The Infection Control Doctor and Clostridium difficile infection Dr David R Jenkins University Hospitals of Leicester NHS Trust, England
250 200 150 100 50 0 Monthly cases of Clostridium difficile (UHL and community combined) 2004-7 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Clostridium difficile in Leicester 2004 2005 2006 2007
Health care in Leicester/shire One million total population University Hospitals of Leicester NHS Trust Three hospitals Single microbiology laboratory for UHL and GPs
C difficile control strategy Patient management Diagnosis Communication Co-ordinated management Clean hands Proton pump inhibitors Antimicrobial control Clean environment and equipment
Clostridium difficile task force Chief executive, Senior clinicians, managers, infection control, antimicrobial pharmacist, C difficile project manager Review infection figures Agree strategy Operational supervision Authorise resources Commission and receive audits Approve communication strategy internal external
Making the diagnosis Specimen collection Criteria for testing for C difficile Methodological approaches Consistent objective recognition of diarrhoea Rapid specimen collection and delivery Censoring by ward staff Consistent objective testing criteria Total number specimens submitted, tested, positive, all ages Censoring by lab staff Daily, same day testing Enzyme immunoassay Ribotyping Rapid, high-sensitivity case ascertainment is essential
Making the diagnosis Diagnosing diarrhoea
Analysing the numbers Important numbers New C difficile infections Deaths Serious complications Review data by: Date Origin Age distribution Statistical process control charts Benchmarking
Acknowledge the numbers before trying to explain them
Clean hands Who? Staff, patients, visitors Where are the sinks? Does everyone know what to do? Is everyone doing it?
Clean environment Day to day cleaning Deep cleaning Equipment
Antimicrobial control Quantitative control 5 days maximum duration without validation code Qualitative control No access to some classes without validation code Prescriber Pharmacist Validation code Microbiologist
Relationship between antibiotic defined daily doses (DDD, total and cefuroxime) and C difficile cases (UHL cases alone, and primary and UHL and community cases combined (total)) 250 Introduction of quantitative restriction policy 3500 UHL C difficile cases Total C difficile cases Monthly number of C difficile cases 200 150 100 50 0 Introduction of qualitative restriction policy Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr 2005 2006 2007 2008 Year and month Antimicrobial pharmacist appointed 3000 2500 2000 1500 1000 500 0 Monthly DDDs Total monthly DDDs (divided by 20 to match cefuroxime scale) cefuroxime monthly DDDs 1.The C difficile outbreak began in 2004 (data not shown) and continued to increase in 2005 and 2006. A sample of C difficile isolates indicated that the 027 ribotype was the predominant ribotype in Leicester at this time. 2. A quantitative antibiotic restriction policy was introduced in August 2006. This limited the duration of the majority of antibiotic prescriptions in UHL to a maximum of five days, unless a longer course was approved by Microbiology. 3. The lack of significant improvement in C difficile numbers prompted the addition of a qualitative antibiotic restriction policy in April 2007, removing virtually all cephalosporin use, and limiting quinolone and macrolide prescriptions. A dramatic fall in C difficilecases occurred subsequently.
Proton pump inhibitors Doses of proton pump inhibitors prescribed in UHL, 2000 to 2005 800000 700000 Annual Defined Daily Doses 600000 500000 400000 300000 200000 Esomperazole Lansoprazole Omeprazole Pantoprazole Rabeprazole total 100000 0 2000 2001 2002 2003 2004 2005 Year
PPI control 250000 200000 Aug 06 launch of PPI Policy PPI type dose units 150000 100000 50000 0 Oct-Dec 06 Jan-M ar 06 April-June 06 Esomeprazole 20mg + 40mg Omeprazole 10mg + 20mg Pantoprazole 20mg + 40mg UHL Total number of dose units July-Sept 06 Oct-Dec 06 Jan-Mar 07 April-June 07 Lansoprazole 15mg + 30mg Omeprazole infusion 40mg Rabeprazole 10mg July-Sept 07
Communication Information staff, patients and relatives, media What is C difficile? Why is it in Leicester? How can it be prevented? How can it be treated? How are we doing?
Patient management Prompt isolation and investigation of diarrhoea patients C difficile ward Treatment according to patient pathway
Controlling C difficile infection Lessons for everyone C difficile will expose your weaknesses The best defence is best practice, all the time.