. All isolates were susceptible to metronizadole and vancomycin (still preferred treatment options) 5

6 So what s changed in this Annex? A number of updates including: IPAC measures CDI testing and surveillance (addition to the case definition and removal of 80 th percentile as an outbreak threshold) Management of CDI outbreaks Overall, stronger positions on patient accommodations, enhanced cleaning practices, baseline rate determination, surveillance and treatments 6

7 There are two major components to successful control of CDI effective infection prevention and control (IPAC) measures and antibiotic stewardship Annex C, 2013 p.5 7

8 IPAC Measures Sustained control of CDI may be achieved with a bundle of IPAC measures directed at interrupting the horizontal spread A system for identification and prompt isolation of suspected or known CDI cases Appropriate environmental services policies and procedures for rooms/bathrooms of CDI cases, including use of sporicides A hand hygiene program A system for disposal of human waste that prevents environmental contamination Access to appropriate and timely laboratory testing 8

9 Treatment New antibiotic option Fidaxomicin Similar to vancomycin for curing CDI and is superior for reducing CDI recurrences New prevention and treatment modalities that are being explored include; probiotics faecal microbiota transplantation 9

10 Other IPAC measures covered are: Discontinuation of precautions for CDI Relapse of symptoms Occupational Health 10

11 CDI Testing and Surveillance Ideally laboratory testing turnaround should be less than 24 hours and the test should be available 7 days per week Testing by molecular methods (PCR) is more sensitive and is now considered testing method of choice If the first molecular test is negative there is no need for a second test Re-testing for test of cure is not indicated Testing should not be carried out on formed stools 11

12 Case Definition of Clostridium difficile Infection (CDI) Laboratory confirmation of C.difficile together with diarrhea* or Visualization of pseudomembranes on sigmoidoscopy or colonoscopy or Histological/pathological diagnosis of pseudomembranous colitis or Diagnosis of toxic megacolon PLUS (newly added to the case definition) For the purpose of defining a case of CDI, there should be 3 or more episodes of diarrhea within a 24 hour period *Remember to initiate contact precautions at onset of diarrhea without waiting for further episodes 12

13 Case Definition Testing can detect C. difficile colonization or disease Results of laboratory testing must be correlated with the clinical condition of the patient/resident 13

14 CDI Outbreak identification and thresholds Cases of CDI occurring at a rate exceeding the normally expected baseline rate for the health care setting during a specified period of time should be investigated as a possible outbreak CDI outbreak definitions incorporate the concept of notification thresholds points that trigger action and dialogue between local public health unit and the facility 14

15 CDI Notification thresholds: For wards/units with 20 beds, three (3) new cases of nosocomial CDI identified on one ward/unit within a seven-day period OR five (5) new cases of nosocomial CDI within a four-week period, 15

16 CDI Notification Thresholds For wards/units with <20 beds, two (2) new cases of nosocomial CDI identified on one ward/unit within a seven-day period OR four (4) new cases of nosocomial CDI within a four-week period, 16

17 CDI attribution: Yours? Ours? Their s? Annex C provides surveillance guidance and this differs from public reporting requirements, which has three levels of attribution Careful and full review of the case clinical information and past history is needed when determining attribution 17

18 CDI Outbreaks (cont d) Facilities that have a facility nosocomial CDI rate that exceeds their annual nosocomial baseline rate for a period of two consecutive months NOTE: This is not valid for a small community hospital, where a single case of nosocomial CDI can artificially elevate the facility rate 18

19 Note: exceeding a threshold does not necessarily imply that an outbreak will be declared Consultation with local public health unit and/or with the local regional infection control network is available for facilities with limited experience in managing CDI outbreaks 19

20 And now over to Grace Volkening CLEANING UP ON CDI 20