Clostridium difficile - krankenhaushygiene

Clostridium difficile - krankenhaushygiene

Clostridium difficile –
aktuelle Epidemiologie in Österreich
Franz Allerberger
Wels, 4. April, 15:20-16:10
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http://ecdc.europa.eu/en/activities/diseaseprogrammes/ARHAI/Documents/Clostridium_%20difficile_infection_in_%20Europe
_A%20hospital-based%20survey_open%20access_%20version_FINAL_18-11-2011.pdf
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http://www.parlament.gv.at/PAKT/VHG/XXIV/AB/AB_12087/fname_267708.pdf
„Die im Einleitungstext der parlamentarischen Anfrage angesprochene Studie „Hospitalacquired Clostridium difficile infection: determinants for severe disease“ von Wenisch JM et al.
(publiziert Dezember 2011 Eur J Clin Microbiol Infect Dis 2011) ist mir bekannt. Untersucht
wurde die Situation in einer Krankenanstalt mit 777 Betten. Eine Hochrechnung von der
speziellen Situation in einer bestimmten Krankenanstalt auf alle Krankenanstalten in
Österreich ist problematisch. Es ist aber nicht notwendig, Hochrechnungen für die Beurteilung
der Situation heranzuziehen. …. Wegen der in Österreich bestehenden Anzeigepflicht
gemäß § 1 Abs. 1 Z 2 Epidemiegesetz für Erkrankungs- und Todesfälle an schwer
verlaufenden Clostridium difficile assoziierten Erkrankungen liegen seit Jahren für
das gesamte Bundesgebiet Zahlen zu Clostridium difficile vor. Die Zahlen werden
monatlich auf der Homepage des Bundesministeriums für Gesundheit (unter Berücksichtigung
des Datenschutzes) veröffentlicht (www.bmg.gv.at). Die Situation in Österreich kann somit
auf der Homepage meines Ministeriums verfolgt werden.“
5
+
Meldedaten Österreich 2009-2012*
2009
2010
2011
2012 *
0 0%
15 14%
27 22%
56 32%
1
110
125
175
160
Verstorben
140
Gesamt
120
Anzahl
100
80
60
40
20
0
2009
2010
2011
2012
Jahre
6
3
Auswertung der ICD10-Diagnosen
1.9.2008 GZ: BMGFJ21765/0013-III/A/1/2008:
Österr. Referenzzentrale für
Clostridium difficileInfektionen des Menschen
„A04.7 Enterokolitis durch Clostridium difficile“
3000
Fallzahl
2500
2.032
2000
1500
Gesamt
1000
500
159
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Verstorben
=7,8%
Jahr
European Centre for Disease Prevention and Control. Point prevalence survey of
healthcare-associated infections and antimicrobial use in European acute care
hospitals – protocol version 4.3. Stockholm: ECDC; 2012.
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Erläuterungen
2. Einführung einer Meldepflicht von
Erkrankungsfällen an einer schwer verlaufenden
Clostridium difficile assoziierten Erkrankung und
Todesfällen an Clostridium difficile assoziierten
Erkrankungen:
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Update of the ESCMID treatment guidance
document for Clostridium difficile infection (CDI)
Severe CDI
Severe or life-threatening CDI is defined as an episode of CDI with
(one or more specific signs and symptoms of) severe colitis or a
complicated course of disease, and/or when one or more
unfavourable prognostic factors is present without evidence of
another cause:
- Marked leucocytosis (leukocyte count > 15 ∙ 109/l)
- Decreased blood albumin (< 30 g/L)
- Rise in serum creatinin level (≥133 μmol/L or ≥1.5 times the
premorbid level)
CDI without signs of severe colitis in patients with high age (≥
65), serious comorbidity, Intensive Care Unit (ICU) admission, or
immunodeficiency may also be regarded as severe.
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Bouza E. (2012) Consequences of Clostridium difficile infection:
understanding the healthcare burden. Clin Microbiol Infect. 18
(Suppl. 6): 5–12
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Update of the ESCMID treatment guidance
document for Clostridium difficile infection (CDI)
Recurrent CDI
Recurrence is present when CDI (based on clinical
picture and microbiological evidence of free toxins
and the presence of toxigenic C. difficile in stool,
and without evidence of another cause of the
symptoms) re-occurs < 8 weeks after the onset of
a previous episode, provided the symptoms from
the previous episode resolved after completion of
initial treatment.
