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.

Clostridium difficile down 21% , MRSA down 14% in new Quarterly HPA figures for England

Health Protection Agency: Quarterly Clostridium difficile and MRSA figures

The HPA figures released today show the most remarkable reduction in Hospital Acquired Infections (HAI) in England.

The latest Clostridum difficile figures, show that there was a 21% decrease to 10,734 cases in patients aged 65 years and over in England, for Q3 2007 (July – September) down from 13,699 in the previous Q2 2007(April – June) and 16% / 2,087 cases down on Q2 2006.

For atients 2 -62 , 2,496 cases were reported in the Q3 2007 (July – September) a 14% drop on the Q2 2007 (April – June).

The latest figures on MRSA bloodstream infections show that there were 1,072 cases reported in England during the July to September quarter of 2007. This represents an 18% decrease on the previous quarter (April to June) when 1,304 reports were received. (HPA Press Release)

Dr Georgia Duckworth , Head of the Agency's Healthcare-Associated Infection and Antimicrobial Resistance Department, said that whilst these figures should be interpreted with care as the surveillance system is undergoing significant changes, “This continued decrease in MRSA bloodstream infections is a major achievement against the seemingly unstoppable rise that we saw throughout the 1990s. Latest figures show a continuing downward trend, despite a backdrop of increasing workloads and complex patient needs.”

Unsurprisingly those Trusts reporting reduction in infections were anxious to spread the good news in their local press ... It does demonstrate that effective action can (and is being taken) be taken.

Hospital 'winning superbug battle'

Royal Bolton Hospital managers welcomed Health Protection Agency (HPA) figures showing the number of Clostridium difficile cases fell by 21 % to 151 in the last 6 months compared with 190 in 2006.

Killer bug cases fell by 100 in last year

Sherwood Forest Hospitals NHS Foundation Trust announced that HPA data reveal 413 cases of Clostridium difficile 2005, 434 in 2006 and have fallen to 333 in 2007.

WHIPPS CROSS: Hospital infections drop

The number people aged 65 or over catching Clostridium difficile had increased at Whipps year by year, reaching 403 in 2006 = this has fallen and from Jan-Sept in 2007 there were 168.

Drop in number of MRSA incidents

The East and North Hertfordshire NHS Trust showed a 37% reduction in recorded cases of Clostridium difficile, from 474 in 2006, to 300 in 2007.Two specialist isolation wards - one at Lister and one at the QEII - were launched in the last 6 months to help combat MRSA and CD.

HOSPITAL REPORTS A DROP IN CASES OF C-DIFF BUG

Royal Devon & Exeter Hospital has seen a small decrease in recorded cases of Clostridium difficile from July to September 2007 for patients older than 65...and a small increase in patients aged two to 64 with the bug.

Simple Soap and water hand washing best for controlling Clostridium difficile

No 1 in a "Cut out and Keep" series on healthy living ..

Clostridium difficile, which is the new drug resistant bacterium that is killing the elderly in hospitals across the developed world, is best removed with washing with simple soap and water a recent Canadian study concludes - this was reported to the 47th Interscience Conference on Antimicrobial Agents and Chemotherapy in Chicago this week.

Dr. Michael Libman, director of the division of infectious diseases at the McGill University Health Centre recruited 10 volunteers and contaminated their hands with Clostridium difficile, one of the most difficult bacteria to combat in hospitals settings. Its usually spread by faecal contamination - Ygh! The volunteers washed with either:

1. Regular soap and warm or cold water,
2. Antiseptic soap and warm water,
3. An alcohol-based solution,
4. And a disinfectant towel.

"The results were striking: the protocols that involved washing with water eliminated more than 98 % of the bacteria, while washing with an alcohol-based solution eliminated almost none! The protocol involving a disinfectant towel eliminated around 95 % of bacteria." Dr. Matthew Oughton, a researcher in Libman's team said.

Clostridium is a sporulating bacterium - it produces extremely resistant spores to survive in hostile environments which develop into bacteria under the right conditions for growth.
Oughton says the results reflect the view that alcohol eliminates the living bacteria but not the spores. The mechanical action of washing combined with the chemical action of soap eliminates both.

It may be of interest that the UK department of health "A simple guide to Clostridium difficile" Dated February 8th 2007 , under notes on infection control, recommends ..".- handwashing (not relying solely on alcohol gel as this does not kill the spores)"

BBC Online, in February this year , reported by the Office for National Statistics that death certiificates issued in the England & Wales (not incl. NI & Scotland) involving Clostridium difficile rose by 69% to 3,800 from 2004-05. The same report stated that .."Rigorous cleaning with warm water and detergent is the most effective means of removing spores from the contaminated environment and the hands of staff, say experts. "

In January 2004, the Health Protection Agency introduced a mandatory reporting scheme for all cases of C. difficile in persons aged 65 and over. Data from the scheme show an increase between 2004 and 2005 in the number of C. difficile reports. (Complete HAI Stats Summer 2007 here )

UPDATE Saturday 8.00 pm BST

"Writing" in the News of the World the premiere "tits'n'bums" rag in the Murdoch stable Prime Minister Gordon Brown says he has ordered a deep clean of every hospital in Britain to tackle hospital "superbugs".

Every hospital will be disinfected and scrubbed clean over the next year

"A ward at a time, walls, ceilings, fittings and ventilation shafts will be disinfected and scrubbed clean," says the Scotsman.

In a desperate attempt to make it look like action is imminent to meet NHS victims complaints -"I've learned from what people have told me and I've heard the need for change," - he also announces some changes / face lifts / improvements ( no timetable provided) -

1. Patients to see GPs out of hours and at weekends. Ho.Ho.Ho. Not in this neck of the woods you won't - you are lucky to seem them between 9.30 and 3.00 with an hours lunch Monday - Thursday

2. He said access would also be improved, whether it be NHS walk-in centres or GP surgeries in high-street stores like Boots or Tesco.

3. Breast and colon cancer screening to include more people.

4. Cervical smear test results will be issued within 14 days, Brown said, without specifying when the changes would take place.

So if you see a nurse / doctor or the rare and stray administrator spraying / misting / their hands with alcohol gels,sprays / misters - (even Chanel No 5) just ask them to wash their hands in nice warm soapy water.

Overcrowded Suffolk Hospitals see Clostridium difficile cases rise - Director lies about it

In response to an FOI request the Department of Health released figures that showed the number of available beds in Suffolk NHS hospitals has decreased by 20% from 1,501 in 1996/7 to 1,194 in 2006/07.

