The latest figures show C difficile rates are climbing. Alison Moore reports on what a major challenge for 2007 will bring

Ten years ago, MRSA became the microbiological organism the public could name. In the past year or so it has been joined by another 'superbug' - Clostridium difficile. While there has been progress in fighting MRSA in hospitals, C difficile may prove to be a tougher target.

Infection Control Nurses Association chair Judy Potter says: 'In the infection control world we have been concerned that this is a big problem for a long time. But all the emphasis was on MRSA [methcillin-resistant Staphylococcus aureus], because that is where the target was. For the past five years, however, we have seen far more cases of C difficile than MRSA.'

Since monitoring began in 2004 the number of cases in hospitals has increased and it is now viewed as endemic in some hospitals. Several experts have referred to it as being 'out of control'.

C difficile causes severe diarrhoea and life-threatening complications, generally in patients who are already taking or have finished a course of antibiotics. Unlike MRSA it occurs as a side-effect of necessary treatment - a small proportion of people carry the organism in their gut and it may flourish when antibiotics kill other bugs.

But it is transmission between patients that causes the most concern. Its spores can survive indefinitely in the environment and are not completely eradicated by many cleaning methods. One particular strain - 027 - is causing concern as it is thought to be linked to more severe illness.

A Department of Health memo leaked to HSJ pointed out that there were more cases of C difficile than MRSA and around four times as many deaths. While MRSA cases have been falling, the figures for C difficile cases in 2005 were 17 per cent above those for 2004. The figures for 2006 - due out shortly - may show a further rise.

A powerful incentive

Health Protection Agency head of healthcare-associated infection Georgia Duckworth suggests that some of the 2005 rise may be due to improved reporting, but that some of it also indicates a real rise.

Reducing C difficile is now one of the six 'high-impact interventions' promoted by the Department of Health. There is a strong financial incentive for trusts to do so - each case extends length of stay by 21 days and costs£4,000. As patients need to be isolated, it can also affect bed management. Under the NHS operating framework unveiled in December, trusts and primary care trusts will now have to agree local targets for C difficile reduction.

But Royal College of Nursing policy manager Howard Catton also sees infection control issues as being crucial for public confidence in the NHS and potentially affecting plans to reduce beds. 'When you look at the occupation rates which some trusts are running at, there is an issue about capacity and bed numbers,' he says. 'If your beds are full all the time then people are moved around more frequently and there is an issue about having time to clean thoroughly.'

Acute trusts now have to report all cases of C difficile among patients who are over 65 (some trusts also voluntarily report those among younger patients). Some of these cases may have developed in the community rather than being acquired in hospital.

The first set of figures to be issued, covering January to December 2006, showed 44,488 cases among the over-65s. The following year's figures showed an increase to 51,690. The rate per 1,000 bed days also increased, from 1.9 to 2.22.

A report issued just before Christmas highlighted concerns about how seriously trusts take C difficile. The HPA and the Healthcare Commission said that over a third of trusts did not routinely follow government guidelines on the management of C difficile in their hospitals. They also reported that:

  • 38 per cent of trusts did not have restrictions in place to prevent inappropriate antibiotic use;
  • over a third were unable to routinely isolate infected patients;
  • two-thirds felt that infection in their trusts had increased over the past three years.

The Healthcare Commission can investigate trusts where there are concerns over serious service failure - as it did at Stoke Mandeville Hospital over C difficile and is now doing at Maidstone and Tunbridge Wells trust. It scrutinises trusts that fail to comply with the core standards of its annual health check, which includes one relating to healthcare-associated infections. Last year 41 organisations are thought not to have complied - their progress will be watched.

Alcohol problems

Safety strategy lead Murray Devine also expects the commission to look at the new locally agreed C difficile targets as part of the health check. The details have yet to be finalised but it is likely the commission will look at whether targets have been set, whether they are appropriate and whether there has been an improvement in infection rates.

There seems to be little argument about the steps which need to be put in place to deal with C difficile. Judy Potter says good antibiotic prescribing policies are the first, preventive, measure. Georgia Duckworth explains that narrow-range antibiotics rather than broad spectrum ones should be used whenever possible.

Good hygiene and cleaning measures can prevent the spread of C difficile between patients. Bleach-based products are generally more effective than other disinfectants. But it can be hard to eradicate every spore.

The thoroughness of cleaning is important and the DoH recommends enhanced environmental cleaning in infected areas. Health unions have highlighted the need for cleaning to be under clinical control and able to respond quickly - which may mean in-house services.

Treatment with hydrogen peroxide has also been effective, but is expensive and may mean the hospital has to go to a specialist contractor. At Royal Devon and Exeter foundation trust, the isolation ward used for C difficile patients was treated with hydrogen peroxide at the end of an outbreak, at a cost of around£8,000.

Hand hygiene is also important: the Center for Disease Control and Prevention in the US says the main means of transmission involves health workers' hands.

Action against MRSA has centred on the widespread use of alcohol handrubs. Unfortunately, these do not totally eliminate C difficile and soap and water is more effective.

This has led to some speculation that C difficile may have spread because alcohol hand rubs have displaced hand-washing. Judy Potter, who is also joint infection control director at the Royal Devon and Exeter, does not subscribe to that view, but stresses that hand washing is essential if a patient has diarrhoea.

Dedicated wards

But there seems to be little correlation between hospitals that are doing well at reducing MRSA and those doing well at reducing C difficile - which may suggest different approaches need to be adopted for the two diseases.

While testing elective patients for MRSA is practical, the same cannot be done for C difficile, which will develop as a result of healthcare interventions. While MRSA could - technically - be eradicated, C difficile is likely to always occur in a few patients.

