Management of Clostridium difficile in NHS trusts
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7535.238 (Published 26 January 2006) Cite this as: BMJ 2006;332:238All rapid responses
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EDITOR – In his recent letter Green highlights a recent report and
press statement by the Healthcare Commission and Health Protection Agency
(HPA) stating that a third of NHS trusts are not adhering to government
guidance on the prevention and control of clostridium difficile
infection1. He makes the valid point that no updated guidance of the
prevention and control has been issued since the guidelines published in
1994 by the Department of Health and then Public Health Laboratory. The
original guidelines advised trusts to have antibiotic prescribing
guidelines to reduce the risk of C. difficile infection.
The appropriate use of antibiotics has become increasingly important
in wake of the now mandatory surveillance of Clostridium difficile
associated disease (CDAD) in acute Hospital Trusts in England since
January 2004. The total number of reports of CDAD in England between
January and December 2004 was 44,488 for 166 Trusts2. Specific guidelines
exist for the antibiotic management of Community Acquired Pneumonia (CAP),
Lower Respiratory Tract Infections (LRTI) and acute exacerbations of
Chronic Obstructive Pulmonary Disease (COPD)3,4,5.
The most recent British Thoracic Society Guidelines3 for the
management of CAP recommended using a severity assessment model based on
CURB-65. They recommend that patients who have a CURB-65 score of 0 or 1
are at low risk of death and do not normally require hospitalisation for
clinical reasons. The BTS guidelines suggest the use of intravenous
cephalosporins only in severe pneumonia.
Recently published guidelines for the management of LRTI by Woodhead
et al.4 advice only the use of oral antibiotics in patients with LRTI (in
the absence of pneumonia). Most guidelines for the treatment of infective
exacerbations of COPD are based on Anthonisen criteria5. Antibiotics are
recommended if two of the three Anthonisen criteria are present
(1.Increased sputum volume 2.Change in sputum colour 3.Increased
breathlessness). Intravenous antibiotics are not recommended unless they
have radiographic changes consistent with a severe pneumonia or they are
unable to take oral antibiotics.
We performed a retrospective study of 50 admissions, coded as
respiratory infections, during a six-week period. Medical records were
analysed and patients were classified into three main categories: CAP,
LRTI and COPD. Antibiotic administration was assessed for each patient and
compared to the British and European Thoracic Society Guidelines.
We found that 53% (8/15) of patients who were admitted with a LRTI
received intravenous cephalosporins inappropriately. In those patients
admitted with a CAP with a CURB-65 score of 0-1, 89% (8/9) patients were
treated inappropriately with intravenous cephalosporins. 56% (5/9) of
those patients admitted with infective exacerbations of COPD with 2 or
more Anthonisen criteria were treated with intravenous cephalosporins.
Our study has shown that intravenous antibiotics (cephalosporins) are
being inappropriately used for the treatment of respiratory tract
infections. We feel that inappropriate prescribing is contributing to the
increasing incidence of Clostridium difficile associated disease (CDAD).
We feel that if trusts are to reduce the incidence of infection from
C.difficile then further education of junior doctors and stricter trust
guidelines for the use of intravenous cephalosporins are needed.
1)Green D. Management of Clostridium Difficile in NHS Trusts. BMJ
2006; 332: 238
2)Surveillance of Clostridium difficile associated disease (CDAD) –
Department of Health August 2005
3)British Thoracic Society Guidelines for the Management of Community
Acquired Pneumonia in Adults BTS guidelines. Thorax 2001; 56: (suppl IV)
(http://www.brit-thoracic.org.uk/bts_guidelines_pneumonia_html)
4)Woodhead F et al. Guidelines for the management of adult lower
respiratory tract infections. Eur Respir J 2005; 26:1138-1180
5)Anthonisen NR et al. Antibiotic therapy in exacerbations of chronic
obstructive pulmonary disease. Ann Intern Med 1987; 106:196 204
Competing interests:
None declared
Competing interests: No competing interests
Improvement targets for rates of Clostridium difficile infection.
Sir,
We read with interest the letter concerning the management of C.
difficile in NHS Trusts1. We have identified a potentially distorting
factor in the delivery of reductions in C. difficile rates.