This exceeds the national (well...English) decline in hospital bed numbers.

In 1996/97, there were a total of 198,848 hospital beds available in England. This has now decreased by 16% to 167,019 beds.

As a conseqence bed occupancy levels at West Suffolk Hospital topped 98% during the first 9 months of this year, despite infection control guidelines recommending a maximum of 85%.(Figures obtained by East Anglian Daily Times by FOI request) On the Thursday before Christmas the main Ipswich hospital was only taking "blue light" patients and out patients were being turned away.

The figures, which only relate to daily levels at 2pm, show that the Bury St Edmunds hospital ran at an average of 98.8% bed occupancy for the first three months of 2007.

This then fell to an average of 98.3% over the first nine months of this year.

Gwen Nuttall, the bossy, impeturbable , unreasoning, penny pinching, box ticking, forceful Lancastrian, no-nonsense director of operations at the hospital trust for the last 4 years , described the process of bed occupancy as "fluid" and added there had been a “significant drop” in the cases of the infection Clostridium difficile. (see below - this is a lie whichever way you cut it) The trust's own FAQ about the bacterium does not mention overcrowding as a factor in it's spread.

“Having fewer beds does not mean there is a higher risk of infection."Ho.Ho.Ho.

Which makes one wonder why the national guidelines suggest that it does.

Furthermore, problems such as the overnight fire at the Royal Marsden Hospital occur (see pic) ...and being in Suffolk , the only region so far to experience an out break of the highly infectious bird flu implies major health risks if hospitals cannot cope initially with highly infective patients.. see Lord Patel Wednesday, December 26, 2007 HPAI A(H5N1) = "highly pathogenic avian influenza virus of type A of subtype H5N1" - Cause for concern with new cases reported

Curiously Richard Spring (West Suffolk, Conservative) | Hansard source asked on 22/11/07

To ask the Secretary of State for Health how many cases of clostridium difficile there were in (a) Addenbrookes Hospital, (b) West Suffolk Hospital and (c) Ipswich Hospital in (i) 2005, (ii) 2006 and (iii) 2007 to date.

The detailed figures are available on the national reports at the Health Protection Agency website but it is evident in the figures given by the Minister in response to the enquiry from Dicky Spring there has been no significant improvement at Ipswich Hospital NHS Trust 347 cases in 2005, 483 in 2006, and283 in the first 6 months of this year.Cambridge University Hospitals NHS Foundation Trust had 400 in 2005 422 in 2006 and evidently things have got worse with 262 in only the first 6 months of 2007.

This also supports the Health Protection Agency report showing a 13% rise in cases of Clostridium difficile (C-diff) at the West Suffolk Hospital at Bury St Edmunds between April and June this year.

This was highlighted by and publicised by Gill Malik, a cleaner at West Suffolk Hospital speaking as a national executive committee member of Unison. Gill who has 20 years' experience as a hospital cleaner, said the number of cleaners on wards was cut a number of years ago and had never recovered.

She said once there were five housekeeping staff per ward, three of whom were dedicated to cleaning. The trust policy was to have 3 dedicated cleaners for every 2 wards.

Unceasingly Hospital Directors ignore the rising (and very lengthy) crisis of in house infections -
see Lord Patel - Thursday, October 11, 2007 Kent & Sussex Clostridium epidemic kills patients - nothing to laugh about see also - Rose Gibb resigns - Kent & Sussex Clostridium epidemic kills patients - all targets met. another box ticking , hard faced bitch resigned over a massive C dif outbreak in Sussex, not before collecting a 1/2 Mn Pound pay off.

In places like Suffolk where bird flu is an ever present threat the demand for rapid, effective action is essential - and a reduction in bed occupancies.

LOrd Patel has an uneasy feeling that he will be returning to this topic sooner rather than later.

Clostridium difficile out break in Northern Ireland kills 16 and 13 seriously ill

The Northern Ireland , National Health Northern Health and Social Care Trust area have recorded 16 hospital related deaths to a virulent strain identified as ribotype 027 Clostridium difficile.

Five deaths in Whiteabbey and one in Braid Valley hospital, Ballymena in the last 3 months have also been linked to the same strain of Clostridium.

Antrim hospital is currently treating 13 patients in a special "a dedicated cohort ward" identified as having contracted illness caused by the contagious bacteria - Clostridium Difficile Associate Diarrhoea (CDAD) which causes violent and often fatal diarrhoea especially in older people.

Currently there are there are currently 26 declared cases of C.difficile, "the bulk of them at the Antrim Area Hospital".

The Trust's medical director, Dr Peter Flanagan, explained that an outbreak of C.difficile is declared when the number of cases increases above the normal level.

"We would expect around 8 cases per month. We currently have around 20 per month," he said.


Lab reports of C-difficile in Northern Ireland increased from 412 in 1996 to 1,486 to 2006. The disease is cited in more deaths than the better known MRSA superbug, the expert said.

Belfast Telegraph - Patients isolated after superbug outbreak at hospital - Friday, October
Belfast Telegraph - 16 recent fatalities linked to superbug - Wednesday, January 23, 2008


Proventec PLC (AIM : PROV) has been awarded a 14-month tender for the sole provision of
specialist steam cleaning equipment by the National Health Service ('NHS') Purchase and Supply Agency with an optional 1 year extension by it's subsidiary, Liverpool based, Osprey DeepClean . The contract results from the recent £50 Mn. extra funding for the Strategic Health Authority.

The company claim that their carried out healthcare studies, carried out
in conjunction with the University College London Hospital is an endorsement that our dry steam cleaning units can provide a higher standard of cleaning and hygiene.


David Chestnutt, Chief Executive of Proventec announcing the contract said, "'Hospitals have a duty of care to provide a clean environment for patients.There have been accusations that the Government's recent initiative for a national deep clean is merely a gimmick. It is not. "

Well he would say that wouldn't he. Bollocks.

Clostridium difficile is a faecal contaminant and a rigorous policy of handwashing with disinfectant soap by all staff, and visitors is the surest way to prevent it's spread....which is why it has spread so relentlessly throughout the UK hospitals.

Listen to and Download "Henry Handwash" MP3

Detailed report on deaths in NI where C difficile is given as a cause 2000/05

Fatal Clostridium difficile outbreaks in hospitals throughout UK - hundreds dead but remarkably, no-one is responsible

Probably one of the worst examples of hospital acquired infections was reported Thursday, October 11, 2007 Rose Gibb resigns - Kent & Sussex Clostridium epidemic kills patients - all targets met.

