Intended for healthcare professionals


Feedback is necessary in strategies to reduce hospital acquired infection

BMJ 2000; 321 doi: (Published 29 July 2000) Cite this as: BMJ 2000;321:302
  1. Sheldon Stone, senior lecturer (s.stone{at},
  2. Christopher Kibbler, consultant, department of medical microbiology,
  3. Anne How, infection control nurse, department of medical microbiology,
  4. Anita Balestrini, principal pharmacist, department of pharmacy
  1. Academic Department of Geriatric Medicine, Royal Free and University College Medical School, London NW3 2PF
  2. Royal Free NHS Trust (Hampstead), London NW3 2QG

    EDITOR—The National Audit Office's report about hospital acquired infection in England emphasises the role of improved surveillance and involvement of clinicians in control of hospital acquired infection. 1 2 The executive summary states that surveillance and feedback to clinicians are central to reducing infection rates and recommends that senior clinicians are encouraged to accept greater ownership for control of hospital acquired infection. This relates strongly to risk management and clinical governance, and the audit office calls for development of the evidence base and dissemination of information on best practice.

    We report here our experience of feedback and the involvement of clinicians in reducing the incidence of Clostridium difficile associated diarrhoea, a common form of hospital acquired infection related to overuse of cephalosporins. In July 1995, because of high endemic levels of C difficile associated diarrhoea in our acute elderly care unit, we introduced an enhanced infection control policy: we restricted use of cephalosporins and gave feedback on rates of C difficile associated diarrhoea and use of antibiotics.

    This succeeded,3 and the policy continued for nearly two years. Rates of C difficile associated diarrhoea fell from 3.83 to 0.91 cases per 100 admissions, and use of cephalosporins fell from 20 to 6 notional seven day courses per 100 admissions (figure).


    Quarterly rate of C difficile associated diarrhoea and use of antibiotics (notional seven-day courses of cephalosporin)

    Feedback was then relaxed because of the absence of the lead clinician, creating what was virtually a multiple crossover study of its effect. Rates of C difficile associated diarrhoea and use of cephalosporins both rose until the end of 1998, when clinicians became aware of the rising levels of the diarrhoea (2.66 per 100 admissions) and started to re-enforce the antibiotic policy. The incidence of new cases of methicillin resistant Staphylococcus aureus had also been fed back to clinicians and, when feedback was relaxed, rose from 2.93 to 4.01 per 100 admissions.

    These data, collected for 7423 consecutive admissions over four years, show the value of feedback in reducing both C difficile associated diarrhoea and use of antibiotics; they support the National Audit Office's recommendations regarding surveillance and the involvement of clinicians in the control of hospital acquired infection.

    This multiple crossover study is the only one to examine and show the effectiveness of feedback in reducing C difficile associated diarrhoea. Feedback reduces both post-surgical infection4 and infection with methicillin resistant S aureus,5 but we believe that success is more likely if initiatives are led by key clinicians. Ownership of strategies tends to result in more care in their use.


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