A letter sent to Chief Executives of Trusts, PCTs and SHAs in
England2 in December 2006 stated that the forthcoming NHS operating
framework for 2007-08 and the NHS contract requires PCTs to agree a local
target with their acute hospital providers for a significant reduction in
C. difficile infections. The target is expected to be "locally
appropriate", and based on "current performance". A reduction of at
least 25% was suggested for Trusts with a rate greater than 4 cases per
1000 bed days (in the over 65s), while maintenance of the current rate
would be an appropriate target for Trusts with a rate of 1 or lower.
The West Midlands SHA initially imposed indicative targets for all
acute Trusts to negotiate with PCT's within the region based, not on the
most recent data, but on the average of 2004 and 2005's figures. The
number of C. difficile infections has increased by over 25% across the
West Midlands during 2006 when compared to this figure. Therefore the
reductions imposed are in many cases far in excess of the targets
suggested in the DoH letter, or as stated by the SHA (Table 1). Since it
was explained to the SHA that these targets are inappropriate, they have
agreed to recalculate them.
When MRSA bacteraemia targets were set, they were imposed centrally
and have been non-negotiable, despite statistical evidence that
demonstrated that the methods used were invalid3. It is now apparent that
the MRSA targets will not be met; if reductions are to be made in C.
difficile rates it is vital that targets are potentially attainable.
Whilst we are in favour of targets which increase the focus on reducing
HCAI, we draw attention to the importance of using contemporaneous base
line data when trying to control a rapidly expanding problem. Infection
control teams in Trusts should ensure they are aiming at the right target,
which should be scientifically valid.
M.A. Cooper MB ChB FRCPath a
Consultant Microbiologist and Director of
Infection Prevention and Control
AND
P.M. Hawkey BSC, DSc, MBBS, MD CPath*b
Professor of Clinical and Public Health Bacteriology and Consultant
Medical Microbiologist
on behalf of the West Midlands Microbiologists Group
a. Royal Wolverhampton Hospitals NHS Trust, Department of
Microbiology, New Cross Hospital, Wolverhampton. WV10 0QP.
b. West Midlands Public Health Laboratory, Birmingham Heart of
England NHS Trust, Bordesley Green East, Birmingham B9 5SS and Division of
Immunity and Infection, University of Birmingham. Birmingham B15 2TT.
* Corresponding Author: Email: p.m.hawkey@bham.ac.uk; peter.hawkey@heartofengland.nhs.uk
Table 1
Trust
Average ratea for 2004-2005
SHA improvement target based on 2004-5 rates (%)
Rate for 2006
Improvement required based on 2006 rate to meet SHA target (%)
A
18.75
3.55
30.14
B
2.75
18.75
2.90
23.10
C
4.22
25.00
5.17
38.68
D
2.33
12.50
3.70
44.86
E
2.60
18.75
2.88
26.74
F
4.55
25.00
4.16
18.03
G
1.13
6.25
3.44
69.19
H
2.76
18.75
2.75
18.55
I
2.74
18.75
5.21
57.39
J
1.86
12.50
4.02
59.45
K
2.21
12.50
2.88
33.00
L
1.46
12.50
1.76
27.27
M
1.34
12.50
2.16
45.83
N
3.04
18.75
2.62
5.73
O
1.36
12.50
3.03
60.72
P
3.47
18.75
3.30
14.55
a Rate
expressed per 1000 bed days for patients aged ≥ 65 years
Competing Interest Statement
All authors declare that the answer to the questions on your
competing interest form (http://bmj.com/cgi/content/full/317/7154/291/DC1)
are all No and therefore have nothing to declare.
References
1. Green D. Management of Clostridium difficile in NHS trusts. BMJ
2006; 332:238.
2. Dear Colleague letter to Chief Executives of trusts, PCTs and SHAs
dated 7th December 2006. Accessed 15.3.07 at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/De...
3. Spiegelhalter DJ. Problems in assessing rates of infection with
methicillin resistant Staphylococcus aureus. BMJ 2005;331:1013-1015
Competing interests:
None declared
Competing interests: 3.05