Infection: Public Reporting
Monthly Report - Clostridium difficile
Number of new cases = 2
Number of patient days = 2,194
Excluding <1 year of age
Infection rate = 2/2,194 X 1,000 = 0.91
Reporting C difficile
What is C difficile?
Clostridium difficile (C difficile) is a bacterium (germ) that causes diarrhea and more serious intestinal conditions such as colitis. It is the most common cause of infectious diarrhea in hospitalized patients in the industrialized world. The use of antibiotics increases the chances of developing C difficile diarrhea. Treatment with antibiotics alters the normal levels of good bacteria found in the intestines and colon. When there are fewer of these good bacteria, C difficile can thrive and produce toxins (poisons) that can cause an infection.
Why are we reporting our C difficile rates?
The Ministry of Health and Long Term Care has recently introduced full public reporting on certain patient safety indicators. We are now required to publish the rates of infection with C difficile that occur in our hospital for children over 1 year of age. Children less than 1 year of age are excluded because up to one-half of healthy newborns can carry the bacteria in their stool but not have any illness. Public reporting is being done as an example of our commitment to patient safety in our hospital and in the province.
What do the numbers mean?
You will see two sets of numbers on the website. One is the number of new C difficile cases that occur each month, and the other is the rate of C difficile infection. The rate is calculated by dividing the number of new cases by the number of patient days that were used in the same month. That number is then multiplied by 1,000 so that it is easily compared from one month to another.
What is a patient day?
One patient day is counted for each day that a patient is admitted into a bed at our hospital (the patient days for this report do not include children under 1 year of age). So if one patient was in the hospital from September 1 to September 30, we would count 30 patient days. If another patient was in the hospital from September 20 to September 25, we would add five more patient days.
Why are we using patient days instead of the number of patients?
The rate is based on patient days instead of the number of patients in the hospital (admissions) because we recognize that patients who stay a long time in the hospital have more risk of getting a healthcare acquired infection than patients who are in for just a few days. If we calculated our rate based on the number of patients we would be suggesting that every patient had the same risk, and that is false. So to provide a more accurate calculation of the rate of infection, patient days are used.
Why are the rates different in different hospitals?
Rates of C difficile infection are affected by many factors. Some of these include the size of the facility, the kinds of patients seen, the kinds of treatment given and the presence of an outbreak in a hospital.
Size of the facility:
In smaller facilities, a single case of C difficile can look very big when we put it in a “rate”. This is because the denominator used (patient days) is much smaller than in a big facility. For example, if “Hospital A” with 30 beds was completely full for 30 days in a month, they would have 900 patients days for the month. If a much larger hospital (Hospital B) had 300 beds, and they were all full for the month, the denominator of patient days would be 9,000.
- If hospital A has 1 case of C difficile in the month, the rate would be 1/900 x 1,000 = 1.11 for every 1,000 patient days.
- If hospital B has 1 case of C difficile in the month, the rate would be 1/9,000 x 1,000 = 0.11 for every 1,000 patient days.
The kinds of patients seen:
Some patients are at a greater risk of getting C difficile infection than other patients. Generally speaking, this includes patients who have serious underlying immune system problems, patients with bowel diseases like Crohn’s disease or ulcerative colitis, patients over 65 years old, and patients who take lots of antacid treatments (like Tums®).
The kinds of treatments given:
Some hospitals have special programs that use treatments that put patients at a higher risk of getting C difficile infection. This includes cancer chemotherapy, surgery on the bowel, and the extensive use of antibiotics.
Hospitals that regularly see patients with the kinds of diseases and treatments that we have talked about might have a higher rate of C difficile infection simply because the patients are at a higher risk.
The presence of an outbreak:
If a hospital has a cluster of C difficile cases or an outbreak, that can make the rate for the month appear very high. As soon as an outbreak is identified, the hospital will put in very strict measures to ensure that the outbreak is stopped as quickly as possible. Once things are back to normal, the rates will return to a normal level.
Questions and Answers About C Difficile
What is C difficile?
C difficile is a bacteria (germ) that causes diarrhea and more serious intestinal conditions such as colitis. This bacteria can live in our intestines. There are many, many bacteria in the intestine that live there all the time (some even help us to digest food). Usually, the other bacteria compete with the C difficile, and don’t let it multiply too much. When the other bacteria are disturbed by something like antibiotics (which kill both good and bad bacteria), then the C difficile takes advantage and start to multiply and can cause an infection. It is the most common cause of infectious diarrhea in the hospital.
Up to one-half of healthy newborns can carry the bacteria in their stool but not have any illness. This is called “colonization”. After the age of 5 years, this carriage rate becomes similar to adults where 5% may carry the bacteria without symptoms.
How do people get C difficile?
When someone is sick with C difficile, the bacteria leave their body with their stool (bowel movement), and can stay in the environment. C difficile bacteria can turn themselves into a special form (spore) that lives for a long time. Someone else can be infected if they ingest (eat) the spores. That can happen if their hands are contaminated with spores, and they touch their mouth. Contaminated hands can be the vehicle to bring the spores to another person.
