The topic of this paper is cutaneous diphtheria. This paper aims to discuss the tools available to infection prevention control teams (IPCT) in recognising outbreaks in the healthcare setting in a potential case of cutaneous diphtheria and how they would response.
Cutaneous diphtheria is a non-respiratory infection caused by the toxin-producing strains of Corynebacterium diphtheriae (C.diphtheriae) (PHE 2018). Characterised by chronic skin ulcers, that can occur anywhere on the body. In many case of cutaneous lesions the source of C diphtheriae has been found to be respiratory diphtheria and carriers (Berih 1995). In fully vaccinated patients cutaneous diphtheria is usually mild and nonspecific, although in those not vaccinated it can be more serious particular if not treated (de Benoist, et al 2004).
Transmission of cutaneous diphtheria occurs by contact with respiratory secretions, infected skin lesions, Koopman and Campbell (1975) suggested that it is more transmittable, than respiratory diphtheria, with the potential to be transmitted to large numbers, particularly those not fully vaccinated, through contaminated environment.
Although cutaneous diphtheria is endemic in some parts of the world, cases in the United Kingdom are rare due to high immunisation rates, nevertheless, outbreaks have been reported particular in those who have returned from countries where diphtheria is endemic. (De Benoist et al 2004, Both et al 2015). Despite routine screening of pharyngeal swabs for C diphtheriae screening for cutaneous diphtheria in wound swabs is not, therefore it is suggested that cutaneous diphtheria is likely to be under reported in the UK. (Shah et al 2017).
Although an outbreak is defined in the Health Protection Scotland (HPS) National Infection Prevention Control Manual Scotland (2016), as two or more linked cases of the same illness. Due to the rarity and potential life threatening condition a single case of cutaneous diphtheria, should be consider as an expectational infection episode that prompts early intervention by the IPCT to ensure appropriate infection control precautions are implemented and contact tracing commenced to prevent an outbreak. (HPS 2016)
Early diagnosis and timely intervention when there is a possible case of cutaneous diphtheria is vital in the healthcare setting. Not only to treat effectively, but to reduce the incidence of the disease and also in containing the infection by implementing effective control measures to reduce the possible scale and severity of an outbreak.
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Diagnosis relies on bacterial culture and confirmation of toxin production in lesion cultures, however it is suggested, the diagnosis of cutaneous diphtheria particular in countries where cases are rare can be delayed because the clinical appearance is nonspecific therefore cutaneous diphtheria is not considered particular when other pathogens are present (Griffith et al 2019). To prevent delayed diagnosis and possible transmission, clinician should consider cutaneous diphtheria infection as a part of the differential diagnosis, swabs from skin lesions should be obtained for culture, particularly in persons with chronic nonhealing skin lesions who have had recent travel to an endemic area. (Bonnet et al 2019). It is essential that clinical information is provided on the laboratory request form when a case is suspected as this will prompt the correct investigations.
Role of Diagnostic Laboratory
The role diagnostic labs plays in detecting a case of C.diphtheriae in a non-healing lesion should not be underestimated. Using largely simple, microbiological, methods that are both rapid, and reliable, assist clinical teams in confirming cases. It is however the role they play in eliminating suspected cases or contacts that is more significant to IPCT in outbreaks, as this can prevent unnecessary clinical investigation, treatment or control measures, such as transmission based precautions including isolation and antibiotic prescribing (Efstratiou et al1999).
On detection of C.diphtheriae in the UK isolates will be referred to the National Reference Laboratory (NRL) for testing by polymerase chain reaction (PCR), to determine speciation and toxigenic (PHE 2019). The local diagnostic lab will communicate immediately to clinician and the IPCT any suspicion of a case of C.diphtheriae. as part of the alert reporting system. The implementing of these system in all healthcare settings is essential to manage cases effectively and in the early identification of outbreaks.
The availability of electronic alert system to IPCT has been suggested to be a real advantage not only in providing real time information to IPCT but to other key stakeholder including wards who will be prompted to initiate appropriate management of the patient (CDC 2014). Application of transmission based infection prevention control precautions including isolation, enhanced cleaning/disinfection of potentially contaminated environments, and treatment with appropriate antibiotics (Griffiths et al 2019).
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To aid IPCT in the their initial assessment, there are number of tools that will assist in gathering epidemiological data and clinical assessment information on the patient’s condition for example the Healthcare Infection Incident Assessment Tool (HIIAT) (HPS 2019). The collection of case-related epidemiological data from the patient can be sometime a challengi due to language barriers and social circumstances. However, information on patient contacts, vaccine status and travel/refugee route, where appropriate, is critical, and should be documented. The development of IPC software however has allowed IPCT to use data pulled from an number of sources such as electronic medical records, electronic case reporting, and clinical laboratory information systems that would have otherwise been undertaken manual.
The IPCT will attempt to identify potential sources of infection and contacts of the suspected cases. The object being to prevent the development of disease among conat who might have been infected with C.diphtheriae. It important that the IPCT identifies close contacts even before NRL confirmation, particular if the patient had recent travel history to country with endemic diphtheria.
Contact tracing is an important strategy employed in surveillance to aid prompt detection of cases and control outbreaks. It involves the identification of those who have come in contact with an infectious person and following them up for the duration of the incubation period of the disease to promptly detect symptoms and signs and institute treatment thus reducing chances of disease spread to other susceptible individuals. It is a primary means of disease prevention.
In UK, as in many countries reporting of case C.diphtheriae to Public Health departments is mandatory which
CDC (2108) suggested this to be critical and sample should be sent to monitor for development of both respiratory or cutaneous illness.
Case of cutaneous diphtheria remain rare in non-endemic countries, particular with high vaccination coverage. However it is a remerging disease in unvaccinated traveller of endemic countries.
Rapid identification of the bacterial pathogen and toxin production is a critical element of patient and outbreak management. Clinician should be made aware of this situation and reinforce the need to sample accordingly non healing wounds.
IPCT need to ensure prompt response to suspected cases taking the necessary actions and measure at the earliest opportunity to reduce the risk of the infection spreading. Electronic alert systems and IPC software are essential assets for IPCT today’s, not only for improving the reporting speed of cases, enhancing data quality, and reducing workload but it can helps identify suspected patients rapidly so they can be isolated, in order to reduce the likelihood of transmission to others.
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