Agencies Urge The NHS To Step Up Measures To Minimise Risk Of Patients Contracting Clostridium Difficile, UK

Main Category: MRSA / Drug Resistance
Article Date: 28 Dec 2005 - 20:00 PDT

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The Health Protection Agency and the Healthcare Commission today (Wednesday) urged the health service to do more to minimise the risk to patients of Clostridium difficile (C. difficile).

C. difficile is a healthcare-associated infection that can cause diarrhoea, sometimes more serious conditions and occasionally death.

The call comes as interim findings of a joint survey, released today, reveal that over a third of trusts surveyed do not routinely follow government guidelines on the management of C. difficile infection in their hospitals.

The survey aimed to provide more information about C. difficile and the measures trusts have in place to deal with the infection.

The agencies are publishing interim findings now, as winter is when the prevalence of C. difficile tends to be highest. More detailed findings will be published in spring 2006.

The two organisations say trusts should:

-- Ensure that their policies on antibiotic prescribing are informed by current guidelines on best practice, and that these policies are properly monitored. Current guidance states that trusts should have up-to-date guidelines for treating specific infections, policies to reduce inappropriate administration of broad-spectrum antibiotics*, and regularly monitor antibiotic usage through audit and feedback to prescribers.

-- Review their procedures and capacity to isolate patients with C. difficile. The isolation of patients is an effective method of rapidly controlling the spread of infection.

-- Ensure that they understand the criteria for testing and reporting samples of C. difficile, and that they comply with the scheme for mandatory surveillance introduced last year. This requires that all NHS trusts report to the HPA the number of cases of infection caused by C. difficile diagnosed in patients 65 years of age and older.

Questionnaires were sent to directors of infection prevention and control. Responses have been received from 118 of the 173 trusts (68%) in England. The survey showed:

-- Thirty eight per cent of trusts surveyed said they do not have restrictions in place to prevent the inappropriate use of antibiotics, which would help to minimise the risk of C. difficile infection.

-- Over a third of respondents reported that they are unable to routinely isolate patients with C.difficile infection. Only 11% of trusts said they have a ward that can be used for isolating patients with C. difficile.

-- Less than half of trusts surveyed use the same recognised definition of an outbreak. Forty percent reported that, in the event of an outbreak, they do not routinely follow guidance, which recommends that they should inform the consultant in communicable disease control.

-- Most of the trusts surveyed also reported that they do not routinely inform the relevant authority that is responsible for monitoring their performance i.e. the strategic health authority, or Monitor in the case of NHS foundation trusts.

-- Two-thirds of respondents felt that the reported incidence of C. difficile infection has increased in their trust during the past three years.

-- A quarter of trusts reported they had closed wards in the past 12 months due to cases of C. difficile.

Responses confirmed that cases of C. difficile are not confined to older people: 41% of trusts estimated that one out of ten cases affected people under the age of 65.

Respondents thought that the most practical measures to reduce the incidence of infection from C. difficile were: improved prescribing of antibiotics (55% of trusts); isolation of patients (39%); clean environments (32%); and improved hygiene (19%).

Over two thirds of trusts thought that the prescribing of antibiotics and the lack of facilities for isolation represented the greatest challenges to controlling infection.

Despite concerns that the severity of the infection has increased in the past few years, most of the trusts surveyed do not routinely collect clinical data on patients with the infection. Sixty-five per cent of trusts reported that they do not routinely record information on deaths from C. difficile.

Marcia Fry, Head of Operational Development at the Healthcare Commission, said:

"This survey reflects the views of the trusts of their own arrangements for managing C. .difficile. It is deeply worrying that a significant number of trusts are not managing to implement existing guidance on C. difficile.

"We recognise that these outbreaks are not easy to control, but trusts must do more to ensure that they have systems in place to protect patients from this potentially lethal infection. We and the HPA will be working with them on this."

Professor Peter Borriello, Director of the Centre for Infections at the Health Protection Agency, said:

"Although we are concerned to see that guidance is not implemented in a uniform way among trusts, the results of this survey will help us to improve our surveillance of C. difficile and learn more about how trusts treat patients and tackle outbreaks. This will then inform the way in which we work with trusts to protect patients"

The Healthcare Commission and the Health Protection Agency will incorporate learning from these interim findings, and the final report, into their respective programmes of work.

For example, the Healthcare Commission will take into account trusts compliance with procedures for the control of infection in its annual health check on NHS trusts and its assessment against the expected hygiene code, the legislation for which is going through the House of Commons.

Related links
-- Download Management, prevention and surveillance of Clostridium difficile - Interim findings from a national survey of NHS acute trusts in England (PDF, 70K)
-- Download Clostridium difficile Questionnaire (PDF, 95K)

1. C.difficile is a micro-organism that causes diarrhoea and can lead to serious Illness and occasionally death. Certain groups are particularly at risk of developing an infection with Clostridium difficile: older people and those who have undergone surgery, and people with serious underlying disease, all in association with recent antibiotic use.

2. Certain broad spectrum antibiotics are harmful to the bacteria normally found in the gut, which can increase the risk of infection from C. difficile.

3. The first set of results from the mandatory surveillance scheme showed there were 44,488 cases of C. difficile reported in those over 65 years of age in England during 2004.

4.The mandatory surveillance programme requires all NHS trusts to report to the HPA the number of cases of infection caused by C.difficile diagnosed in patients 65 years of age and older in their trust.

5. The Department of Health recommends the need for policies and procedures for handling C.difficile cases in both outbreak and non-outbreak situations. The policies that should be covered include antibiotic prescribing polices to minimise the use of broad-spectrum antibiotics.

6. Part 2 of the Health Bill gives the Secretary of State for Health the power to issue a code of practice on the prevention and control of healthcare associated infections. The Bill obliges the Healthcare Commission to enforce the code and take it into account when we conduct our annual review of healthcare organisations.

7. The survey looked at:

-- the reported incidence and pattern of C. difficile infection

-- approaches that already exist to prevent and manage outbreaks of the infection in hospitals

-- the challenges preventing trusts from being able to control outbreaks

-- the views of professionals on what should be done to reduce the incidence of the infection

8. Questionnaires were sent to directors of infection prevention and control in all 173 acute trusts across England in October 2005. Responses have been received from 118 of the 173 trusts (68%) and these have been incorporated into the report.

9. The results will provide a context for the investigation that the Healthcare Commission is undertaking into the outbreak of C. difficile at Stoke Mandeville Hospital, part of Buckinghamshire Hospitals NHS Trust, due to be published next year

10. The Chief Medical Officer and the Chief Nursing officer have issued a joint letter to all NHS trusts reminding them of:

(1) the requirements of the mandatory surveillance scheme operated on behalf of the Department of Health by the Health Protection Agency (HPA)

(2) recommendations for microbiological investigation of outbreaks, and

(3) the need for policies and procedures to be in place to minimise the risk of infection caused by C. difficile and to implement control policies when cases occur.

11. The Healthcare Commission is the independent inspection body for both the NHS and the private and voluntary healthcare sectors. It exists to promote improvements in the quality of healthcare in England and Wales. The Healthcare Commission has 15 commissioners and is chaired by Professor Sir Ian Kennedy who was chairman of the public inquiry into children's heart surgery at Bristol Royal Infirmary, published in 2001

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