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Ambulant erworbene CDI
Neben dem Anstieg der Häufigkeit nosokomialer
Erkrankungen wird über ein vermehrtes Auftreten
ambulant erworbener CDI berichtet. 10 - 27% der
CDI sind Community-assoziiert.
Ein CDI-Fall ist klassifiziert als Community“assoziierte CDI, wenn (a) der Beginn der
Symptome außerhalb des Krankenhauses oder im
Krankenhaus innerhalb von <48 h nach
Krankenhausaufnahme erfolgte und (b) innerhalb
der vergangenen 12 Wochen kein Aufenthalt in
einer Gesundheitseinrichtung vorlag (Kuijper et al. 2006).
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„Stool specimens were provided by 306 patients (161 female) with acute diarrhea.
Pathogens were detected in 71 (23.2%) patients, with incidence peaks in Febr. and
30
June.“
2
25
6
20
> 60
40-59
20-39
5-19
0-4
15
11
2
3
2
10
1
6
1
1
5
4
0
1
1
0
2
3
2
0
5
1
2
0
2
0
0
1
0
3
3
1
1
4
0
2
0
1
1
0
Salmonella
Campylobacter
Yersinia
C.difficile
Rotavirus
Adenovirus
Norovirus
Giardia
Cryptosporidium
> 60
1
1
0
2
3
0
2
1
0
40-59
2
1
1
2
1
1
6
1
0
20-39
2
3
0
6
5
1
11
0
2
5-19
0
2
0
3
3
0
4
0
0
0-4
0
0
0
1
1
2
4
0
0
Neusiedl am See (6000 Einwohner, 3 prakt. Ärzte) Studie 2007
Infection 2009; 37: 103–108
Wilcox M. (2012) Overcoming barriers to effective recognition and diagnosis of Clostridium
difficile infection. Clin Microbiol Infect. 18 (Suppl.6): 13–20, December 2012
„Many clinicians still believe that a majority of
CDI cases occur endogenously, with patients
already harbouring C. difficile on admission to
hospital and CDI developing following
subsequent antibiotic therapy. This is a
common misconception, as asymptomatic
carriers of toxigenic C. difficile are significantly
less likely than non-carriers to develop CDI [1].“
Kyne L, et al. (2000) Asymptomatic carriage of Clostridium difficile and
serum levels of IgG antibody against toxin A. N Engl J Med 342: 390-397.
1.,
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Clostridium difficile Ribotypen in Östereich, 2012:
Krankenhausbasierte Multicenterstudie
Alexander INDRA, Daniela SCHMID, Steliana HUHULESCU,
Karl STICKLER, Markus HELL, Franz ALLERBERGER, on
behalf of the Austrian C. difficile Study Group*
* Collaborators: Ojan Assadian, Christoph Aspöck, Elisabeth
Bischof, Susanne Equiluz-Bruck, Gebhard Feierl, Friederike
Geppert, Monika Gilhofer, Gabriele Hartmann, Simone
Höfler-Speckner, Oskar Janata, Uwe König, Monika Leeb,
Andrea Lenger, Dorothea Orth, Ildiko-Julia Pap, Ulrike
Pomper, Wolfgang Prammer, Lukas Reiter, Karl Silberbauer,
Brigitte Stoiser, Heinz Stradal, Maria Szupancsitz, Herwig
Tomantschger, Agnes Wechsler-Fördös, Gerhard Tucek,
Astrid Urban, Eva-Maria Zeitlberger.
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Figure . Minimum spanning tree analysis of 270 C. difficile type 027 isolates by MLVA. Each circle represents either one unique
isolate or more isolates that have identical MLVA types. Thick lines represent single-locus variants, thin lines represent double-locus
variants, and the interrupted lines represent triple-locus variants between MLVA types.
Grey shadings indicates portioning of groups of more the two single-locus variants.
