Previously, as the IP&C team do not have access to patient records, an email was sent to GP’s with a request to complete a ‘Post infection review’ form and the prior prescribing was reviewed against prescribing guidelines, but response was poor, and it was a challenge to understand the risk factors in order to suggest ways to reduce community CDI. Therefore, a pilot was trialled in March and April 2024 to gather this information from GP’s on each case using a less time consuming process, that would collate data and provide presentation graphs to support the findings. Changes and updates were made on the feedback, and the Community onset C.difficile analysis 2024/25 was launched on 1^st April 2024.

Questions included in the Community onset CDI analysis 2024/25 MS Form

1. What was the date the sample was taken?
2. What date was the result available to the practice?
3. Please select all risk factors for CDI applicable to this patient. (drop down list)
4. Was the patient a resident of a Care or Nursing Home?
5. Is there any relevant underlying morbidity as listed? (drop down list)
6. How many days prior to the sample did the patient become symptomatic?
7. Was there a delay in sampling?
8. Has the patient had a previous episode of CDI or C diff colonisation (GDH positive on lab result)?
9. Has the patient consulted their GP in the 3 months prior to the positive result?
10. If so, what was this due to a respiratory infection? (if yes, then continued to…if No then to 15,18 and 19)
11. Does the patient have a history of previous respiratory infections?
12. Was a microbiology sample taken?
13. Was the patient prescribed antibiotics in primary care for a respiratory infection? If so which?
14. Was the antibiotic choice in line with SCAN guidance? 
15. Has the patient seen the GP within the last 3 months due to a Urinary tract infection? (if yes than same questions for respiratory as above and also…if no skip to 18)
16. Did the patient have a urinary catheter of any kind, in the 3 months prior to CDI result?
17. Was a urine dipstick performed to aid diagnosis of a UTI?
18. Has the patient seen the GP within the last 3 months due to cellulitis or a skin / soft tissue infection?
19. Has the patient seen the GP within the last 3 months due to a wound infection (including leg ulcers, diabetic foot ulcers and bites)? If so what?
20. Has the patient seen the GP within the last 3 months due to a long-term condition?
21. Has the patient had an inpatient episode in the last 3 months, if yes please forward Discharge Summary?
22. Has the patient received chemotherapy in the last 6 months?
23. What date was the treatment for CDI commenced?
24. What treatment was prescribed and was this prescribed as per SCAN guidelines or following microbiologist advice?
25. Was the patient taking a Protein Pump Inhibitors (PPI) within 3 months prior of the CDI result?
26. Was the patient taking laxatives at the time of the sample?
27. Was the patient taking Imodium or equivalent prior to the CDI result?

How to set up and MS Forms

Set up and MS Forms link. Suggested questions attached.

ICB – Setting up a dataset for your area (can be by non-clinical administration).

1. After 16^th of each month, download the UKHSA DCS report for the previous months CDI. (The deadline for trusts to upload data is 15th of each month, so to avoid missing cases, wait till 16^th)
2. Filter in the ‘Community Onset – Community Associated’ (COCA) and the ‘Community Onset – Indeterminate Association’ (COIA) in column BO ‘Apportionment Rule Category’ only.
3. Select
4. Save onto an excel spreadsheet and password protect as will contain PID.
5. Title the columns Unique ID, Specimen date, GP Practice, Pt name, DOB,     NHS No, Request date sent, Request date received, Reminder request sent. You may want to separate areas or by acute trusts, e.g. BU0001 or OX0001 for 2 different counties.
6. Fill in the name of the GP practice for each case.
7. Send an email using the template below with the appropriate Unique ID number and patient details to each GP. Use Subject heading ‘‘Name of GP surgery’ request for information’.
8. Add date request sent to excel spreadsheet and a column to add when the GP responded. Reminders can be sent to non-responders the following month.

Providing reports

Log on to MS Forms

Click on responses (top left corner), download a copy in excel Remember to date/ID spreadsheet, as responses will continue to be submitted), select appropriate graphs required and add context from the responses. Check and share your form results.

Email template used to send to GP’s

Dear Name of GP practice

Please forward to the patients’ GP.

Dear Doctor

Your patient (AB), NHS No 000-000-0000, DOB 00/00/1900, tested positive for C.difficile infection (CDI) on 01/01/2001. Please copy the ID <insert local ID>, and paste into the <insert local MS Forms page link> to complete the investigation into this community onset GP CDI sample.

We appreciate that this patient may not have had contact with primary care recently, but we would appreciate your feedback in order to understand risk factors and reduce CDI categorised as community onset.

This data gathering process is designed to be less time consuming for GP’s, it supports the delivery of Regulation 12: Safe Care and treatment (CQC) and Criteria 1 of the Code of Practice. Any learning from analysis of CDI cases should be included in the practices Annual Infection and Prevention Control Statement. An anonymised report of all GP CDI samples will be presented at the ICB quarterly Infection Prevention Control Committee and is available on request.

On completion of the form, please submit and click on the 3 dots in the top right-hand corner, click on print and from the drop down, save as a PDF for your records.

Please email <insert local email address>if you have queries about this form or would like to provide feedback. We would value your comments on how the form can be improved.

Kind regards

Suggestions

• Set up a spreadsheet with all GP generic email addresses for ease of process
• As described above, maintain a protected spreadsheet of all UKHSA DCS, COCA and COIA with Unique ID, date of CDI, patient, name, NHS No, DOB, GP, when request sent, whether request received, date reminded if needed.
• Every month check which GP’s have not responded to the request and send a gentle reminder, add date reminder sent to the main spreadsheet, ideally one reminder and then cease.

Further any further information please contact Hilary Munube bobicb.ipc@nhs.net

References

1. Annual epidemiological commentary: Gram-negative, MRSA, MSSA bacteraemia and C. difficile infections, up to and including financial year 2023 to 2024.
2. Clostridioides difficile infection: antimicrobial prescribing NICE
3. Clostridium difficile infection: risk with broad-spectrum antibiotics NICE
4. The use of faecal microbiota transplant as treatment for recurrent or refractory Clostridium difficile infection and other potential indications. Joint British Society of Gastroenterology (BSG) and Healthcare Infection Society (HIS) guidelines
5. UK 5-year action plan for antimicrobial resistance 2024 to 2029, UK

Further Reading

1. Recent work has demonstrated that numerous cases are missed, either due to inadequate diagnostic tests or lack of clinical suspicion.

2. A point-prevalence study on community and inpatient Clostridioides difficile infections (CDI) – support recommendations for improving diagnosis in patients presenting with diarrhoea in the community, to guide good practice to limit the spread of CDI.

3. European study – Improving care for patients with Clostridioides difficile infection – A clinical practice and healthcare systems perspective concluded:

• Limited integration between primary and secondary care can delay diagnosis and treatment
• Awareness about CDI diagnosis and treatment can be low, especially among primary-care providers

4. Recurrent Clostridium difficile Infection: Risk Factors, Treatment, and Prevention, Jung Hoon Song, You Sun Kim https://pmc.ncbi.nlm.nih.gov/articles/PMC6346998/#:~:text=2.-,Use%20of%20antibiotics,difficile%20after%20CDI%20diagnosis.&text=A%20meta%2Danalysis%20showed%20that,2.05%3B%20p%3C0.00001).