A report from health watchdog, the Healthcare Commission, concluded that infection by Clostridium difficile probably or definitely killed at least 90 patients and was a factor in the deaths of a further 241 in 3 Hospitals (Maidstone Hospital, Kent and Sussex Hospital, Pembury Hospital) run by the Maidstone and Tunbridge Wells NHS Hospital Trust . Kent Police and the Health and Safety Executive were to examine the report to cosider if there was a case for criminal prosecution. BBC Full report 128 pages

Now Kent Police and the HSE have concluded their review . This consisted, it appears, of series of interviews with the Commission's lead investigators and all the experts who considered the information gathered by the Healthcare Commission in compiling their report. HSE has concluded that whilst mistakes had been made, there is insufficient information to launch a criminal investigation.

It must be remebered that the Healthcare Commission report stated .."Due to poor documentation and record keeping by the trust, a lack of agreed methods and staff being unable to recollect events, the Healthcare Commission has been unable to clarify the precise nature, timing and findings of the various case note reviews undertaken by the trust. "

Which must gladded the hearts of the relatives of 331 people who died in the massive outbreak which was reported immediately prior to the premature departure of CEO Rose Gibb. This highly unpopular , but highly paid lady (her salary was reportedly £150K pa plus 12.5 K pension contribution and her £250 K payoff is still subject of litigation) was responsible for the hugely unpopular "reconfiguration "plans for the two hospitals which saw the down grading of Maidstone Hospital A&E services. Her plans had also included the loss of children’s and maternity services.

Sandra Caldwell CB, HSE Deputy Chief Executive, is reported saying that she has expressed her sympathy to all those affected.

She also makes the astonishing conclusion that ," from the information available, we cannot establish with certainty a causal link between failings to manage infection and the death of any particular person. "

"The Trust has acknowledged that mistakes were made and their senior management team has changed substantially."

So that's alright then.

See previous posts on this case here

However this is a repeat performance by our Sandra (since promoted it seems) - some may remember this on Tuesday, November 20, 2007

Stoke Mandeville Hospital escapes HSE prosecution after Clostridium outbreak kills 33 people
Stoke Mandeville Hospital was investigated by the HSE after a Healthcare Commission (HC) report claimed that there were “serious failings” in the hospital’s response to Clostridium difficle infection infecting 334 and killing 33 patients between October 2003 and June 2005.

The HSE decided that they were unable to bring criminal proceedings against the trust due to a lack of “admissable evidence”.

Thames Valley Police and the Crown Prosecution Service were asked to consider the HC’s report under the terms of the “Work-Related Deaths Protocol”.

Their conclusion was there was insufficient evidence of a “causal link” to the action of any individual and the deaths of the patients involved.

Sandra Caldwell, HSE Director of Field Operations, said:“On the basis of the evidence available, HSE did not find sufficient admissible evidence to be able to bring criminal proceedings against the Trust, alleging a link between management failures and particular deaths.”

OPT - 80 a new weapon in the armoury to fight Clostridium difficile ?

Perhaps there is some good news for managers of filthy, badly run NHS hospitals as Optimer Pharmaceuticals experimental drug, codename OPT-80, saw a 92.1 % rate of “cure” compared with 89.8 % in patients taking Vancocin (Vancomycin) , (made by ViroPharma of Pennsylvania) in a Phase 3 trial for the treatment of Clostridium difficile.

In addition, only 13.3% of patients treated with OPT-80 experienced a recurrence vs. 24.0% for Vancocin (p = 0.004).

The study involved 629 patients in the United States and Canada and was conducted in more than 100 clinical sites throughout North America. OPT-80 is the only antibiotic therapy currently in Phase 3 worldwide clinical development for Clostridium difficile infection.

Optimer have been conducting late-stage studies of the drug under fast-track status from the FDA, which allows it expedited review because the drug addresses a serious unmet and growing medical need.

The next step is to complete the on-going second Phase 3 study at clinical sites in Europe and North America to support an NDA filing."

The news has produced a healthy response to the shares - Optimer (Nasdaq : OPTR) .

OP- 80 a new type of antibiotic

OPT-80 is the first in a new class of antibiotics called macrocyclics, which inhibit the bacterial enzyme RNA polymerase, resulting in the death of Clostridium difficile. The narrow spectrum profile of OPT-80 may eradicate Clostridium difficile selectively with minimal disruption to the normal intestinal flora. This may facilitate the return of the normal physiological conditions in the colon and reduce the probability of CDI recurrence.

Case Notes - Important BBC 4 Documentary reporting some success in Hospital Acquired Infections.

Case Notes is a BBC4 documentary programme presented by Dr Mark Porter who delves every week into what the medical profession does and doesn't know. This week he turned his attention to Hospital Acquired Infections. Like all Case Notes programmes it was informative, authoritative and is also available online as a repeat for 7 days, as a a full Transcript or as as Podcast.

This week the programme addressed what the Press like to call "Superbugs" -

"Hospital acquired infections - like ... MRSA and Clostridium difficile - are rarely out of the headlines these days. So how worried should we be? And what can you, and your hospital do, to reduce the risk? " the programme asked and provided an excellent and encouraging reponse.

Hospital Acquired Infections (HAI) were a problem first brought to a wider public attention when the Audit Commission led by the brilliant forensic mind of Sir John Bourn reported, not on the clinical problems but the costs of the lamentable record of people entering hospital for a cure and ending up with an infectious and sometimes fatal illness. In its original February 2000 report, the NAO noted that hospital-acquired infections (HAI) were (then) costing the NHS around £1 billion a year and resulting in at least 5,000 deaths - which broadly coincided with the experience in US hospitals.

A progress report issued 4 years later on Wednesday 14th July 2004 delivered the shocking news that the Department of Health’s mandatory MRSA reporting system had revealed an 8% increase in the number of Staphylococcus aureus bloodstream infections from 17,933 in 2001-02 to 19,311 in 2003-04. Of these, about 40% were MRSA, making the UK’s rate among the worst in Europe.

At the time Sir John Bourn said:

" .... I am concerned that, four years on from my original report, the NHS still does not have a proper grasp of the extent and cost of hospital-acquired infection in trusts.

