Clostridium difficile-associated disease in Ireland

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Clostridium difficile-associated
disease in Ireland
Clostridium difficile as a notifiable disease
C. difficile Enhanced Surveillance
New cases of Clostridium difficile-associated disease
(CDAD) in persons two years or older have been
notifiable in Ireland under the disease category acute
infectious gastroenteritis (AIG) since 4th May 2008.
Recurrent CDAD cases are not currently notifiable.
Although the information notified through CIDR has
given important preliminary information on the burden
of new cases of CDAD in Ireland, it represents an
underestimate of the true burden of infection
(capturing new cases only) and does not capture
information on the origin or onset of cases. Since 1st
August 2009, national collation of C. difficile enhanced
surveillance commenced on a voluntary basis in
Ireland. Information on case type, origin, onset and
severity of CDAD is collected. CDAD case definitions
proposed by the European Centre for Disease Control
are employed. By the end of 2009, 33 hospitals were
participating, corresponding to 30 acute public
hospitals (seven regional, 21 general, two specialist
hospitals) and three private hospitals.
There were 4,359 notifications of acute infectious
gastroenteritis (AIG) in 2009, of which 1,897 (44%)
were new CDAD cases, giving a national crude
incidence rate (CIR) of 44.7 new CDAD cases per
100,000 population. All cases were laboratory
confirmed. This represents a decrease from 56.9
cases per 100,000 population reported in 2008 (table
1). Regional variation was observed in the incidence
of CDAD (table 1); however, this most likely reflects
differences in diagnosis and reporting rather than true
variation in disease incidence.
As in 2008, new cases of CDAD in 2009 were more
prominent in female patients (57.6%) and older age
groups. The mean age of cases was 71 years (range
2-102 years) (figure 1) and 1418 cases (74.7%) were
reported in the over 65 year age category. Of note,
the 75-84 year age group had the highest number of
cases (615, representing 43% of the over 65 year age
group).
The majority of CDAD cases (67%) were notified by
healthcare institutions. Patients classified as
‘hospital inpatient’ had the highest occurrence of
cases accounting for 64% of all cases notified.
Of the remaining, 9% were classified as GP patients,
3% hospital outpatient, 2% as ‘other’ and 22% as
either ‘not specified’ or ‘unknown’. However, this data
does not provide information on the origin or onset of
CDAD; rather it represents the location of the patient
at CDAD diagnosis. Information on the origin and
onset of CDAD cases is collected as part of the
enhanced surveillance system.
The seasonal trend is indistinguishable at present as
only one complete annual data set is available. In
addition, identification of seasonal patterns is
hindered by late and batch notifications from
institutions.
In 2009, nine Clostridium difficile outbreaks, all
healthcare-associated, involving 50 patients were
notified on CIDR (table 2). Six of these were linked to
hospitals, two to nursing homes and one to a longterm care facility.
Health Protection Surveillance Centre
From August to December 2009, there were 527
cases of CDAD reported to the enhanced surveillance
project, 444 (84.3%) new cases and 79 (15%)
recurrent CDAD. Of these, 337 (64%) originated
within the participating hospital. This corresponds to
an overall national CDAD incidence rate of 3.2 cases
per 10,000 bed days used. This rate is based only on
the number of cases that originated in the
participating healthcare facility and is calculated using
acute public hospital activity data from the National
Hospitals Office at the Health Services Executive. There was a wide range in the incidence of CDAD
infection among participating hospitals (range, 0 – 8.6
cases per 10,000 bed days used, median, 2.7 cases)
with general hospitals showing a higher median
incidence rate (CDAD rate = 3.8, n = 21) compared to
tertiary hospitals (CDAD rate = 3.0, n = 7) over the
five month period. This is likely due to the differences
in patient case mix, C. difficile ribotypes, testing
facilities and practices, antibiotic policies and
surveillance resources between hospitals.
Most cases were in females (59%) and in the over 65
age group (74%). While the majority of cases were
associated with healthcare facilities, specifically acute
hospitals (78%), 15% of all CDAD cases were
community-associated (figure 4). Ten percent of all
healthcare-associated cases originated in nursing
homes. Of note, while the majority of patients with
CDAD had onset of symptoms in a healthcare facility
(75%), predominantly in acute hospitals (acute
hospitals 90%, nursing homes, 9%), a significant
proportion of patients with CDAD had onset of
symptoms in the community (24%) (figure 4).
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There was a low incidence of severe CDAD (defined
as admission to ICU or surgery due to complications
arising from CDAD) reported in 2009 (1%, n = 5).
National Typing Project
In March 2009, HPSC in conjunction with St. Vincent’s
University Hospital and University College Dublin
conducted a one month national C. difficile typing
study. Participating healthcare facilities collected
clinical details of all CDAD cases in March 2009,
which included; case type, onset and origin of CDAD,
antimicrobial exposure prior to diagnosis and case
severity. In addition, faecal specimens from patients
with CDAD were submitted for PCR ribotyping.
