Clostridium Difficile Infection Surveillance Protocol

Clostridium Difficile Infection Surveillance Protocol

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Background

Clostridium difficile is a Gram positive, spore forming bacterium that is rarely found in healthy adults but is a frequent cause of healthcare associated diarrhoea. Some strains of C. difficile produce toxins that can cause a spectrum of gastrointestinal disease ranging from mild diarrhoea to fulminant colitis that that may lead to intestinal perforation and death.

Clostridium difficile infection (CDI) is primarily a hospital associated disease resulting from:

  • normal bowel flora of patients being disrupted through antibiotic treatment, cytotoxic therapy,  immunosuppression and gastric acid suppression; and/or
  • Opportunities for transmission of the organism to patients within a hospital environment.

Public Health Services monitors and reports on CDI identified within the acuteTasmanian public hospitals: Royal Hobart Hospital (RHH), Launceston General Hospital (LGH), Mersey Community Hospital (MCH), and the North West Regional Hospital (NWRH). Surveillance methods used are outlined in this protocol.

Definitions

Inpatient healthcare facility – facility where patients can be admitted for overnight stay and includes acute private or public hospitals, rural hospital, sub-acute facility, long term care facility and nursing home.

Inpatient – a patient who has a minimum of an overnight stay in a healthcare facility.

Outpatient – a patient who visits a healthcare facility for a medical, allied health or similar appointment.

Day case – a patient who attends a healthcare facility for a full or part day for a course of treatment.

Diarrhoea–unformed faeces that takes the shape of the container

Clostridium difficile infection (CDI) case definition – all cases of diarrhoea where:

  • the stool sample yields a positive result in a laboratory assay for C. difficile toxin A and/or B; or
  • a toxin-producing C. difficile organism is detected in the stool sample by culture or other means.

Note: an additional positive specimen collected from the same patient more than eight weeks since the last positive test is regarded as a new case.

Exclusions to the case definition

  1. Cases where a previous positive test has been obtained within the last eight weeks.
  2. Patients less than two years old.

CDI case exposure classifications are identified for all CDI cases:

CDI case exposure classifications

Description

  1. Healthcare Associated (HCA) – Healthcare facility   onset

A patient with CDI symptom onset (or date and time of stool specimen collection if a laboratory system is used) >48 hours* after admission to a health care facility

  1. Healthcare   Associated (HCA) – Community onset

A patient with CDI symptom onset (or date and time of stool specimen collection if a laboratory system is used) in the community or within 48 hours (2 days) of admission to a healthcare facility, provided that symptom onset was less than four weeks after the last discharge from a healthcare facility.

Attribute to:

  • the   reporting period during which the case patient was discharged from the   healthcare facility before CDI symptom onset.
  • the   healthcare facility from which the patient was last discharged, providing the   patient was an inpatient of that healthcare facility for more than 48 hours   (2 days).
  1. Community associated

A patient with CDI symptom onset (or date and time of stool specimen collection if a laboratory system is used) in the community OR within 48 hours* of admission to a healthcare facility, provided that symptom onset was more than 12 weeks after the last discharge from a healthcare facility.

  1. Indeterminate onset

A  CDI case that does not fit any of the above criteria for exposure setting (eg onset in community but within four and 12 weeks of discharge from a healthcare facility).

Unknown exposure

Exposure setting cannot be determined because of a lack of data

Recurrent CDI case

An episode of CDI that occurs within eight weeks or less after the onset of a previous CDI episode, provided that CDI symptoms from the earlier episode resolved with or without therapy

Surveillance process

  • CDI episodes identified at the RHH, LGH, MCH and NWRH are notified electronically to the Tasmanian Infection Prevention and Control Unit (TIPCU) by the identifying laboratory.
  • Laboratory notifications are entered into the TIPCU spreadsheet by TIPCU personnel within two working days of receipt.
  • TIPCU perform data validation quarterly in consultation with the relevant infection control personnel.
  • Electronic forms are stored in the TIPCU shared drive.
  • Validated data is published quarterly within eight weeks of the end of the relevant quarter.

Data validation

CDI data is validated quarterly in the following way:

  • Identifying laboratories perform a data extraction of all CDI identified at in the RHH, LGH, MCH and NWRH during the relevant quarter and send the extracted data to TIPCU.
  • TIPCU apply the case definition to the cases, remove case definition exclusions and categorise each case according to the ‘CDI case exposure definition’
  • TIPCU sends CDI data to hospital infection control personnel to cross check against their own CDI notifications for the relevant quarter.
  • The validated data is returned to TIPCU.

Surveillance process responsibilities

Notification

Data

Laboratory

  • Notifies results to TIPCU electronically each quarter
  • Hospital   identification number
  • Date of   birth
  • Sex
  • Specimen   date
  • Specimen   laboratory number
  • Name of   organism
  • Other   testing results –culture, GDH, toxin, PCR

TIPCU

  • Enters minimum patient data into CDI spreadsheet after accounting for exclusion criteria
  • Applies ‘CDI case exposure definition’ to all cases identified within Tasmanian public hospitals
  • Requests cross check of data from hospital infection control personnel
  • Updates data following validation.
  • Surname – initials
  • First name – initials
  • Laboratory code
  • CDI case exposure classification
  • Current hospitalisation – hospital   code,  date of admission, date of   discharge

Infection control personnel; General Practitioner

  • Cross checks data and CDI case exposure definitions
  • Returns validated data to TIPCU within 2 weeks of receipt of request.
  • Ward where specimen taken

·

Information management

All information held by TIPCU is in linewith the information privacy principles as set out in the Personal Information Privacy Act 2004.

Information shared by laboratories (public and private) pursuant to the Public Health Act 1997 is held in accordance with the Personal Information Privacy Act 2004.

All data or information requests must be referred to the Director of Public Health.

Contact details

Tasmanian Infection Prevention Control Unit

Telephone – (03) 6166 0605

Email – tipcu@dhhs.tas.gov.au

Communicable Diseases Prevention Unit

Telephone (24 hours) – 1800 671 738

Facsimile – (03) 6173 0821

Tasmanian Infection Prevention and Control
Public Health Services
Department of Health and Human Services

GPO Box 125 Hobart 7001

www.dhhs.tas.gov.au/tipcu tipcu@dhhs.tas.gov.au

Department of Health and Human Services, Tasmania
Published 2016. Copyright—Department of Health and Human Services

Permission to copy is granted provided the source is acknowledged

Authors

  • Ms Fiona Wilson, TIPCU
  • Ms Lucy Hughson, TIPCU
  • Dr Tara Anderson, TIPCU
  • Ms Anne Wells, ADON PHS

Suggested reference: Wilson, F, Hughson, L, Anderson, T and Wells, A (2016),Clostridium difficile (CDI) surveillance protocol, Hobart: Department of Health and Human Services.

December 2016