"The war against hospital-acquired infection must be pursued on many different fronts: ranging from tackling the factors which inhibit good practice, including a more robust approach to antibiotic prescribing and hospital hygiene, though instituting a system of mandatory surveillance, to persuading all NHS staff to take responsibility for, and contribute towards, effective infection control."

It is unnerving that a well run, well funded, well staffed inner city hospitals of the University Hospitals of Leicester NHS Trust are still, 7 years on struggling manfully to control this problem.

In the programme Mark Porter talks to Dr David Jenkins ,the Director of Infection Prevention and Control, Andy Powell, Head of Facilities and Caroline Trevithick, Lead Infection Control Nurse about their plans.

Preventing entry of infected patients by swabbing for MRSA before admission, annual deep cleaning (see pic) to help keep the hospital environment clean and rigorous hand washing procedures to prevent cross contamination between health workers and patients, and visitors have all been introduced as well as isolation of infected patients. There has also been an intensive and combined programme with GP's and hospital clincians to control the use and types of antibiotics routinely used for routine treatment of infections.

University Hospitals of Leicester produce a very good well illustrated leaflet - Understanding and Preventing Infections - Answers to the most common questions patients ask about two of the most talked about ‘superbugs’, MRSA and Clostridium Difficile). Downloadable PDF (!) (1.46 MB)(also available in 6 languages in printed format)

Mark Porter asked Dr Jenkins how he saw the situation at Leicester in terms of battling C.difficile and MRSA?

JENKINS .."It's early days yet because we have had a problem with C.difficile in Leicester.... our numbers now are the lowest for many years, in fact lower than they were before this new strain (the 027 strain of C.difficile ) came along. Clearly this is something we do need to keep an eye and we're certainly not complacent about that."

".... the government set a target for halving MRSA bloodstream infections by the end of March. At the moment we're on track for 70% reduction, so over performing from that point of view."

Studies in the developed world have now clearly identified the costs and consequences, of MRSA. In the UK, the National Audit Office (NAO), an organisation with no direct health responsibilities it must be noted, are the people who have been instrumental in driving changes, essentially for economic, not clinical reasons. To the direct costs must be added the consequences of claims for damages - Lesley Ash (pic) the popular TV actres has just won a reported £5Mn. settlement for crippling MRSA infection.

Paradoxically, as a result of more rigorous definitions, improved reporting, and defined responsibilities for infection control in hospitals it is evident that the problem is larger and more pervasive in UK hospitals than initial studies had indicated.

For example it was only 3/4 years ago that the scale of the Clostridium difficile levels of infections and fatalaties became apparent , even to health workers at all levels and Infection Control staff - whose function has now become critical in managing clinical success in the way it is now calculated and reported.

The Press have been assiduous in promoting the happy story that anxious patients and relatives wringing their hands in grief have been replaced by nursing staffs educated in hand washing.

Probably if there was a Royal College of Hospital Cleaners, anxious to protect their members interests, such a simple solution identifying the prime cause of sloppy cleaning, might not be promoted with such zeal. Nor expensive and largely pointless "deep cleaning" ... whose presence and signage suggests more a desire to provide public re-assurance rather than any meaningful medical benefit.

The story from Leicester (Whose University is the leading and most progressive Department in treating patients rather than illness) is one of modest success, naturally no hospital would take part if they couldn't display such effort, energy, directed zeal and demonstrable results.

That's the Good News - but there is plenty of bad News.

There were different results from a BBC programme which focussed on just one hospital trust in early 2004.

BBC reporter Danielle Glevin went undercover in May 2004 in the Kent and Sussex Hospital to report a scandalous story .

In the resulting programme Hugh Pennington an eminent consultant microbiologist (He led a public inquiry into the 2005 E. coli outbreak in South Wales) said it was a dirty hospital.."the worst I've ever seen" . Rose Gibb the Chief Executive of the Maidstone and Tunbridge Wells NHS Trust responded "The hospital has cleaning problems".

There were subsequently two major outbreaks in their 3 hospitals of Clostridium difficile - 150 patients were affected between October and December 2005.

In a second outbreak from April to September 2006 285 patients were affected.

A report from health watchdog, the Healthcare Commission in October 2007 (3.5 years after the BBC programme) , concluded that infection by Clostridium difficile probably or definitely killed at least 90 patients and was a factor in the deaths of a further 241 in 3 Hospitals (Maidstone Hospital, Kent and Sussex Hospital, Pembury Hospital) run by the Maidstone and Tunbridge Wells NHS Hospital Trust . Kent Police and the Health and Safety Executive are now examining the report.

CEO Ms Rose Gibb ( a qualified nurse), resigned a day ahead of the publication of the report with an award of a years salary (£150,000), half of that has been paid despite the Health Minister Johnson's attempt to stop it and she is claiming for the balance of £75,000.

There are similiar problems reported recently in Suffolk Scotland and Northern Ireland
and Stoke Mandeville.

Stoke Mandeville Hospital was investigated by the HSE after a Healthcare Commission (HC) report claimed that there were “serious failings” in the hospital’s response to Clostridium difficle infection infecting 334 and killing 33 patients between October 2003 and June 2005. The HSE decided that they were unable to bring criminal proceedings against the trust due to a lack of “admissable evidence”.

...and Finally

Preliminary Health Protection Agency figures released this week show the most remarkable reduction in Hospital Acquired Infections (HAI) in England.

The latest Clostridum difficile figures, show that there was a 21% decrease to 10,734 cases in patients aged 65 years and over in England, for Q3 2007 (July – September) down from 13,699 in the previous Q2 2007(April – June) and 16% / 2,087 cases down on Q2 2006.

For patients 2 -62 , 2,496 cases were reported in the Q3 2007 (July – September) a 14% drop on the Q2 2007 (April – June).

The latest figures on MRSA bloodstream infections show that there were 1,072 cases reported in England during Q3 ( July/ September) 2007. This represents an 18% decrease on the previous quarter (April to June) when 1,304 reports were received. (HPA Press Release)

Whilst these dramatic reductions have raised a few eyebrows, indicating a massive level of success in 3 months not obtained in the previous 7 years, ther has been, at last some demonstrable success in the fight against HAI.... first raised as a problem 8 years ago by an Accountant.

Rose Gibb resigns - Kent & Sussex Clostridium epidemic kills patients - all targets met.

