How to squash a superbug - trends in C difficile treatment

According to the UK's Office for National Statistics, there were 1,646 deaths occurring from Clostridium difficile infection in England and Wales in 2012 - 407 fewer than in 2011. Mortality rates also fell for the fifth consecutive year, down from 19.6 deaths per million of population in 2011 to 15.3 in 2012. Yet it remains the most common bacterial infection acquired in UK hospitals.

Any death from a hospital-acquired infection (HAI) is a tragedy and, institutionally, at least at some level, is symptomatic of professional or managerial failure.

Nevertheless, the experience of the NHS is being held up as an example to the rest of the world, especially Europe and the US, of how to tackle and take on this nasty and potentially fatal intestinal superbug.

A winning campaign

The UK's rates of C difficile have plummeted since the mid-2000s, thanks to Cleanyourhands, a robust hospital-based public health and hygiene surveillance and education campaign, backed by mandatory reporting and sanctions. Indeed, to illustrate how far things have come, the Office for National Statistics estimated in 2009 that, between 2004 and 2007, there were more than 20,000 deaths in the UK linked to C difficile, and more than 6,000 associated with MRSA.

Compare this with the US, where, according to the Centers for Disease Control and Prevention (CDC), C difficile is linked to the deaths of 29,000 Americans a year, infecting about 450,000 people. In Europe, a major report released in 2004 estimated that there were as many as 39,000 missed cases each year, quite apart from reported cases, which is, again, much more than in the UK.

"The UK's experience, and record, has been a major success," enthuses Professor Mark Wilcox, head of microbiology at Leeds Teaching Hospitals and Public Health England's lead on the disease.

"Since the peak in C difficile incidence and mortality in the UK in 2007/08, there has been about an 80% decrease in the number of incidents and deaths.

"We are still uncertain which element of the Cleanyourhands campaign was the most effective control measure, but what we are clear about is that a previously high rate was driven down. C difficile in the UK has been very successfully controlled," he adds.

The Cleanyourhands campaign was launched in England and Wales in 2004 following a number of scandals around HAIs in the mid-2000s. It focused on instilling in medical staff, patients and visitors the importance of hand-washing to prevent the spread of MRSA and C difficile, and thus highlighting the necessity for them to wash their hands every time they entered or left a ward. It also identified five fundamental moments when sanitising is necessary. These are before patient contact, before an aseptic task, after exposure to body fluid, after patient contact, and after contact with patient surroundings.

Other elements included the provision of alcohol hand rub at the bedside, the distribution of posters reminding healthcare workers to sanitise, and the provision of materials empowering patients to remind healthcare workers to clean their hands.

The campaign was accompanied by staff audit, inspection and a compliance regime, including the setting of mandatory surveillance and performance management targets for trusts.

UK takes the lead

Unfortunately, Europe and the US are yet to follow the UK's lead. The European Commission has, since 2009, made it clear it wants member states to put in place more active surveillance for HAIs, including C difficile. However, last year's EUCLID study (or European multicentre, prospective, biannual, point-prevalence study of C difficile infection in hospitalised patients with diarrhoea) showed there was still a long way to go.

The study found that declared rates of infection had increased by 70% since a previous study in 2008, but also collected faecal samples on two different days in the summer and the winter - so samples that were not formally tested and reported. When it examined these, it found the official reported figures were out by at least 25%.

Using data from 482 hospitals in European countries, it showed that, in a single day, an average of 109 C difficile infections (CDIs) were missed because of a lack of clinical suspicion or inadequate laboratory testing, potentially leading to more than 39,000 missed cases in Europe each year. Incidence of CDI in Europe had increased from 4.12 to 7.90 cases per 10,000 patient bed days between 2008/09 and 2012/13 respectively. Cases of the virulent ribotype 027 strain were now the most common in Europe. Moreover, countries with the highest rates of CDI testing had the lowest rates of this epidemic C difficile strain.

As Wilcox highlights, "In Europe there has been less success. There is less awareness about C difficile, and a considerable number of countries, especially in eastern Europe, do not have health surveillance programmes, so we simply do not know what is happening or the scale of the problem. There were also problems in some parts of Germany, especially where it borders some of those eastern European countries."

When it comes to the US, it is clear there is also a long-standing problem, even though the CDC, much like the European Commission, has rated C difficile one of the top-three threats, explains Wilcox.

"The US has very high rates, something that has been known about for years but which has not been brought under control. Some of those [CDC] figures may well be over-inflated, but you are still looking at figures comparable to the UK's rates when they were at their worst. So the message does not appear to be getting through," he says.

"The healthcare system in the US is much more fragmented, so it is much harder to get a standardised process in place. There has been talk about non-reimbursement from the insurance perspective, where an infection can be deemed to be the fault of the hospital or institution - which would certainly appear to be a possible effective tool - but that hasn't happened yet," adds Wilcox.

Follow the leader

So, what's the answer? Wilcox's response is refreshingly straightforward: "Look at what the UK did, and copy that." To that end, at a practical, patient-care level, it's about ensuring that staff (and visitors) are being scrupulous about hygiene and cleanliness - that messages, awareness and best practice are backed by audit and inspection - and that this is all complemented by speedy diagnosis and treatment when cases do arise.

"It is also about visibility," adds Wilcox. "You [the UK], for example, now have a high number of NHS trusts where they will display C difficile and MRSA rates on their home page. Nowadays, it is one of the top ways in the UK to categorise how well an institution is doing."

While many observers were sceptical when the Cleanyourhands campaign was launched, the results speak for themselves, Wilcox concedes. But maintaining this success is about continuing and constant focus, prioritisation and activity, even once the numbers are going in the right direction.

As Wilcox highlights, "NHS trusts still have to meet the targets set for them; there is still the same performance management framework in place - which includes monetary incentives and fines associated with meeting or not meeting your objectives. The pressure has not been removed, even though the numbers have come down - the emphasis is on constantly improving and continuing to reduce the numbers, not just on maintaining the fall achieved.

"The good news is that we know how to control this. But you can also see the occasional resurgence of it, and so it is about maintaining a high degree of awareness, education and vigilance," he says.

Five ways to tackle C difficile

Health surveillance: "You have to have an effective health surveillance system in place. It is really the bread and butter thing you must do, because if you don't, you have no idea what the problem is, or whether you even have a problem," says Wilcox.

Proactive education and diagnosis: "You have to have a sensible and quick way of making diagnoses. If you don't know how to diagnose and manage the infection, the problem is only going to get worse," he recommends.

Public reporting, mandatory targets and management incentives: "Whether or not your public reports are attached to specific objectives, requirements or even fines, public reporting focuses the mind. C difficile and MRSA rates can also be a good marker of how an institution is doing in terms of delivering on its healthcare quality more widely," argues Wilcox.

A ground-level system for curbing transmission: "At the clinician level, you need to be aware of the probability of C difficile within an organisation or on a ward; you need to know how to make a diagnosis, crucially an early one, and you have to have a system in place for minimising the spread of the disease once a diagnosis has been made," says Wilcox.

Put in place a diarrhoea assessment policy: "This can help to limit the spread of the disease and ensure that diagnosis and treatment happen as quickly as possible, and then the disease can be controlled with antibiotics," he adds.