How do I know if I have C difficile?
Once someone has ingested the spore, it can live quietly with the other bacteria in their intestine. If the C difficile grows and multiplies, it can produce a toxin that can cause swelling in the intestine. That causes diarrhea and sometimes abdominal pain. In some cases it can be very severe. To find out if the diarrhea is caused by C difficile, your doctor will order a test that can identify the toxin.
What are the symptoms of C difficile infection?
C difficile infection usually causes mild to moderate diarrhea, which may be accompanied by abdominal cramps and fever. In children, diarrhea is the most common symptom. In some cases, it can cause more severe diarrhea, and in rare cases, surgery is necessary because the intestine is so badly damaged. In extreme cases, C difficile infection can cause death.
Who is at risk of getting an infection with C difficile?
People who have been on antibiotics are at greater risk of developing an infection with C difficile, because these drugs disrupt the balance of bacteria in the intestine. As well, old age, other serious illnesses and poor overall health can increase the risk for more severe disease.
Why is C difficile such a problem now?
C difficile has been identified as a concern in healthcare for more than 30 years, but recently a new strain was found that seems to be causing more problems. As a result, all hospitals have been looking at C difficile more closely than ever before.
Can C difficile be treated?
Yes. Sometimes, stopping the antibiotics that you are taking can stop the C difficile infection, because the normal bacteria grow back and take control again. There are special antibiotics that are used to treat C difficile infection. Sometimes they have to be given for more than one course of treatment, but they are normally very effective in treating the infection.
Can my family and friends get C difficile?
Healthy people who are not taking antibiotics are at very low risk of getting C difficile infection. To protect themselves against the small risk, they should wash their hands after visiting you, and follow the precautions that the staff explains to them. You may still have visitors when you have C difficile, but they must understand the importance of cleaning their hands when they leave your room. They must also wear gowns and gloves if they are caring for you, like the staff do, and they should not sit on the bed or on a commode chair.
What is CHEO doing to make sure I am safe?
Looking closely at the C difficile cases is an important step in making sure you are safe. This is called surveillance, and it allows us to know whether there is a problem in the hospital and to understand how big the problem is. As well, we provide education to our staff about the risk of C difficile and the importance of hand washing to prevent spreading diseases. If there is a cluster of cases of C difficile, we ensure that our cleaning staff are involved in additional cleaning activities. Because we monitor the situation so closely, we can give the right medicine very early if it is needed to treat the infection.
What should I do at the hospital?
Always wash your hands after using the bathroom and before eating. Remind others, including your doctors and nurses, to wash their hands before touching you. Cleaning hands is the best way for everyone to prevent spreading C difficile and other germs. If you have diarrhea that splashes on to the floor or another surface in your room, you must tell your nurse immediately, as it will need to be properly cleaned.
Why are special precautions or isolation needed?
Patients who are sick with C difficile can spread the spores in their environment more easily than patients who are not sick. Since there are other sick patients in the hospital, and many patients who are getting antibiotics, there are lots of people at risk of having an infection if they get C difficile. We don’t want the C difficile to spread to them. To help protect everyone, we use special precautions, including gowns and gloves and lots of hand washing when we care for someone who has C difficile. If you have diarrhea from C difficile in the hospital, you will be put on special precautions. This might mean that you have to move to a single room, or you might have a special commode or toilet to use while you are having diarrhea. Visitors who come to see you while you are on special precautions should not be visiting other patient rooms. We will ask you to stay in your room until your diarrhea stops. Once you stop having diarrhea for 2 days, these special precautions will be stopped.
What should I do when I go home?
Remember, healthy people like your family and friends who are not taking antibiotics are at very low risk of getting C difficile infection.
Wash your hands for at least 15 seconds:
- after using the toilet,
- after touching dirty or contaminated surfaces,
- before eating or
- before preparing meals.
Also, remind other people in your home to wash their hands regularly. If your caregivers must handle feces or other body fluids, they should wear gloves and wash their hands when they take the gloves off.
Cleaning the house:
An all-purpose, regular household cleaner can be used even if you have C difficile. Be sure to follow the instructions on the label and use good friction (rubbing) when cleaning a surface. Toilets and bathrooms need extra attention. If feces have splashed onto a surface, they must be removed first, and then cleaning done with the household cleaner. If it is possible, use your own bathroom until your diarrhea stops.
If clothes are soiled with feces, they should be washed separately after rinsing off the feces. Hot water and soap are helpful to remove the bacteria, and drying clothes in a dryer is also helpful.
Regular cleaning of dishes, either in a sink with soap and hot water or in a dishwasher is fine. You shouldn’t share dishes or utensils.
It is very important that you take all your medication as prescribed by your doctor. Do not use any drugs from the drugstore that will stop your diarrhea (e.g. Imodium®).
Talk to your doctor:
If the diarrhea does not stop, or comes back, contact your doctor.
Information from the Ontario Ministry of Health and Long-Term Care.