Clostridium difficile in hospitals - a present and growing danger

Lord Patel has always maintained an unhealthy interest in the communicable diseases that patients enjoy during their hospital visits, since the National Audit report in 2002. It is evident that Clostridium difficile (especially amngst the elderly) is a a growing and very unpleasant problem.

Updates on Clostridium difficile in NI Hospitals

The Irish Times reports that Stormont (NI) Health Minister Michael McGimpsey has allocated an additional expenditure ( well he called it an "investment") £9 million would be invested over the next 3 years in a bid to improve patient safety and reduce the spread of infections like MRSA and Clostridium difficile

Single rooms are to be introduced in Northern Ireland hospitals and a new e hospital being built in Co Fermanagh will be the first to have single rooms for all appropriate patients. new measuress have also been introduced , including restrictions on visitors, a rolling programme of unannounced hygiene inspections to all hospitals and a new dress code for all health care staff.

An official outbreak of Clostridium difficile ( of a highly virulent ribotype 027 ) has been declared at Antrim Hospital (which Members of Stormont's health committee visited yesterday) where a specialist ward has been set up to treat patients after the number of cases in a month nearly trebled.

Updates on Clostridium difficile in Scotland

C. difficile Working Group, 1st report in December 2007 on the (now mandatory) surveillance of Clostridium difficile associated disease (CDAD) in Scotland (which only has data for cases in hospital patients > 65 years) states that there were 6035 cases for the whole of Scotland. The annual rate for Scotland per 1000 acute occupied bed days in persons ≥ 65 years old was 2.03 which they say is "comparable to rates generated in England".

The report is a model of it's kind and it is good to see that "approximately 65 % of the laboratory data are received by HPS via the electronic reporting system ECOSS (Electronic Communication of Surveillance in Scotland)". Analysis of samples includes ribotyping which is best presented int his graph - only two cases of ribotype o27 were found with 1 isolate in October.

In a sombre conclusion they say

"In conclusion this first year of data collection under the mandatory surveillance programme for Scotland has shown that healthcare associated Clostridium difficile associated disease is a significant problem throughout the healthcare system in Scotland. CDAD is today considered the leading cause of healthcare associated diarrhoea in the industrialised countries."

It is interesting to note that on Monday, 29 October 2007 Lord Darzi of Denham Parliamentary Under-Secretary, Department of Health in answer to a question from Lord Morris was only able to give such figures up to 2005. But they were alarming

	1999	2001	2002	2003	2004	2005
Mentions of C.diff	918	1,150	1,338	1,702	2,155	3,697
Number of these where underlying cause of death is C. diff	499	661	709	912	1,187	2,008

Figures from ONS for deaths involving CDI for primary care trusts cannot be provided "without disproportionate costs".

The number of deaths in hospital in Fife involving Clostridium difficile were 23 in 2005, and 41 in 2006 , where it was the main cause have gone down, from 13 in 2005, to 11 in 2006 which means that thenumber of deaths where the bug was considered to be a contributing cause trebled in one year.

NHS Highland said there had been 120 cases of Clostridium difficile last year, up from 50 in 2005, C. difficile was also an "underlying or contributing cause of death" for 5 patients in the area last year.

Clostridium difficile Ribotype 027 - Global incidence

Since 2003, the emergence and distribution of a hypervirulent strain of Clostridium difficile PCR ribotype 027 has been described in North America, Japan, England and Wales, Ireland, the Netherlands, Belgium, Luxembourg, and France, and has also been detected in Austria, Scotland, Switzerland, Poland and Denmark and has ben present in Sweden for several years.This new epidemic strain (PFGE type BI/NAP1 in the USA , also called ribotype 027) appears to be more virulent, with the ability to produce greater quantities of toxins A and B due to a mutant toxin controlling gene.

C. difficile is difficult to culture and none of the commercially available toxin tests differentiate between the various strains of C. difficile - it also appears to be it is resistant to newer fluoroquinolones. Both factors which may have aided it's rapid spread.

Alyson Smith Thames Valley Health Protection Unit, Bucks,UK reported the first evident UK cases in June 2005.