Finally, if a hospital does get an outbreak then patients need to be nursed in a way that minimises the risk of the outbreak spreading. That may mean individual patients being nursed in single rooms or, if a significant number of patients are affected, on a dedicated ward or side ward. Personal protective equipment for staff in contact with body fluids is also recommended.

Ms Potter says that setting up a dedicated ward brought the outbreak at her hospital to an end. With hindsight, it should have been done earlier, she says, but at the time the hospital did not know it was dealing with a virulent form of the bacteria.

'We thought a change in antibiotic prescribing protocols for community-acquired pneumonia was the cause and focused on that,' she says. 'When this did not achieve the reductions we expected we did more investigations and found we had the more virulent 027 strain. As the number of cases was still too high and we now knew we had the 027 strain we opened the ward.'

Once the patients were clustered together - and the risks of infecting other patients significantly reduced - the outbreak was contained and died out in a matter of weeks.

'What other trusts are struggling with is adequate isolation facilities - few hospitals have enough side rooms to cope. The infection control teams are having difficulties convincing trust managers that that is the way forward,' she says.

Isolation wards mean unoccupied beds that are not available to other patients. 'We need to take the brave step of saying we will use a ward for this, there will be empty beds on it and we will not use them in any circumstances.'

This is easier for trusts with a single site, she says: multi-site trusts which try to designate an isolation ward will face problems such as transferring patients, patients being separated from the specialty that was looking after them and accessibility for visiting relatives, she says. Side wards or bays may have to be used instead.

So will local targets - meant to be in place by April - make a difference? 'It is a shame that it requires targets to get the necessary action, but if setting targets does enable people to take the appropriate action where infection control teams are struggling to get their managers to take it seriously then targets will help,' says Ms Potter.

'However, some trusts may not be able to reduce any further. We are at the lowest level for four years and we would be struggling to get it any lower than now. There are other trusts which have always had very low rates - they may be a bit aggrieved to be told to reduce rates further.'

The guidance on target-setting suggests that trusts with good records on C difficilemay not be asked to make reductions - those with rates of less than one per 1,000 bed days may be asked to maintain this. However, those with rates of 4 per 1,000 or above may be asked for reductions of at least 25 per cent.

That may be a tough task. Ms Duckworth says: 'Some trusts are facing endemic situations. It's very difficult to turn round an endemic situation because it takes a long time to get there. But it is important that people get in the frame of mind that they can do something about it and that they will be supported to do something. For years trusts were driven by financial agendas - maybe that has something to do with the infections getting out of control in the first place.'

NHS Alliance chief executive Michael Sobanja says that although much infection control expertise lies in hospitals, which may appear to put PCTs at a disadvantage in negotiating realistic but stretching targets, they could seek advice from experts if they need to. PCTs have infection control committees with input from their directors of public health. 'PCTs have got to enter into a dialogue with hospitals to see where they are now and what is reasonable, given their case-mix and prevalence in the community,' he says.

Some PCTs are in the early stages of doing this. The four PCTs in the Tees area, for example, are starting negotiations with clinicians in their two main providers. 'This has involved a review of the 2006 data, a review of the action plans in place to reduce C difficileas well as taking into account recommendations sent to all trusts,' says Bev Reilly, who is leading for the PCTs. 'Key local factors will be things like how trusts fare against isolation facilities, antibiotic policy adherence, microbiology access/diagnosis, infection control practices and cleaning and disinfection policies.'

The year ahead

Putting the burden of target-setting on local bodies avoids the bad publicity the government has seen with its nationwide MRSA target. Failure to hit targets will effectively become a local issue - although what sanctions PCTs will have or be willing to use if trusts do not meet them is uncertain. Georgia Duckworth sees the ultimate sanction as PCTs taking away their business and commissioning elsewhere.

But Professor Richard James, of Nottingham University's centre for healthcare-acquired infections, points out that targets rely on data and on measuring the right things - and the C difficile surveillance is only on over-65s. Yet in the US there has been concern over severe cases in younger age groups, not previously thought at risk.

A new drug in phase three clinical trials may help, says Professor James. Ongoing work on the genetic code of the 027 strain may also lead to greater understanding of how it works. But in the short term, C difficile could be a serious challenge to hospitals. While it is unlikely to be eradicated completely, reducing transmission between patients is likely to be a priority for managers in the coming year.

Infection in specialist hospitals: how one trust cut C difficile

Plymouth Hospitals trust has one of the lowest rates of C difficile among specialist hospitals - it fell from 1.5 cases per 1,000 bed days in 2004 to 1.36 cases in 2005, according to the HPA. Figures for 2006 are broadly in line with this, whereas many hospitals are expected to have shown a rise.

Infection control director Dr Peter Jenks puts a lot of this down to good antibiotic prescribing policies across the trust. 'Our policies are very tight and get monitored and audited closely. We have promoted using very narrow spectrum agents and some antibiotics are only released with microbiological approval.'

The trust also scrutinises new cases of C difficilecarefully to find out why they have occurred. One area in which Dr Jenks is interested is the use of proton pump inhibitors, which affect the acidity of the stomach. Acidity plays a major role in killing microbes that get into the stomach. Dr Jenks monitors PPI use in the trust and sees prudent use as one way to further reduce cases.

He expects to have conversations with local PCTs about a local target but, with an already low rate, the trust will find it difficult to make major reductions.

Although the trust has limited isolation facilities, the infection control team insists that patients with C difficileare put in a side room. This seems to have been effective in controlling cross-contamination within the hospital.

So far the trust has not had any identified cases of 027 C difficile, although other hospitals in the region have.

But only a fraction of cases are typed and Dr Jenks would like to see more typing done nationally.