A report from health watchdog, the Healthcare Commission, concluded that infection by Clostridium difficile probably or definitely killed at least 90 patients and was a factor in the deaths of a further 241 in 3 Hospitals (Maidstone Hospital, Kent and Sussex Hospital, Pembury Hospital) run by the Maidstone and Tunbridge Wells NHS Hospital Trust . Kent Police and the Health and Safety Executive are examining the report. BBC Full report 128 pages

CEO Ms Rose Gibb ( a qualified nurse) who took up the job in late 2003, resigned ahead of the reports publication on Friday 4th October. Chairman of the Trust Mr James Lee Mr said the appointment of a new chief executive may take a few months.

As CEO Rose Gibb was responsible for the hugely unpopular "reconfiguration "plans for the two hospitals which would see a down grading of Maidstone Hospital A&E services. Her plans had also included the loss of children’s and maternity services.

There were two major outbreaks - 150 patients were affected between October and December 2005.

258 patients were affected in a second outbreak from April to September 2006 .

This search of the BBC website alone produces a detailed history of how this nationwide Clostridium epidemic has grown remorselessly as an obsession with centrally devised targets for hospital performance has gripped hsopital managers.

http://search.bbc.co.uk/cgi-bin/search/results.pl?scope=all&edition=d&q=clostridium

See also here

The screen pic above is from a BBC undercover investigation when BBC reporter Danielle Glevin went undercover in May 2004 in the Kent and Sussex Hospital Go here first and follow links. The interview with Rose Gibbs is here. This was before the 2 major outbreaks.

A sample of the Conclusions of the healthcare Commission report ...

"The trust told us that there had been no deaths that were definitely caused by C. difficile between April 2004 and March 2006. In the Healthcare Commission’s sample of 50 patients who died and had contracted C. difficile between April 2004 and September 2006, our experts found that in 26% of the cases (13) it was definitely or probably the main cause of death and in 78% (39), C. difficile had definitely or probably contributed to the patients’ deaths. "

"Due to poor documentation and record keeping by the trust, a lack of agreed methods and staff being unable to recollect events, the Healthcare Commission has been unable to clarify the precise nature, timing and findings of the various case note reviews undertaken by the trust. "

"The chief executive was widely viewed as being difficult to challenge. "

"Communication between the trust and the PCTs focused on numbers of patients treated and associated costs. There was very little focus on the quality of care. "

UPDATE 12th Oct. Apparently Ms Gibb received a payment of £250,000 severance pay (salary was reportedly £150K pa plus 12.5 K pension contribution) and Health Minister Johnson has asked for any payment to be delayed, pending clarification. It is not unusual for such payoffs to be made tax free as pension contributions.

Stoke Mandeville Hospital escapes HSE prosecution after Clostridium outbreak kills 33 people

Stoke Mandeville Hospital was investigated by the HSE after a Healthcare Commission (HC) report claimed that there were “serious failings” in the hospital’s response to Clostridium difficle infection infecting 334 and killing 33 patients between October 2003 and June 2005. The HSE decided that they were unable to bring criminal proceedings against the trust due to a lack of “admissable evidence”.

Thames Valley Police and the Crown Prosecution Service were asked to consider the HC’s report under the terms of the “Work-Related Deaths Protocol”. Their conclusion was there was insufficient evidence of a “causal link” to the action of any individual and the deaths of the patients involved.

Individual victims, or thier families may of course prosecute in particular cases where they believe clinical negligence may have occurred.

Sandra Caldwell, HSE Director of Field Operations, said:

“On the basis of the evidence available, HSE did not find sufficient admissible evidence to be able to bring criminal proceedings against the Trust, alleging a link between management failures and particular deaths.”

“We did find some breaches relating to the requirements to keep documents. However, as these were not directly linked to any of the deaths and were of a relatively minor nature, HSE decided that it would not be in the public interest to bring legal proceedings against the Trust and its managers in relation to these matters."

An investigation into the handling of C. difficile outbreaks at Maidstone and Tunbridge Wells NHS Trust in which 90 people died is still being carried out by the HSE and Kent Police.
The Healthcare Commission report July 24th 2006 ..

"The primary factor however, was the failure to isolate patients with the infection. The nature of the hospital made control of the infection extremely difficult. There were few single rooms that could be used to isolate patients with infections and, in 2003, the number of rooms available for isolation was cut further because of the Trust’s decision to reconfigure its wards and ring fence beds to prioritise other patients.

The Trust’s drive to meet the target for A&E, which requires all patients have a maximum wait of four hours from admission to discharge, led to some patients with infections being admitted or moved out of A&E within the target time into open wards rather than isolation facilities. "

Complete HC report on the outbreaks at Stoke Mandeville here as pdf

C. Difficile Support group website

See also previous post hereThursday, October 11, 2007 Rose Gibb resigns - Kent & Sussex Clostridium epidemic kills patients - all targets met.

Also see all Clostridium posts here

More Clostridium difficile deaths and infections in Northern Ireland but outbreak over (?)

There has been a major outbreak of Clostridium difficile in Northern Ireland in the last year. After taking a rigorous and robust 3 pronged approach The Northern Health and Social Care Trust (fascinating Management Structure chart pdf) are widely trumpeting that the outbreak is now crushed and only 2 more unecessary deaths and 11 infections occurred last month - although they failed to reveal at which hospitals these infections were located.

Since last summer over 61 deaths have been linked to C. difficile of which 40 (now 42) have died this calendar year. When we last covered this topic 2 months ago the respective figures were 53 and 32. see Saturday, July 05, 2008 Northern Ireland Clostridium difficile deaths and infection continue despite throwing money at it £6 Mn "investment" by McJimpsey

So the NHSCT have declared the outbreak over "as at August 31st" because " there had been a sustained reduction in the number of new cases and there was no evidence of recent transmission."

Meanwhile they will continue with their multi million £ three-pronged policy against this faecal contaminant ;

1. Infection control procedures - including restrictions on visiting ***
2. Rigorous antibiotic management
3. Enhanced environmental cleaning

Not to mention carryong on spending the £9m the NI Health Minister Michael McGimpsey has thrown (he calls it an "investment") at Northern Health and Social Care Trust, with the very modest aim of reducing MRSA by 10% and C. difficile by 20% by March 2009. Ulster Unionist and property developer 60 year old McJimpsey spends nearly half the NI total Budget.

The Northern Health and Social Care Trust emply 13,000 staff providing services to a population of around 440,000 in rural and suburban communities with an annual budge of £500 million.