EUROSURVEILLANCE: submitted
Rapid communication
Occurrence of C. difficile PCR-ribotype 027 in
Romania
Alexandru Rafila, Alexander Indra, Gabriel Adrian
Popescu, Günther Wewalka, Franz Allerberger. Serban
Benea, Ioana Badicut, Steliana Huhulescu
Romania
Italian isolates
A
Austria
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Table. CDI case classification, severe manifestations and all-cause 30-day mortality stratified
for RT 027, 078 and "any other ribotype" (N=171)
Ribotypes
Healthcareacquired
n (%)
Communityacquired
n (%)
027
29 (85.3)
3 (8.8)
2 (5.9)
078
7 (77.8)
2 (22.2)
Other
89 (69.5)
TOTAL
125 (73.1)
(N1=34)
Indetermin
Surgical
able
intervention
n (%)
n (%)
Intensive
care
n (%)
30-day
mortality
n (%)
0 (0)
0 (0)
3 (8.8)
0 (0)
0 (0)
1 (11.1)
0 (0)
29 (22.7)
10 (7.8)
1 (0.8)
1 (0.8%)
12 (9.4)
34 (19.9)
12 (7.0)
1 (0.6)
2 (1.2)
15 (8.8)
(N2=9)
(N3=128)
(Ntotal=171)
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Indra A, Schmid D, Huhulescu S, Stickler K, Hell M, Allerberger F, on behalf of the Austrian C. difficile Study
Group (2013) Clostridium difficile ribotypes in Austria, 2012: A multi-center, hospital-based survey. Wien Klin
Wochenschr: submitted
Conclusion: The fact that more than
85% of the RT 027 isolates were
healthcare-associated, as compared
to 70% healthcare-association for
non-RT 027 isolates underlines the
ongoing nosocomial transmission of
this clone in Austrian hospitals.
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According to Barbut and Rupnik, the most important
control measure that ought to be implemented is
surveillance of CDI and the response in a timely
fashion to any case increase, regardless of whether
it is caused by a known or a newly emerging potential
hyper-virulent genotype.1
Other experts recommend that ribotyping is
undertaken on all samples, in order to allow for the
detection not only of outbreaks associated with
epidemic strains, but also of case clusters in the
hospital that are associated with poor environmental
decontamination or hygiene practices.2
1. Barbut F, Rupnik M. 027, 078, and others: Going beyond the numbers (and away from the hypervirulence). Clin Infect Dis
2012; 55: 1669-1672.
2. Patel TA, Smith R, Hopkins S. Ribotyping in the detection of Clostridium difficile outbreaks in a single university hospital. J
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Hosp Infect 2013; 83: 77-79.
Schmid D. et.al. (2013) Increased risk of death in hospitalized patients with C. difficile infection in comparison to patients with
non-CDI diarrhoe in Austria. Epidemiol Infect Submitted
Table 1. Study patients by enteric pathogen and pre-discharge case-fatality and diarrhoea-associated mortality by enteric pathogen
Enteric
pathogen
Study
sample
Pre-discharge
case fatality
Ntotal=270
Diarrhea-associated
pre-discharge
mortality by
pathogen
Ndeaths=31
C. difficile
90 (33.3%)
18/90 (20.0%)
Norovirus
99 (36.7%)
11/99 (11.1%)
Campylobacter
48 (17.8%)
1/48 (2.1%)
Adenovirus
20 (7.4%)
1/2 (50.0%)
Salmonella
18 (6.7%)
0/18 (0)
Rotavirus
10 (3.7%)
0/10 (0)
Yersinia
1 (0.4%)
0/1 (0)
Shigella
1 (0.4%)
0/1 (0)
Aermomonas
1 (0.4%)
0/1 (0)
18/31 (58%)
11/31 (35.5%)
1/31 (3.2%)
1/31 (3.2%)
0
0
0
0
0
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Schmid D. et.al. (2013) Increased risk of death in hospitalized patients with C. difficile infection in comparison to patients with
non-CDI diarrhoe in Austria. Epidemiol Infect Submitted
Table 2- Characteristics of the total study population, and segregated of the CDI-patient group (N=90) and
non-CDI diarrhoea patient group (N=180) * t-test; ** Chi-square test; ***Fisher’s Exact Test
Total
CDI patients
n=90
non-CDI
diarrhoea
