Jane Stockley
Chris Catchpole
Carole Clive
November 2012
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Clostridium difficile disease
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
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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
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Spores not killed by alcohol gel – handwashing
required
Risk from environment and other patients
? 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
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Any antibiotic (3-15X risk)
Increasing age
Surgery
Proton pump inhibitors?
Cancer
Chemotherapy
Environment for
acquisition
 ? diclofenac
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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
Dial, CMAJ, 2008
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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
The Prescribing of Cephalosporins and Quinolones in Primary Care
No. of Prescriptions
30,000
25,000
20,000
Cephalosporins
15,000
Quinolones
10,000
5,000
0
2006-07
2007-08
2008-09
2009-10
Year (April-March)
2010/11
Ciprofloxacin and Gentamicin Resistant Organisms, and
ESBL Detection Patterns in Bacteraemia
% Total No. of Organisms
25.0
20.0
15.0
Ciprofloxacin resistant
10.0
Gentamicin resistant
ESBL Producers
5.0
0.0
2006-07
2007-08
2008-09
2009-10
Year (April to March)
2010/11
Incidence of C. Diff. Infections Across Worcestershire
Acute Hospital (within
48 hrs of admission)
300
No. of Cases
250
Acute Hospital (48 hrs
post admission)
200
Community Hospital
(within 48 hrs of
admission)
150
100
Community Hospital
(48 hrs post
admission)
50
General Practice
0
2007-08
2008-09
2009-10
Year (April-March)
2010-11
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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%)
Rate Cdiiff per 100,000 aged 2+
180
160
140
120
100
80
60
40
20
0
England
Worcestershire
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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
Pie Chart Indicating Age
3%
Pi Chart indicating Age
6%
Under 50
Under 50
51- 60 years
48%61 - 70 years
71 - 75 years
76 - 80 years
81 + years
18%
51-60
61-70
71-75
6%
75-81
81+
19%
2011-2012
% of cases that have had a recent
hospital stay
% of cases that have had a recent
course of antibiotics
% of cases that have recently had or
were on PPIs
% of cases that have had a course of
antibiotics and on PPIs
2012-2013
69
75
86
86
59
46
48
46
% of cases recently had cytotoxic drugs
88
8
92
7
% of cases with recent or continued use
of laxatives
28
29
% of cases on either/or antibiotics/PPIs
TREND
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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
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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
 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
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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
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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