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Cases of C.difficile infection in England are falling (1) . Recent
guidance from the Department of Health for the management of C.difficile
infection (2) outlines new evidence and approaches to delivering good
infection control and environmental hygiene to ensure further reductions
continue. The document details key recommendations for healthcare
providers and commissioners for prevention as well as management.
One of these recommendations is that Trusts should use a standard
definition of a Period of increased incidence (PII) of Clostridium
difficile infection (CDI), i.e. two or more new cases (occurring
>48hours post admission, not relapses) in a 28-day period on a ward.
When a PII is identified, it is recommended that a standard set of actions
be put in place (recommendation 2.5) including ribotyping of isolates and
ward audits. An outbreak of CDI is then defined as two or more cases
caused by the same strain related in time and place over a defined period
that is based on the date of onset of the first case.
At the Heart of England NHS Foundation Trust (HoEFT), the infection
prevention and control team has been using this approach for defining a
PII of CDI since January 2008. The only difference in our protocol is that
we use a locally developed C.difficile audit tool rather than the
C.difficile High Impact intervention (HII)(3) tool as specified in the
guidance. Our audit tool reviews ward practices as a whole, evaluating
hand washing, cleanliness of ward equipment, environment and infection
control practice. In contrast to the HII, which is applicable if a C
difficile positive patient is present, the audit tool developed at HoEFT
does not require a C difficile positive patient to be present. This is
essential as it is our policy to transfer all C difficile positive
patients to a cohort ward, but factors associated with the acquisition of
C difficile remain on the base wards. This audit is undertaken weekly by
a member of the infection prevention nursing team with immediate feedback
to the ward. Common findings where the ward fails the audit are poor
hygiene of toileting equipment, especially commodes, and poor
environmental hygiene. An antibiotic audit is also performed weekly by the
ward Pharmacist and these audits continue until a “pass” (score of
>90%) is achieved for three consecutive weeks and there have been no
further cases of CDI on the ward.
The use of this standard set of interventions for PII has, in our
Trust, assisted in prevention of further cases on the base wards. During
2008, the number of wards, each month, which meet the definition of
increased incidence of C.difficile infection has decreased from a mean of
12 per month in the first quarter to 5 per month in Quarter 4. There were
no major changes in the Trust Antibiotic policy nor any change in the
Trust C.difficile infection Policy during this time.
We believe this approach on wards with two or more cases of
C.difficile within 28 days, has prevented further transmission by early
targeted intervention.
REFERENCES
1. Cases of C.difficile fall in England. News in brief. BMJ 2008;337:a2330
2. Clostridium difficile infection: How to deal with the problem,
Department of Health and Health Protection Agency, January 2009.
3. High Impact Intervention No. 7: Reducing the risk of Clostridium
difficile. www.clean-safe-care.nhs.uk
Competing interests:
Savita Gossain, Katie Hardy and Peter Hawkey are in receipt of research funding from Becton Dickinson for research on diagnostic testing for C.difficile infection
Competing interests:
No competing interests
31 March 2009
Savita Gossain
Consultant Medical Microbiologist
Katie Hardy, Diane Thomlinson, Itisha Gupta, Peter Hawkey
HPA Laboratory,Heart of England Foundation Trust, Bordesley Green East, Birmingham, B9 5SS
Standard interventions for wards with periods of increased incidence of Clostridium difficile infection
Cases of C.difficile infection in England are falling (1) . Recent
guidance from the Department of Health for the management of C.difficile
infection (2) outlines new evidence and approaches to delivering good
infection control and environmental hygiene to ensure further reductions
continue. The document details key recommendations for healthcare
providers and commissioners for prevention as well as management.
One of these recommendations is that Trusts should use a standard
definition of a Period of increased incidence (PII) of Clostridium
difficile infection (CDI), i.e. two or more new cases (occurring
>48hours post admission, not relapses) in a 28-day period on a ward.
When a PII is identified, it is recommended that a standard set of actions
be put in place (recommendation 2.5) including ribotyping of isolates and
ward audits. An outbreak of CDI is then defined as two or more cases
caused by the same strain related in time and place over a defined period
that is based on the date of onset of the first case.
At the Heart of England NHS Foundation Trust (HoEFT), the infection
prevention and control team has been using this approach for defining a
PII of CDI since January 2008. The only difference in our protocol is that
we use a locally developed C.difficile audit tool rather than the
C.difficile High Impact intervention (HII)(3) tool as specified in the
guidance. Our audit tool reviews ward practices as a whole, evaluating
hand washing, cleanliness of ward equipment, environment and infection
control practice. In contrast to the HII, which is applicable if a C
difficile positive patient is present, the audit tool developed at HoEFT
does not require a C difficile positive patient to be present. This is
essential as it is our policy to transfer all C difficile positive
patients to a cohort ward, but factors associated with the acquisition of
C difficile remain on the base wards. This audit is undertaken weekly by
a member of the infection prevention nursing team with immediate feedback
to the ward. Common findings where the ward fails the audit are poor
hygiene of toileting equipment, especially commodes, and poor
environmental hygiene. An antibiotic audit is also performed weekly by the
ward Pharmacist and these audits continue until a “pass” (score of
>90%) is achieved for three consecutive weeks and there have been no
further cases of CDI on the ward.
The use of this standard set of interventions for PII has, in our
Trust, assisted in prevention of further cases on the base wards. During
2008, the number of wards, each month, which meet the definition of
increased incidence of C.difficile infection has decreased from a mean of
12 per month in the first quarter to 5 per month in Quarter 4. There were
no major changes in the Trust Antibiotic policy nor any change in the
Trust C.difficile infection Policy during this time.
We believe this approach on wards with two or more cases of
C.difficile within 28 days, has prevented further transmission by early
targeted intervention.
REFERENCES
1. Cases of C.difficile fall in England. News in brief. BMJ 2008;337:a2330
2. Clostridium difficile infection: How to deal with the problem,
Department of Health and Health Protection Agency, January 2009.
3. High Impact Intervention No. 7: Reducing the risk of Clostridium
difficile. www.clean-safe-care.nhs.uk
Competing interests:
Savita Gossain, Katie Hardy and Peter Hawkey are in receipt of research funding from Becton Dickinson for research on diagnostic testing for C.difficile infection
Competing interests: No competing interests