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LETTERS: David Green Management of Clostridium difficile in NHS trusts BMJ 2006; 332: 238 [Full text]

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Management of Clostridium Difficile in NHS Trusts

Ben Esdaile, Raja Reddy, Annie Sykes and Bobby Mann.   (21 February 2006)

Improvement targets for rates of Clostridium difficile infection.

Peter M Hawkey, Mike Cooper   (28 March 2007)

Management of Clostridium Difficile in NHS Trusts 21 February 2006
Ben Esdaile, Senior House Officer West Middlesex University Hospital, Twickenham Road, Isleworth, Middlesex TW7 6AF, Raja Reddy, Annie Sykes and Bobby Mann. Send response to journal: Re: Management of Clostridium Difficile in NHS Trusts	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
Improvement targets for rates of Clostridium difficile infection. 28 March 2007
Peter M Hawkey, Professor University of Birmingham, U.K., Mike Cooper Send response to journal: Re: 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 3.05 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/Dearcolleagueletters/DH_063090 3. Spiegelhalter DJ. Problems in assessing rates of infection with methicillin resistant Staphylococcus aureus. BMJ 2005;331:1013-1015 Competing interests: None declared