Call for urgent action to improve CDI management

Experts from across Europe came together with members of European Parliament to discuss ways to improve current gaps in diagnosis, treatment, control and surveillance.

The event follows on from the launch of the CDI in Europe report in April 2013, which was supported by multiple European stakeholders and quoted in the European Parliament Resolution on Patient Safety and HAI.^₂ The Resolution calls on Member States and the European Union to do more to address HAIs like CDI.2 CDI is one of the top ten HAIs in European hospitals³ and has surpassed MRSA as a leading cause of healthcare-acquired infection in several European countries.^4,5

This meeting coincides with The Lancet Infectious Diseases publication of EUCLID, the EUropean, multi-centre, prospective bi-annual point prevalence study of CLostridium difficile Infection in hospitalised patients with Diarrhoea, the largest ever prevalence study of CDI across Europe. This ground breaking study included data from 482 hospitals across 20 European countries; it found there are an estimated 40,000 missed cases of CDI each year.¹ With around 8,000 hospitals in the EU,⁶ the true European total of missed CDI cases is likely to be significantly higher.

“Guidelines recommend that testing for CDI should be carried out on all unformed stools when the cause of diarrhoea is not clear. However, we are still seeing an issue with a lack of clinical suspicion and so lack of testing for CDI, and sub-optimal tests still being used”, commented Professor Mark Wilcox, Professor of Medical Microbiology, Leeds Teaching Hospitals & University of Leeds. “If we are to address the considerable burden that CDI places on patients and healthcare systems we need urgent action to standardise the diagnosis and management of CDI across Europe.”

The EUCLID study results detail markedly higher CDI case rates compared with previous studies.^1,7 Yet due to a lack of clinical suspicion and sub-optimal testing, on a single day across Europe, an average of 74 in-patients with CDI were not tested by their hospital and an additional 34 patients received a false-negative result for CDI.¹
 
Hospitals using optimised methods for CDI laboratory diagnosis increased between the two study periods from 32.5% in 2011-12 to 48% in 2012-13.¹ Notably, hospitals with higher testing rates generally had lower prevalence of PCR-ribotype 027,¹ one of the most virulent ribotypes associated with CDI epidemics.⁸ This suggests that increased CDI awareness and using optimal testing methods can reduce the spread of epidemic strains.¹

The proportion of UK hospitals using optimal laboratory diagnosis was the highest of all countries, in line with national guidelines; consequently, under- and misdiagnosis was relatively uncommon. This serves as an example of how improved monitoring of CDI can help to reduce infection rates. While national surveillance schemes have been associated with reduced incidence of CDI in some countries, this remains a major healthcare burden.^{9,10,11,12,13}

CDI is a recurring and preventable bacterial infection¹⁴ that results in severe, and potentially deadly, diarrhoea.^15,16 In Europe the incidence and severity of CDI is increasing, posing a major threat to healthcare systems and patients alike.^17,18,19,20

During the European Parliament event, MEP Karin Kadenbach led discussions on the burden of CDI within the policy context of European action on HAIs. Joined by a number of pan-European scientific societies and clinical experts, the group discussed their respective roles in addressing HAIs and explored ways to collaborate to improve the quality of care to patients.

“I was delighted to host this important event. While we have a good understanding of patient safety and HAIs, the importance of addressing these remains under-appreciated in healthcare settings. Member States have made good progress in recent years to adopt patient safety and HAI measures, but the economic crisis has slowed this process and this issue is now lower on governmental agendas”, commented Karin Kadenbach, Member of European Parliament. “Given that many HAIs are preventable, the Commission anticipates that infection prevention and control measures should save public health costs, but action needs to be taken now.”

