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It is alarming that so many NHS trusts are still not doing enough to
prevent healthcare associated infection. We need to consider why
healthcare professionals sometimes find it difficult to accept that
healthcare associated infection matters and that the interventions touted
by infection control teams might actually work. An argument that every
hospital’s Director of Infection Prevention and Control will recognise is
‘where is the evidence?’.
Since our hospital is a near neighbour of Tunbridge Wells and
Maidstone NHS Trust, where there was an outbreak of Clostridium difficile
associated diarrhoea (CDAD) in 2006, [1] we conducted a prospective cohort
study of 92 cases of CDAD in our trust during 2007. The overall, all-cause
30 day mortality was 37.0% and was 45% among patients with severe
disease. Severe disease was defined as the presence of two or more out of;
>5 liquid stools / 24 hours; temperature >38oC; abdominal pain,
tenderness or bloating; dehydration or shock requiring parenteral fluids;
total white cell count >15x109/L; albumin <25g/l.
In the light of these findings we implemented an initiative to combat
CDAD in our trust in January 2008 which consisted of three interventions
1) a ward for the cohorting and management of CDAD patients 2) an
antibiotic policy encouraging use of penicillins and aminoglycosides in
place of cephalosporins and quinolones and 3) a treatment algorithm
recommending vancomycin rather than metronidazole for the management of
patients with severe disease. To assess the impact of these measures we
compared the monthly rates of CDAD and the monthly usage of cephalosporins
and quinolones in 2008 with those from 2007. Independent samples t-tests
were used to determine significance. We conducted a further prospective
cohort study of 79 consecutive CDAD cases.
The average monthly number of new CDAD cases was 40% lower in 2008
than 2007 (13.8 vs 23.1 (p<0.001)) and the average number of defined
daily doses of cephalosporin and quinolone antibiotics dispensed by our
pharmacy fell by 35% and 53% respectively (both p<0.001). Comparing the
two cohorts of CDAD cases, there were no differences in age, gender,
number of co-morbid diseases and severity at diagnosis. Nevertheless the
all cause mortality among patients with severe disease (25%) was 44% lower
in 2008 than in 2007 (p=0.03, Fishers Exact Test).
In January 2009 the Department of Health published new guidance on
prevention and management of CDAD.[2] The principle components of this are
the three interventions we introduced last year. None of these has been,
or is ever likely to be, subjected to a large-scale clinical trial. Our
data set is small and has been obtained at a single centre, but this is
its great strength. We have demonstrated that both the rate and outcome of
CDAD can be rapidly improved by simple interventions and this has been
enormously powerful in maintaining the enthusiasm of healthcare
professionals and managers in our hospital. We would urge clinicians and
managers who are struggling to get the infection control message across to
put their interventions to the test.
Combating healthcare associated infection; more evidence might help.
It is alarming that so many NHS trusts are still not doing enough to
prevent healthcare associated infection. We need to consider why
healthcare professionals sometimes find it difficult to accept that
healthcare associated infection matters and that the interventions touted
by infection control teams might actually work. An argument that every
hospital’s Director of Infection Prevention and Control will recognise is
‘where is the evidence?’.
Since our hospital is a near neighbour of Tunbridge Wells and
Maidstone NHS Trust, where there was an outbreak of Clostridium difficile
associated diarrhoea (CDAD) in 2006, [1] we conducted a prospective cohort
study of 92 cases of CDAD in our trust during 2007. The overall, all-cause
30 day mortality was 37.0% and was 45% among patients with severe
disease. Severe disease was defined as the presence of two or more out of;
>5 liquid stools / 24 hours; temperature >38oC; abdominal pain,
tenderness or bloating; dehydration or shock requiring parenteral fluids;
total white cell count >15x109/L; albumin <25g/l.
In the light of these findings we implemented an initiative to combat
CDAD in our trust in January 2008 which consisted of three interventions
1) a ward for the cohorting and management of CDAD patients 2) an
antibiotic policy encouraging use of penicillins and aminoglycosides in
place of cephalosporins and quinolones and 3) a treatment algorithm
recommending vancomycin rather than metronidazole for the management of
patients with severe disease. To assess the impact of these measures we
compared the monthly rates of CDAD and the monthly usage of cephalosporins
and quinolones in 2008 with those from 2007. Independent samples t-tests
were used to determine significance. We conducted a further prospective
cohort study of 79 consecutive CDAD cases.
The average monthly number of new CDAD cases was 40% lower in 2008
than 2007 (13.8 vs 23.1 (p<0.001)) and the average number of defined
daily doses of cephalosporin and quinolone antibiotics dispensed by our
pharmacy fell by 35% and 53% respectively (both p<0.001). Comparing the
two cohorts of CDAD cases, there were no differences in age, gender,
number of co-morbid diseases and severity at diagnosis. Nevertheless the
all cause mortality among patients with severe disease (25%) was 44% lower
in 2008 than in 2007 (p=0.03, Fishers Exact Test).
In January 2009 the Department of Health published new guidance on
prevention and management of CDAD.[2] The principle components of this are
the three interventions we introduced last year. None of these has been,
or is ever likely to be, subjected to a large-scale clinical trial. Our
data set is small and has been obtained at a single centre, but this is
its great strength. We have demonstrated that both the rate and outcome of
CDAD can be rapidly improved by simple interventions and this has been
enormously powerful in maintaining the enthusiasm of healthcare
professionals and managers in our hospital. We would urge clinicians and
managers who are struggling to get the infection control message across to
put their interventions to the test.
References
1. Healthcare Commission. Investigation into outbreaks of
Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust. 2007.
Available at
http://www.neli.org.uk/IntegratedCRD.nsf/ead760eba70bb94f8025755c0058e55...
2. Department of Health and the Health Protection Agency. Clostridium
difficile infection: How to deal with the problem. 2009. Available at:
http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1232006607827
Competing interests:
None declared
Competing interests: No competing interests