*** Visiting Policies in NI Hospitals

Western Health and Social Trust have issued a "Hospital Visiting Policy" a 12 page document dateed August 2008 which has the fascinating restriction :

Visitors should be advised that in the interest of promoting patient privacy that camera phones, cameras and camcorders should not be used within the ward area except in Maternity Department where special guidance in available.

The Southern Health and Social Care Trust have a 13 page "Acute Hospital Visiting Policy" which is undated and different to the above which has the injunction :

For confidentiality reasons cameras on mobile phones, cameras and camcorders arenot to be used by visitors within the ward area without seeking permission from wardstaff

The Belfast Health and Social Care Trust (the biggest with 22,000 employees and possibly he biggest employer in NI) revealed a "Knock out plan for C difficile " just one month ago - The Trust’s Medical Director, Dr Tony said on August 7th - “It is our intention to deliver a knock out blow to C difficile in Belfast hospitals”. This included strict adherence to the rules on visiting.

They do not appear to have any published policy on visiting but have a web page that identifies 4 simple rules dated April 4th 2008 ..

• to clean their hands before and after visiting a hospital ward
• not to visit if they feel unwell, have a cold, diarrhoea or vomiting
• not to bring perishable foods in to hospitals
• stick to the visiting times and the numbers of visitors allowed at one time.

The recently introduced restrictions on cameras refelect public hysteria about phtography but also prevent foer example (as has happened) the awkward squad taking pics of

... filthy unwashed floors, faecal smears on toilets, filthy sheets , discarded wound dressings etc.,

There were on census day 29th April 2001 ,1,685,267 people in N. Ireland (curiously females 863,818 significantly outnumbered males 821,449 ) - slightly more than the population of Merseyside..

Why do they need three bodies to organise their healthcare ?

Why can't those three bodies have a single simple staightforward standardised policy with rules and guidelines on visiting ? (Indeed why don't we have national one ?)

Lies, Damned Lies and Medical Statistics

In 1995, the Department of Health issued guidance that gave NHS Trust chief executives overall responsibility for ensuring the provision of effective infection control arrangements.

The Hospital Infection Working Group believed in 1995 that it might have been possible to achieve a 30 per cent reduction in hospital acquired infection.

Nothing very much happened until the National Audt Office reported in February 2000 , (when they were searching to control costs and not disease) - The Management and Control of Hospital Acquired Infection in NHS Acute Trusts in England (HC 230 Session 1999-00). Under the eagle eye and discerning analysis of Sir John Bourn it was noted that at any one time, 9 per cent of patients had an infection that had been acquired during their hospital stay. (Note these were called Hospital Acquired Infections HAI's)

The effects varied from extended length of stay and discomfort to prolonged or permanent disability and death. Based on American experience they calculated that in the England at least 5,000 patients a year, death. These infections were costing the NHS as much as £1 billion a year and around 15 per cent could be prevented by better application of good practice, releasing resources of £150 million for alternative NHS use.

In a a comprehensive study commissioned by the Department of Health and undertaken by the London School of Hygiene and Tropical Medicine and the Central Public Health Laboratory January 2000 and referred to by the NAO it was concluded (see Page 24 of the report) ;
Over the course of a 13 month period, 7.8% of patients acquired an infection during their stay in the study hospital which presented during the in-patient period.

A further 19.1% of patients who did not present with an infection during the in-patient phase, reported symptoms of, and in some cases received treatment for, an infection manifesting post discharge which may be associated with their hospital admission.


Patients with one or more infections incurred costs that were on average 2.8 times greater than uninfected patients, an average additional cost of £2,917 per case (ranging from £1,122 for urinary tract infections to £6,209 for bloodstream infections).


Patients who acquired an infection remained in hospital on average 2.5 times longer than uninfected patients, an average equivalent to 11 extra days.


Patients with a hospital acquired infection were 7.1 times more likely to die in the hospital than uninfected patients (after controlling for patient characteristics such as age, sex, diagnosis, admission speciality and type and pre-exiting illness). The death rate also varied with patient characteristics (for example 38% of elderly care patients who acquired a hospital infection died compared with 8% of elderly patients without a hospital acquired infection who died).


Extrapolating the results of this study to NHS Trusts throughout England, the overall cost to the NHS of hospital acquired infection was £986.36 million comprising £930.62 million hospital costs plus a further £55.74 million costs due to infections which occurred post discharge.

It is therefore both insteresting and instructive that The Health Protection Agency FAQ's on MRSA has this helpful advice ..

Where does the figure of 5000 deaths due to MRSA each year come from?

This figure is incorrect. It comes from a very rough estimate of the number of deaths which may be attributed to all hospital acquired infections (HAI), not just MRSA. The estimate was made in 1995 by a working group of the Public Health Laboratory Health Service. It used an estimate of the percentage of deaths associated with all HAIs made in the USA in the 1980s (1% of all deaths in the USA). This percentage was applied to the total number of deaths occurring in the UK, yielding a crude estimate of 5,000 deaths from HAI.

Fast Forward to today

The National Statistical Office has today published figures for England and Wales for mention of MRSA and Clostridium difficile on death certificates. (See graph at top of post from ONS website)

The 3rd report into the number of death certificates in England and Wales that mentioned
Staphylococcus aureus infection increased each year from 2001 to 2005, from 1,211 to 2,083. The percentage of these deaths where Staphylococcus aureus was specified as meticillin resistant (MRSA) rose from 61 % in 2001 to 78 % in 2005.

The age standardised rates for deaths involving MRSA doubled for both males and females between 2001 and 2005. For men the rate increased from 12.5 to 25.0 per million population, while for women it rose from 6.7 to 14.5 per million population.

The 2nd annual report into the number of death certificates in England and Wales that mentioned Clostridium difficile increased from 1,214 in 2001 to 3,807 in 2005. Between 2004 and 2005 the number of deaths involving C. difficile increased by 69 %.

Age-standardised rates for deaths involving C. difficile among males in England and Wales almost tripled between 2001 and 2005, from 13.1 to 37.6 per million population. Among females, rates more than tripled, from 12.8 per million to 38.9 per million.

The complete statistics can be found in in Health Statistics Quarterly 33 (Spring
2007), published today.

They also point out that "Most of the deaths involving S. aureus or MRSA were in the older age groups. Mortality rates in 2005 for deaths involving MRSA in the 85 and over age group were 702 and 387 deaths per million population for males and females respectively. In the under 45 age group there were 1.1 and 0.8 deaths per million population for males and females respectively."