In the Netherlands, St. Jansdal Hospital in Harderwijk, the incidence of C. difficile-associated diarrhoea (CDAD) increased from 4 per 10 000 patient admissions in 2004 to 83 per 10 000 in the months April to July 2005 -this was characterised as C. difficile ribotype 027. (see also In total 17 Dutch institutions have detected patients with ribotype 027 so far, 15 hospitals
and 2 nursing homes )

In December 2007, C. difficile PCR ribotype 027 was found in two cases of C. difficile-associated disease treated in a hospital in Oslo, Norway.

Evidently treatment of severe or recurrent C. difficile -associated diarrhea is an evolving science and recent literature from outbreaks of severe disease in Canada and the U.S. suggest that mortality is associated with advanced age (≥ 75 years), immunosuppression, shock requiring vasopressors, very high WBC (> 50,000 cells/mm), and elevated lactate levels ( ≥ 5 mmol/L).

Advice from the Dutch Working Party on Infection Prevention is that in all patients who develop diarrhoea in hospital, especially during or after treatment with antibiotics or chemotherapeutic agents, an infection with C. difficile ribotype 027 should be suspected... and treated accordingly.


Hospitals on alert as superbug C difficile becomes resistant to key drug - news report in the Scotsman Sunday January 28th states that a new report by public health officials at the Health Protection Agency Centre for Infections has a report that taken from patients in the Leeds area of England showed that a C difficile ribotype 001 , the 2nd most common in the UK had "reduced susceptibility" to metronidazole - the antibiotic of choice in treating infections.That leaves only vancomycin as the last line of defence for antibiotic treatment.

Out of 88 tests 21 showed "reduced susceptibility".

Examination of the HPA website could find no evidence of the quoted report

There is however a useful article by Jon Brazier, Consultant Clinical Scientist and Head of the
Anaerobe Reference Laboratory, part of the National Public Health Service for Wales Microbiology Cardiff laboratory situated in the University Hospital of Wales. This can be found here. Clostridium difficile disease: a case of greater virulence and new risk factors page 20 HPA magazine Volume 5 Suimmer 2006. This has valuable information on the increasing numbers and spread of different ribotypes of C. difficile within the UK.

See also the Leeds Health Trust Annual report November 26th 2007 - The total number of C difficile laboratory reports for LTHT (indicative of cases of antibiotic-associated diarrhoea) across the Trust: 860(≥65; 648) in 2006/7, 645(≥65;490) in 2005/6, 692 in 2004/5, 743 in 2003/4, and 883 in 2002/3. The C. difficile rate for patients equal to or greater than 65 years in LTHT for 2004 was 2.0/1000 bed days, for 2005 1.86/1000 bed days, and for 2006 1.53/1000 bed days. Nationally there has been an increase of 5.5% in the number of C difficile reports for patients equal to or greater than (≥) 65 years.

Leeds have introduced routine intensive prospective molecular and clinical surveillance of hospital and community CD cases to determine the relative prevalence of epidemic strains, and the spread of CD 027. It is the only such service in the UK. We have examined ~500 cases in detail. C. difficile 027 was identified in both hospital and GP patients (4% of all cases), mainly causing mild/mod disease, and with only minimal evidence of spread or clustering. Intensive surveillance will continue to improve our understanding of C. difficile infection epidemiology and to detect emergent strains.

The Health Protection Agency asked Leeds to establish and lead a Clostridium difficile Ribotyping Network for England (CDRNE). The CDRNE consists of six regional microbiology laboratories in England: Leeds (Reference Laboratory, Leeds General Infirmary), Birmingham (Heartlands Hospital), London (University College Hospital), Manchester (Manchester Royal Infirmary), Newcastle (Newcastle General Hospital) and Southampton (Southampton General Hospital). The CDRNE service is now operational, and is to be used by hospitals/infection control teams in England to investigate increased frequency or severity of cases of C. difficile infection, increased mortality, or increased recurrence rate.


PS : Minister humiliated over Rose Gibb NHS payout Rose Gibb resigned 1 day ahead of a damning Healthcare Commission report into two outbreaks of Clostridium difficile, which led to the deaths of at least 90 patients, at Maidstone and Tunbridge Wells NHS Trust . She will receive a £75,000 pay-off despite the Health Secretary Alan Johnson’s pledge at the time that it would be witheld.