 

References
1.    KA Davies et al. Underdiagnosis of Clostridium difficile across Europe: the European, multicentre prospective, biannual, point-prevalence study of Clostridium difficile infection in hospitalised patients with diarrhoea (EUCLID). The Lancet Infect Dis. 2014;14:1208-19. Available at: http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(14)70991-0/fulltext
2.    Committee on the Environment, Public Health and Food Safety. Report on the report from the Commission to the Council on the basis of Member States' reports on the implementation of the Council Recommendation (2009/C 151/01) on patient safety, including the prevention and control of HAIs (2013/2022(INI)), European Parliament 2013.
3.    European Centre for Disease Prevention and Control. Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals. Stockholm: ECDC; 2013.
4.    Meyer E et al. Associations between nosocomial meticillin-resistant Staphylococcus aureus and nosocomial Clostridium difficile-associated diarrhoea in 89 German hospitals. J Hosp Infect. 2012;82(3):181-6.
5.    UK Health Protection Agency. English national point prevalence survey on healthcare-associated infections and antimicrobial use, 2011: preliminary data. London; Health Protection Agency, 2012.
6.    European Commission. European hospital survey: benchmarking deployment of e-health services (2012–2013). 2014.
7.    Bauer MP et al, for the ECDIS Study Group. Clostridium difficile infection in Europe: a hospital based survey. Lancet 2011; 377: 63–73.
8.    Kuijper EJ, Coignard B, Tull P. Emergence of Clostridium difficile-associated disease in North      America and Europe. Clin Microbiol Infect. 2006;12 Suppl 6:2–18.
9.    Adler A, Schwartzberg Y, Samra Z, Schwarts O, Carmeli Y, Schwaber M J and the Isreali Clostridium difficile diagnostics study group. Trends and changes in Clostridium difficile diagnostic policies and their impact on the proportion of positive samples: a national survey. Clin Microbiol Infect. 2014; Doi: 10.1111/1469-0691.12634 (Epub ahead of print)
10.    Updated guidance on the diagnosis and reporting of Clostridium difficile. Epub.
11.    Wiegand P N, Nathwani D, Wilcox M H, Stephens J, Shelbaya A and Haider S. Clinical and economic burden of Clostridium difficile infection in Europe: A systematic review of healthcare-facility-acquired infection. J. Hosp. Infect. 2012;81:1-14.
12.    McGlone SM, Bailey RR, Zimmer SM, Popovich MJ, Tian Y, Ufberg P, Muder RR, Lee BY. 2012. The economic burden of Clostridium difficile. Clin. Microbiol. Infect. 2012; 18:282-9.
13.    Laqu T, Stefan M S, Haessler S, Higgins T L, Rothberg M B, Nathanson B H, Hannon N S, Steingrub J S, Lindenauer P K. The impact of hospital-onset Clostridium difficile infection on the outcomes of hospitalized patients with sepsis. J. Hosp. Med. 2014; Doi: 10.1002/jhm.2199 (Epub ahead of print).
14.    McMaster-Baxter NL, Musher DM. Clostridium difficile: recent epidemiologic findings and advances in therapy. Pharmacotherapy. 2007;27:1029-39.1.
15.    Ananthakrishnan AN. Clostridium difficile infection: epidemiology, risk factors and management. Nat Rev Gastroenterol Hepatol. 2011;8:17-26.
16.    Sunenshine R, McDonald L. Clostridium difficile-associated disease: new challenges from an established pathogen. Cleve Clin J Med. 2006;73:187-97.
17.    Lyytikäinen O, et al. Hospitalizations and Deaths Associated with Clostridium difficile Infection, Finland, 1996–2004. Emerg Infect Dis. 2009;15:761–5.
18.    Soler P, et al. Rates of Clostridium difficile infection in patients discharged from Spanish hospitals, 1997-2005. Infect Control Hosp Epidemiol. 2008;29:887-9.
19.    Vonberg RP, et al. Clostridium difficile in Discharged Inpatients, Germany. Emerg Infect Dis. 2007;13:179-80.
20.    Freeman J, et al. The Changing Epidemiology of Clostridium difficile Infections. Clin Microbiol Rev. 2010;23(3):529–549.

04.12.2014