Questions and Answers

• What is Clostridium difficile (C. difficile)?
• What is Clostridium difficile-associated disease (CDI)?
• What causes Clostridium difficile-associated disease (CDI)?
• What are the risk factors for CDI?
• How is C. difficile transmitted?
• Why is C. difficile such a serious hospital-acquired infection (HAI)?

• What is being reported?
• How frequently will hospitals have to report on CDI?
• Why is Ontario requiring hospitals to report cases of C difficile?
• Will this reporting happen in real time, or will there be a delay?
• What is a CDI rate? Please explain the term ‘XX per 1000 patient days’.
• Why are hospitals placed into one of five categories : Small; Large Community; Mental Health; Acute Teaching; Complex Continuing Care & Rehabilitation? Why were these five categories chosen?
• What conclusions should patients draw from a high number of cases of CDI in a hospital? Does this mean their chances of catching CDI or other hospital acquired infection is higher, or that the hospital is unsafe?
• Should patients be making decisions about where to seek care based on this information?
• What should hospitals be doing if their CDI rates are high?
• When a hospital has an outbreak of C. Difficile, what happens?

C. difficile is just one of the many types of bacteria that can be found in the environment and the bowel. C. difficile is the most common cause of infectious diarrhea in hospitals and long-term care homes. It has been a known cause of health care associated diarrhea for about 30 years.

When C. difficile bacteria grows in the bowel, it produces toxins. These toxins can cause a disease known as Clostridium difficile infection (CDI). CDI can damage the bowel and cause diarrhea. The effects of CDI are usually mild but sometimes can be more severe. Symptoms can range from mild diarrhea to high fever, abdominal cramping, abdominal pain and dehydration. In severe cases, surgery may be needed, and in extreme cases CDI may cause death.

CDI can sometimes occur when antibiotics are prescribed. Antibiotics work by killing off bacteria – the bad bacteria – but also good bacteria. Without the presence of the typical “good” bowel bacteria, the C. difficile bacteria may start to grow and produce toxins that can cause CDI. CDI can damage the bowel and may cause diarrhea.

Certain people are at increased risk for acquiring CDI. These risk factors include :

• History of antibiotic usage
• Bowel surgery
• Chemotherapy
• Prolonged hospitalization
• Being elderly
• Serious underlying illness or debilitation

The spread of C. difficile occurs due to inadequate hand hygiene and environmental cleaning; therefore, proper control is achieved through consistent hand hygiene and thorough cleaning of the patient environment.

Good hand hygiene i.e. cleaning hands thoroughly and often is the single-most effective way to prevent the spread of infectious diseases like C. difficile.

There are a number of strains of C difficile that have become extremely toxic in recent times. This is a problem in a number of countries around the world, including the UK and the United States.

In the case of C. difficile, it is thought that over-use or inappropriate use of certain types of antibiotics has played a role in the increasing toxicity of the bacteria.

Beginning September 26, 2008, all Ontario hospitals will be required to publicly report on their own websites CDI rates and the number of patients with hospital-acquired CDI occurring during a calendar month in their facilities.The MOHLTC will also have the reported number of cases and the rates by hospital site posted on its own website : http://www.ontario.ca/patientsafety

Hospitals will be reporting their CDI data for every calendar month.

For the first reporting cycle, hospitals were expected to report CDI data collected between August 1-31st, 2008.

Every month thereafter, hospitals are required to report monthly data to the Ministry by the 15th of the following month and then report these data to the public via the hospital’s website by the last day of every month.

Hospitals have been mandated through a regulatory change in the Public Hospitals Act to report this information to the ministry and on the hospital’s publicly accessible website. The government has moved forward with public reporting because by producing valid, reproducible data the health care system is able to track and manage CDI in hospitals.

At each month’s end, the data posted on the ministry’s website will reflect the data collected for the previous calendar month.

The rate is calculated by dividing the number of new cases observed at the hospital site by the number of patient days per reporting period, multiplied by 1000. Rates are expressed as cases per 1,000 patient days and exclude patients less than one year of age. This rate calculation allows the level of hospital activity to be taken into account, which may fluctuate over time and is different across hospitals.

The hospitals are placed into one of these categories to facilitate more relevant comparisons. These hospital types generally encompass differences in hospital size and patient case mix. For example, teaching hospitals serve in general more complex or sicker patients compared to other hospital types.

The number of cases of CDI in a hospital does not mean that the hospital is unsafe. A number of factors should be always be considered, such as the size of the hospital, the populations that the hospital serves, and whether the cases were acquired within the hospital or in another facility or the community. In addition, compliance with excellent infection control practice, available facilities, appropriate use of antibiotics and surveillance systems are among other factors that can impact how much CDI is observed in a hospital.

A patient’s decision reqarding where to seek care should be based on the availability of the best resources to provide them the highest quality of care. No single indicator, or in this case rate, should be used to judge a hospital as each aspect of a hospital’s performance and quality is important.

Hospitals that identify a high rate of CDI should review their infection prevention and control practice to ensure that it aligns with what has been provided to all of them, including the PIDAC documents ‘Best Practices for the Management of Clostridium difficile in all health care settings’, ‘Best Practices for Hand Hygiene in all health care settings’ and the MOHLTC ‘Just Clean Your Hands’ program.

In addition, they should review their environmental cleaning practices to ensure that they are following the PIDAC C. diffiicile best practice document. Hospitals should also consult with their local public health unit to identify any further action that is required.

The hospital must call its local public health unit and inform it of the outbreak. An Outbreak Management Team, consisting of members of the hospitals infection prevention and control program, affected departments representation from the local public health unit, is formed.

This group provides the day-to-day management of the outbreak and is the liaison between the hospital and public health. At the end of the outbreak, this group will review all aspects of the outbreak and provide recommendations to the hospital to assist in preventing future outbreaks.