However the Health Protection Agency's MRSA surveillance units figures for England (Note NOT the UK) , up to November 27th 2006 show

1. There were 51,690 reports of Clostridium difficile disease in people aged 65 years and over in 2005, a 17.2% increase on 2004.

2. A total of 3,517 MRSA bacteraemia episodes was reported during the period October 2005 to March 2006. This marks a small decrease in the number of reports compared to the
beginning of the mandatory surveillance scheme and a 1.5% decrease on the previous six
months.
Pert, pretty , glamorous and gorgeous Dr Georgia Duckworth, of the Health Protection Agency, says "We're on a plateau (?)but there is some evidence that individual hospitals and departments – principally those with the worst rates – are getting better." One might reasonably ask Dr Georgina quite what a plateu is and how it applies to the graph at the head of this article. Perhaps she could be familiarised with the expression "Straws, grasping at?"

So since 1995, when the Department of Health issued guidance that gave NHS Trust chief executives overall responsibility for ensuring the provision of effective infection control arrangements.

Hospital Acquired Infections have increased

Deaths from Hospital Acquired Infections MRSA / CD have increased over all hospital admissions and especially in the elderly - plus 65 age group. (Note no-one has mentioned Multiple Drug Resitant TB (MDRTB) .... Yet)

Commenting on the figures Health Minister Lord Hunt said "... we are now starting to see significant reductions in rates of MRSA infections." ! and ..."We have also provided £50 million funding which will give a cash injection to trusts to boost infection control measures."

One might reasonably ask My Lord Hunt what he means by "significant reductions in rates of MRSA infections" Perhaps he could be familiarised with the expression "Straws, grasping at?" It should be pointed out that My Lord Hunt's NHS career began in 1972 when he joined Oxford Regional Hospital Board as a works study officer. See pic below.


A Useful history of MRSA / HAI and the threat of Multiple Drug resistant TB can be found here

Also a Daily Torygraph article 21st Jan 2007 How have we fallen so far behind in battle to beat MRSA? makes comparisons with other European countries experience and the failure to use a 2 phase policy of testing people admitted to hospital (preventing so called Community Acquired Infections) and isolation until cured used in successfully for many years in Holland.

Perhaps these two routes mught produce faster solution at lower costs than an obession with hand wringing washing and blaming the cleaners .. Lord Patel has for long and often said that of there was a Royal College of Hospital Cleaners you would never have heard of HAI's, MRSA, Clostridium.

Nose swabs and rapid MRSA testing - see New Scientist 6th February 2007 won't solve the problem but they (with 100% isolation facilities) will help.

Clostridium difficile vaccine - development on track that may produce a useable vaccine in at least 3 years time.

Jab to beat superbugs: British vaccine could save thousands of lives a year is the Evening Standard screaming headline today. (and stablemate Daily Mail)

Well up to a point Lord Copper.

On the 18th December Acambis (LSE: ACM), a vaccine development company, who are developing the first (and only) vaccine against Clostridium difficile-associated disease (CDAD) announced that "a number of vaccine formulations that show improved stability profiles compared with material used in previous Phase 1 trials." ...in outside the lab speak that means they were getting better at producing a potential vaccine.


Furthermore they said they would start (initiate) a proof-of-concept trial of its vaccine towards the end of 2008, which will provide data within 12-18 months of commencing the study.

Dr Michael Watson, Acambis' Executive Vice President, Research & Development, said in their press release of that date ;

'C. difficile-associated disease is a major public health problem and Acambis has the only vaccine in development. We have previously shown that this vaccine can achieve seroconversion rates of up to 100% and, with our formulation work now completed, we are focused on getting our vaccine to proof-of-concept as quickly as possible.'

Acambis say that there are at least 360,000 cases of CDAD in the US alone, with estimated annual costs to the US and European healthcare systems totalling more than $5bn

No need to get excited about jabs crushing superbugs, hygienic handwashing, more controls on antiobiotic use, isolation of patients meanwhile might help.

Northern Ireland Clostridium difficile related deaths jump 22% in one year

The bad news is, reports the BBC that Clostridium difficile, was mentioned on the death certificates of 77 people in Northern Ireland last year up 22% ( 14) from 2006 - a province way ahead of the mainland for recording and reporting health statsistics.

30 such deaths were recorded in the last 4 months of 2007 at the following hospitals ;

Altnagelvin - 1
Antrim - 9
Belfast City - 4
Causeway - 1
Craigavon - 2
Robinson Memorial - 1
Royal Victoria - 1
Ulster - 3
Whiteabbey - 5
All others - 3

See previous posts on the outbreak in Northern Ireland here. and it's connection to the emerging and highly virulent ribotype o27 variant.

A spokesman for the Northern Health and Social Care Trust confirmed that it is now dealing with 15 'active' cases of C.Difficile with six of those classified as recovering. This is a drop from the previous week 16active cases and 8 'recovering' - the week before, there were 27 cases in total.

UPDATE Monday 11th Feb BBC - More C. diff deaths in Northern Trust area

On Friday, the Department of Health released interim figures which showed it contributed to 77 deaths last year.

The total has not changed but a breakdown shows C. diff played a part in the deaths of 34 people in the Northern Trust area - nine more than previously said.

Northern Ireland Clostridium difficile deaths and infection continue despite throwing money at it £6 Mn "investment" by McJimpsey

The the Northern Health and Social Care Trust covers Ulster / Northern Ireland. A regional outbreak of patient deaths in which a Clostridium difficile infection has contributed , has continued since last summer.

In total 53 deaths have been attributed to the gut infection , which spreads by faecal contamination , it can be fatal, especially in older patients ( 80% of cases reported are in the over 65-age group) , of these cases , 32 deaths have been recorded since January.

The Trust has just confirmed that there were a further 22 new recorded cases in June with a further 2 deaths in which C. difficile was a contributory factor .

The Northern Trust have undertaken a concerted program of action to contain and eliminate the disease in their hospitals, and the , Health Minister Michael McGimpsey has made available (although he calls it an "investment") of £9m with the very modest aim of reducing MRSA by 10% and C.difficile by 20% by March 2009.