Information on 211 CDAD cases was submitted from
33 inpatient healthcare facilities. The national median
CDAD rate in acute hospitals was 2/10,000 bed days
used (range 0 - 13).
Seventy-nine percent of cases (166) were new and
18% (38) were recurrent. The median age of cases
was 78 years and 76% of patients (160) had received
antimicrobial therapy within eight weeks prior to
CDAD diagnosis. Eighty-three percent of cases (176)
were healthcare-associated, of which 13% (23)
originated in nursing homes. Ten percent (21) of
cases were community-associated.
Thirty-four percent of toxin-positive faecal specimens
submitted (72) failed to grow C. difficile on culture. Of
the 139 samples successfully cultured, the most
common ribotypes encountered were; 027 (19%), 001
(16%), 106 (13%), 078 (10%) and 014 (8%).
Ribotypes 001 (21%), 027 (20.7%) and 106 (19.5%)
predominated among new cases with 027 (37.5%),
001 (21%) and 078 (16.6%) among recurrent cases.
Conclusion
The collation of national data on C. difficile through
both surveillance systems has provided a valuable
insight into the burden of CDAD in Ireland.
Data to date suggests a decline in the number of new
CDAD cases reported in 2009 compared to 2008,
Health Protection Surveillance Centre
however, due to the large weekly variability in the data
it is too soon to determine if this decline is significant.
Fifteen percent of all CDAD cases reported in 2009
were recurrent infections. Recurrence of CDAD is
difficult to manage clinically, can result in severe
infection, places a burden on already limited isolation
resources and results in significant patient morbidity.
Therefore, knowledge of the burden of recurrent
CDAD in Ireland is important to help guide
preventative strategies.
During 2009, 15% of all CDAD cases from hospital
inpatients (including patients admitted through
emergency departments and outpatient clinics) were
associated with the community and 10% of cases
were associated with nursing homes. This indicates
that C. difficile is no longer an infection limited to the
hospital setting. Moreover a quarter of all cases had
onset of symptoms in the community. This information
collected on the burden of CDAD outside acute
hospitals will help to direct appropriate preventative
and control programmes at a national level.
In March 2009, national C .difficile ribotype data was
collected for the first time. In addition to highlighting
the burden of CDAD outside acute care facilities, this
study demonstrated the overall predominance of PCR
ribotype 027 at this time.
National guidelines for the surveillance, diagnosis,
management, and prevention and control of CDAD in
Ireland are available for download
(http://www.hpsc.ie/hpsc/AZ/Gastroenteric/Clostridiumdifficile/) and hospital
antibiotic stewardship guidelines available at
http://www.hpsc.ie/hpsc/AZ/MicrobiologyAntimicrobialResistance/Strategyforthe
controlofAntimicrobialResistanceinIrelandSARI/Antibio
ticStewardship/Publications/. All healthcare
professionals must promote practices known to
reduce the incidence of CDAD including; antimicrobial
stewardship and compliance with infection prevention
and control measures. These measures are outlined
in the national guidelines.
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Table 1. Number of notified cases, crude incidence rate of CDAD in Ireland by HSE area, 2009, and total
number with estimated crude incidence rate for 2008.
HSE Area
East
Midlands
Mid West
North East
North West
South East
South
West
Total 2009
Total 2008**
No. of cases
705
44
184
84
133
251
237
259
1897
1624
*CIR incl. 95% C.I.
47 [43.5 - 50.5]
17.5 [12.3 - 22.7]
51 [43.6 - 58.4]
21.3 [16.7 - 25.9]
56.1 [46.6 - 65.6]
54.5 [47.8 - 61.2]
38.2 [33.3 - 43.1]
62.5 [54.9 - 70.1]
44.7 [42.7 - 46.7]
56.9 [54.6 - 59.2]**
* Rates calculated using 2006 census data
** Using the number of notifications over the 35 week period in 2008, the estimated CIR for a 52 week period was calculated
Rate per 100,000 population
1200
Female
1000
Male
800
600
400
200
0
0‐4
5‐9
10‐14 15‐44 45‐54 55‐64 65‐74 75+
Age Group (Years)
*Rates calculated using 2006 census data
Figure 1: Age and Sex distribution of CDAD in Ireland, 2009
Table 2. C. difficile outbreaks reported in Ireland in 2009 by HSE area
HSE
Region
Outbreak location
Total number
ill
East
Nursing Home
6
Mid-West
Mid-West
North East
North East
North East
Hospital
Hospital
Hospital
Nursing Home
Hospital
Comm. Hosp /Long-stay
unit
Hospital
Hospital
3
19
7
2
4
South
South
West
Health Protection Surveillance Centre
2
3
4
3 of 4
90.0
80.0
Unknown
70.0
Recurrent Cases
60.0
New Cases
%
50.0
40.0
30.0
20.0
10.0
0.0
Community
Healthcare
Origin
Community
Healthcare
Onset
Figure 2. Origin and Onset of CDAD Cases by Case Type, Aug – Dec 2009
Health Protection Surveillance Centre
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