patients
n=180
p
Sex= female
187 (69.3%)
77.5 (18-102)
60 (66.7%)
73.2 (21-91)
127 (70.6%)
70.1 (18-102)
0.5139**
Median age (range)
196/270 (72.6%)
69/90 (76.7%)
127/180 (70.6%)
Characteristics of study
subjects
Age >= 65 years
Moderate and severe comorbidity
Health-care associated
Duration (d) of diarrhoea
(mean, min; max)
Age group < 65 years
Moderate and
severe co-morbidity
54/270 (20.0%)
26 (28.9%)
28 (15.6%)
171 (63.3%)
80 (88.9%)
91 (50.6%)
7.6 days (1-82)
12.5 days (1-82)
5.5 days (1-42)
N=74
N=21
N=53
Age group >= 65 years
9/74 (12.2%)
N=196
6/21 (28.6%)
3/53 (5.7%)
N=69
N=127
Moderate and
severe co-morbidity
45/196 (3.0%)
20/69 (29.0%)
25/127 (19.7%)
0.2027*
0.2886
0.0098**
<0.0001
<0.0001*
0.0131***
29
0.1392
The majority of extra hospital costs are
allocated by length of stay
Additional
• length of stay (LOS)
• revision operations
• additional investigations
• therapy (antibiotics)
„The majority of extra hospital costs are allocated by length of stay. Additional:
revision operations, additional investigations, therapy (antibiotics)“
Slide graduity: Petra Gastmeier
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Schmid D. et.al. (2013) Increased risk of death in hospitalized patients with C. difficile infection in comparison to patients with
non-CDI diarrhoe in Austria. In preparation
Figure 1; Kaplan-Meier survival estimates CDI (N=90; blue line)
and non-CDI diarrhoea patients (N=180; red line)
Time (d) since diagnosis of diarrhoea
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RKI 2013: Evaluation Report Unit 32: Surveillance
[death notifications]
Nicht namentlich; z.B. HIV, connatale
Toxoplasmose, Echinokokkose
Meyer et al. J Hosp Infect 2012*:
Incidence of nosocomial cases
(per 1000 patient-days)
0.19 MRSA cases (incl. colonisation)
0.37 CDI
*2007 KISS Daten
368
-> 52.738 CDI-cases
8.8% = 4.641
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DE: 2011 4.009 fatal traffic-accidents in 2011
Vergleich CDAD-KISS
Alle Krankenhäuser
KISS 2008, 2011
Indikator
Median
(n= 54, 127)
Gesamt Inzidenzdichte*
0,60
0,62
Österreichische KH
KISS 2008, 2011
Median
(n=7, 9)
0,60 0,63
Inzidenzdichte*
nosokomiale CDAD-Fälle
0,37
0,37
0,51
0,41
Inzidenzdichte*
schwere Fälle
0,01
0,02
0,01
0,04
* = … /1000 Patiententage
Data graduity: Petra Gastmeier (14.1.2013)
AT -> 9.294 CDI/Jahr
7.472 CDI/Jahr
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Belagstage AT 2010: 18.225.139 -> 7.472 CDI Fälle
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Wenisch JM, Schmid D, Tucek G, Kuo HW, Allerberger F, Michl V, Tesik P,
Laferl H, Wenisch C (2012) A prospective cohort study on hospital
mortality due to Clostridium difficile infection. Infection 2012
Oct;40(5):479-84.
“Considering a total of 266 acute care
hospitals in Austria with approximately
15 million hospital days per year and
based on incidence rate and case
fatality observed in our study in one
acute care hospital, a total of 7097
cases of hospital-acquired CDI resulting
in an estimated 1279 deaths could be
expected every year in Austria.”
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Besonderer DANK an:
Ojan Assadian, Christoph Aspöck, Elisabeth Bischof,
Susanne Equiluz-Bruck, Gebhard Feierl, Friederike
Geppert, Monika Gilhofer, Gabriele Hartmann,
Markus Hell, Simone Höfler-Speckner, Oskar
Janata, Uwe König, Monika Leeb, Andrea Lenger,
Dorothea Orth, Ildiko-Julia Pap, Ulrike Pomper,
Wolfgang Prammer, Lukas Reiter, Karl Silberbauer,
Karl Stickler, Brigitte Stoiser, Heinz Stradal, Maria
Szupancsitz, Herwig Tomantschger, Agnes
Wechsler-Fördös, Gerhard Tucek, Astrid Urban,
Eva-Maria Zeitlberger
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