This involves a program of ;

Containment –patients have been nursed in isolation and experience across the country shows that for greater numbers, a dedicated isolation ward leads to greater/speedier reduction as efforts are concentrated in one spot. The Trust designated a ward at Antrim Hospital in January specifically for C. Difficile infected patients. (Standard procedure in Dutch hospitals for decades)

Control use of antibiotics : "Rigorous" reviews and audits of the use of antibiotics. The newer, broad-spectrum antibiotics contribute to the development of infection by eradicating the normal bowel flora and allowing C. Difficile to flourish. To counteract this we have:

- revised the Antibiotic Policies to try to reduce the use of antibiotics associated with C. Difficile;

- audited the prescribing of antibiotics to ensure compliance; and

- informed General Practitioners of the situation and issued revised guidance on the use of antibiotics in the community to them.

Infection control by hand washing , greatly "enhanced" - greatly enhanced environmental dedicated cleaning teams; (i.e doing what they should normally do) plus the replacement of equipment which is not easy to clean.

Hospital visitors to patients with a C difficile infection should wash hands with soap and water before and after visiting their realtive;

- Not bring children , food, or flowers or visit if ill for any reason

- Not not sit on patients beds or touch patient's equipment, and reduce their possession to a minimum - and co-operate with staff.

The US based Committee to reduce Infection Deaths (RID) have a very useful 15 STEPS YOU CAN TAKE TO REDUCE YOUR RISK OF A HOSPITAL INFECTION list which anyone expecting to be hospitalised or has a realtive in or due to go to hospital would should read.

Also read the WSJ article November 27, 2007 Our Unsanitary Hospitals by Betsy McCaughey which promotes the revolutionary idea that food manufacturers, restaurants are tested by outside bodies - why not hospitals ?

Ignaz Semmelweis (b. July 1st 1818 in Buda - 210 years ago ) he said puerperal fever, which killed mothers in childbirth, was spread by dirty doctors. In 1847 he discovered that hand washing with chlorinated lime solutions reduced the incidence of fatal puerperal fever from about 10 percent (range 5-30 percent) to about 1-2 percent. He called them murderers. His contemporraries (and his wife) , quite literally in 1865 had him thrown in a mad house where he died, 14 days later, possibly after being severely beaten by guards. (More)

He is now seen as a pioneer of antiseptic procedures. The stamp above was issued in Austria, 1965, on the 100th anniversary of Semmelweis’ death - although he was strictly a Hungarian . Clever people the Austrians they have convinced the world that Mozart was Austrian and Hitler was a German.

Dying in an NHS Hospital near you - More Customer Choice

On publication of the annual figures for Clostridium difficile infections and associated deaths the headline in the Daily Mirror headline screamed " Superbug scandal: 6,500 killed by C.diff in one year - Minister admits delay as C.diff leaps 72% "

Gobshite and Rentaquote Ben Bradshaw who has some sort of vague connection with the Minister of Health - bag carrier, tea maker , admitted the Government had not done enough in previous years to tackle the bug, caused by dirty wards. He said: "We concentrated rightly on MRSA in the beginning. We may have come to this late."

"But we are taking action now. We are implementing ward-to-board action on this - right from the ward sister up to the boardroom."

"Ward to Board action" worth 'is weight in Gold that lad. Should have been in PR.

Whilst Ministers aren't multi-tasking ,the real world is and as the Daily Telegraph points out today Clostridum ( 72% rise since 2006 10 dead each day) is a single problem amongst many - as figures obtained by Andrew Lansley, the shadow health secretary show.

Currently only 3 infections are required to be reported to the Health Protection Agency - MRSA, Clostridium difficile and antibiotic resistant enterococcal (GRE) bloodstream infections. Other hospital infections reports are voluntary and must understate the levels of infection and attendant problems.

1. Staphylococcus aureus, a potentially fatal infection which in its antibiotic resistant form is known as the superbug MRSA. The infection can cause septicaemia and toxic shock syndrome. It rose 6% from 2002 to 13,648 recorded cases in 2006.

2. Hospital-acquired infections of E.coli, which also has a potentially deadly strain, have risen by 48 %.

3. Klebsiella spp infections have risen by 48 % since 2002, to 5,198 cases. The infection can cause Klebsiella pneumonia, which has a high mortality rate because it tends to target patients with underlying diseases, such as chronic lung problems. This is an HAI which has caused major problems in Israel and Lord Patel posted about this a year ago March 31, 2007
Hospital Acquired Infections - A Bad News Day - when he wrote ..."The emergence of multi-drug resistant Klebsiella will become a global concern just as MRSA's have ,and increasingly Multiple Drug Resistant TB's (MDRTB) have been invading the EU from eastern Europe and Russia whose prisons are a huge and potent resevoir of HIV / TB - the perstent habit of health autorities to conceal the problem from the public only hinders the resolution of the problem.... unless of course the policy is to kill off the old and save on their pension benefits."

4. Streptococcus pneumoniae infections rose by 9% to 4,553 cases. It can cause pneumonia, meningitis and brain abscesses.

5. Coagulase negative staphylococci, which causes bloodstream infections, was up 126 % to 14,943 cases in 2006.

6. Acineobacter baumannii has it's own website somewhat sensational it does appear that this is a major problem with soldiers returning from medical treatment in Gwermany after wounding in Iraq and Afghanistan ....

£50Mn is going to be spent on "deep" cleaning ... so that's all right then. This has nothing to do with reducing the number of beds and runnin gthem at near 100% occupancy,

GP Practice nurses taking the strain..

Ann Keen (Parliamentary Under-Secretary (Health Services), Department of Health) gave some interesting figures on 4th March - GP practice nurses 2001 - 18,389 , 2004 - 19,846 , 2007 23,797 a rise over 6 years of 30%.

If , I refer an asthmatic to Secondary care they see the Respiratory Nurse Specialist.

If, I refer a diabetic to Secondary care they see the Diabetic Nurse Specialist.

If, I refer someone with Multiple Sclerosis to Secondary care they see the Multiple Sclerosis Nurse Specialist.

If, I refer an epileptic to Secondary care they see the Epilepsy Nurse Specialist.

If, I refer a prostate problem to Secondary Care they see the Prostate Assessment Nurse Specialist

If, I refer an person with crippling osteoarthritis to Secondary Care they see a Physiotherapist

If, I refer a schizophrenic to Secondary care they see the Community Mental Health team.

If, any of these people have a knowledge-base greater than my own I will eat Lord Darzi's (rarely dirty) surgical scrubs.

If from Dr Rant ... always worth reading but NOT before you visit any establishment run by the NHS.