Annex C: - CDI What’s the diff? 4 th Annual Outbreak Management Workshop September 19, 2013 Naideen Bailey & Grace Volkening
Annex C: - CDI What’s the diff?
4th Annual Outbreak Management Workshop
September 19, 2013
Naideen Bailey & Grace Volkening
www.oahpp.ca
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. 2009
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Background
• Mandatory public reporting of nosocomial CDI began in Ontario public hospitals in Sept. 2008
• 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
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Emerging CDI knowledge
• Data is starting to accumulate regarding community-associated 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
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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)
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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 80th percentile as an outbreak threshold)
• Management of CDI outbreaks
• Overall, stronger positions on patient accommodations, enhanced cleaning practices, baseline rate determination, surveillance and treatments
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“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
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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
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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
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• Discontinuation of precautions for CDI
• Relapse of symptoms
• Occupational Health
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Other IPAC measures covered are:
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• 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
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CDI Testing and Surveillance
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• 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
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Case Definition of Clostridium difficile Infection (CDI)
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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
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• 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
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CDI Outbreak identification and thresholds
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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,
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CDI Notification thresholds:
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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,
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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
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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
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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
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