Proposal for a survey on infection

prevention and control practices in

European countries (EUNETIPS network)

Background

In 2011–2012, 29 EU/EEA Member States and Croatia participated in the first EU-wide,
ECDC-coordinated point prevalence survey (PPS) of healthcare-associated infections (HAIs) and
antimicrobial use in acute care hospitals.
Data from a total of 273 753 patients in 1149 hospitals were submitted to ECDC.
The prevalence of patients with at least one HAI in acute care hospitals in the PPS sample was 6.0%
(country range 2.3%–10.8%). Of a total of 15 000 reported HAIs, 7.7% were gastro-intestinal
infections account, with Clostridium difficile infections accounting for 48% of them. In the list of
top microorganisms responsible for HAI, C difficile was eigth, accounting for 5.4% of all isolates.
This was much higher than the 2% of all microorganisms in HAIs, in a point prevalence sruvery
conducted in Europe in 2008, thus indicating an increased incidence of C. difficile infections in
more than half of the countries.
In addition, infections with C. difficile are most likely underdiagnosed in several countries,
as shown by the variability of the percentage of healthcare-associated gastro-intestinal infections
that were confirmed as cases of C. difficile infection and by the absence of a correlation between
the oral treatment of C. difficile infection and the prevalence of the infection in some countries (e.g.
Lithuania).
EUNETIPS is a network of 22 European scientific and professional societies in 17 European
countries, involved in HAI prevention and control, with the aim to promote infection prevention
for patient safety, to promote better cooperation among nations, to share experiences, to promote
and support initiatives in infection prevention for patient safety particularly at a European level,
recognizing and making the most of all single member societies. In a European scenario of
increasing incidence of Clostridium difficile infection, economic restrains and emerging problems
in infection control practices (i.e. environmental disinfection/sanification, adherence of healthcare
workers to best infection control practices, more complex care for critically ill patients with a wider
use of invasive devices, etc..), there is a need for a better understanding of current infection
prevention and control practices for Clostridium difficile, including:

- Presence of guidelines and recommendations (national, regional, produced by a

scientific/professional society, etc…) on Clostridium difficile infection
- Identification of cases
- Lab algorithms for diagnosis
- Methods used for surveillance
- Strategies for prevention including antimicrobial stewardship programmes, contact
isolation measures, environmental disinfection/sanification, infrastructure requirements,
education and training.
Aim of this survey is to give a deeper insight on the strategies for prevention and control of
Clostridium difficile infection in Europe and on the relevance of scientific/professional societies to
promote and support initiatives against this threatening infection.

Methods

Filling out a questionnarie (in preparation), each scientific/professional society will provide
information on the existence or absence of guidelines / recommendations and on certain specific
items, as described above, addressed to specific issues.
Data will be processed centrally and, after discussion and feedback with all the
scientific/professional societies, the EUNETIPS responsible and the study proposers will be
disseminated through conferences, publications and educational/training material, according to
previously established rules by counterparties.
QUESTIONNARIE (draft to be discussed)

1. In your country, do you have official guidelines/recommendations addressed to Clostridium difficile

infection?
|_|no |_|yes |_| don’t know
If yes*, developed by |_| scientific/professional society |_| Ministry of Health |_| Regional
health agency !_! other health organization (please, specify…………………………………..)

2. In your country, do you have specific definitions for:

a. Healthcare-onset, healthcare-facility associated CDI
|_|no |_|yes |_| don’t know
If yes, please specify the
definition:_________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________

b. Community-onset, healthcare-facility associated CDI

|_|no |_|yes |_| don’t know
If yes, please specify the
definition:_________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________

c. Community-associated CDI
|_|no |_|yes |_| don’t know
If yes, please specify the
definition:_________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
 _____________________________________________________________________________

d. Recurrent CDI
|_|no |_|yes |_| don’t know
If yes, please specify the
definition:_________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________

e. Who did provide these definitions*:

Ministry of Health |_| Regional Health authorities |_| Scientific/Professional Societies |_|
Other |_| (please, specify__________________________________________________)

3. In your country, do you have an official approved/recommended algorithm for Clostridium difficile
diagnosis?
|_|no |_|yes |_| don’t know
If yes:
3a. approved/recommended by whom?_____________________________________
3b. which is the algoritm?
- 1 toxin positive on proper stool sample !_!
- 2 toxins positive on proper stool sample !_!
- GDH + 2 toxins on proper stool sample|_|
- Always and only PCR on stool sample |_|
- GDH and PCR (if GDH is positive) !_!
- Other |_|, please specify:________________________________________________
3c. in the document, should all stool samples from in-patients with diarrhea be tested for C diff ?
|_|not mentioned |_|yes, always |_|yes, only if requested by the physicians |_|don’t know

If no:
3d. do you know who is sampled for CD in the hospital of your country?
!_! all patients with diarrhoea (>48 h from admission) |_| all patients with diarrhoea, if
requested by the physician |_| don’t know

4. Do you have an ongoing surveillance of Clostridium difficile cases?

 no|_| yes|_| don’t know |_|
5a.if yes, please specify the methodology*
|_|notification/reporting by lab |_|notification/reporting by clinician with chart review
|_!other (please, specify)
5b. if yes, at which level*?
|_|national surveillance
|_|regional/county surveillance
|_|hospital based surbeillance
other|_| (please, specify)
5. Do you have incidence data on Clostridium difficile infection?
no|_| yes|_| don’t know |_|

5a. if yes, to which period of time? (from………. to……………….)

5.b if yes, do you have data expressed as*

|_| rate per 10,000 (or 1000) inpatient-days
|_| number of C difficile cases/number of inpatients
|_| numer of C difficile cases/number of stool samples sent to the lab for C diff diagnosis

6. Do you have national/regional/hospital and/or scientific/professional society antimicrobial

stewardship programmes in your country*?
|_|none |_|don’t know
|_|yes, only national |_|only regional |_|only hospital-based
|_|only by scientific/professional society (please specify_________________________)
|_|recommended by more institutions (please specify__________________________)

7. Which healthcare-associated precautions are recommended for Clostridium difficile infections in

your country?
|_|none |_|don’t know |_|only standard precautions |_| contact precautions

8. Are isolation precautions recommended by official guidelines in your country*?

|_|yes, national guidelines/recomendations |_|yes, regional guidelines/recommendations
|_|yes, only hospital based guidelines/recommendations |_|yes, only scientific/professional
societies |_|no |_|don’t know
9. Please, specify which measures are recommended for contact precautions in your country*
|_|no guidelines/recommendations |_| don’t know
|_|use dedicated patient care items and equipment
|_|use gown and gloves for contact with body substances and environment
|_| Place patients with CDI in private rooms if available
|_| Give isolation preference to patients with fecal incontinence if room availability is limited

10. Which hand hygiene is recommended for healthcare workers caring for C diff cases?
|_| normal handwashing (soap and water) |_| alcohol-based hand hygiene
|_|there is no recommendation |_|don’t know

11. Are rooms of patients with C diff infection environmentally decontaminated after the patient is
discharged, according to guidelines/recommendations?
|_| no, normal cleaning |_| don’t know |_|yes, with household bleach
|_| yes, with other (please, specify________________________________________)

12. Did your scientific professional society make any education/training programme in the last year in
your country?
|_|no |_|yes (please, specify how many |_|_|)

*: more than one reply