Improvement targets for C difficile must be valid

We have identified a potentially distorting factor in the delivery of reductions in Clostridium difficile rates.1 A letter sent to chief executives of trusts, primary care trusts, and strategic health authorities in England in December 2006 stated that the forthcoming NHS operating framework for 2007-8 and the NHS contract require primary care trusts to agree a local target with their acute hospital providers for a significant reduction in C difficile infections.2 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 people over 65), while maintenance of the current rate would be an appropriate target for trusts with a rate of 1 per 1000 bed days or lower.

The West Midlands Strategic Health Authority initially imposed indicative targets for all acute trusts to negotiate with primary care trusts in the region, based not on the most recent data but on the average of 2004 and 2005 figures. The number of C difficile infections has increased by over 25% across the West Midlands during 2006 compared with this figure. Therefore the reductions imposed are in many cases far in excess of the targets suggested in the letter from the Department of Health, or as stated by the strategic health authority (table⇓). Since it was explained to the authority that these targets are inappropriate, it has agreed to recalculate them.

When targets for methicillin resistant Staphylococcus aureus (MRSA) bacteraemia were set, they were imposed centrally and have been non-negotiable, despite statistical evidence showing that the methods used were invalid.3 The MRSA targets will not be met; if C difficile rates are to be reduced targets must be potentially attainable. Although we are in favour of targets that increase the focus on reducing hospital acquired infections, we draw attention to the importance of using contemporaneous baseline 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.