European Antibiotic Awareness Day - Redux - educating qualified doctors about antibiotic resistance

18th November 2008 was the first-ever European Antibiotic Awareness Day, and was apparently celebrated throughout the 27 EU Member States. (website)

The intention was for public health authorities in all Member States to raise awareness (ie spend a lot of money on a publicity campaign) to highlight the need for "rational" use of antibiotics.After all the official website claims " The inappropriate use of antibiotics has become a serious threat to public health in
Europe."

In the UK - where (unlike many EU countries, antibiotics are only available on prescription ) the Department of Health’s Advisory Committee for Antibiotic Resistance and Healthcare Associated Infection (ARHAI) organised a national conference (Chairman Professor Roger Finch Professor of Infectious Diseases at the University of Nottingham and Consultant to the Nottingham University Hospitals NHS Trust + 18 members ) . This was aimed at health science journalists and health professionals in a one day event at the Science Museum, South Kensington, London.

Amazingly, in their literature they claim that inthe UK .."Most patients are prescribed antibiotics without the doctor knowing the cause of the infection." and that ...."Antibiotics are commonly prescribed for respiratory infections when most of these are caused by viruses not bacteria."

If this is the state of education of General Practioners and truly reflects normal practice then we DO have a problem. Surely this cannot be correct ?

Anyway quietly they are having another go.

Professor Brian Duerden CBE, Inspector of Microbiology and Infection Control; Dr Keith Ridge, Chief Pharmaceutical Officer with Dr Ridge Chief Pharmaceutical officer , wrote to his colleagues on February 20th to raise awareness to that antibiotics don’t work on colds, most coughs or sore throats. His letter is here (PDF) and if a Doctor can order leaflets online here and simple Guide to Clostridium and MRSA infections.

So that is why the Daily Telegraph had an NHS ad promoting Antibiotic Awareness Day yesterday. Here is a European logo - anyone who can explain the signficance of the hedgehog is welcome to explain - we thought they were currently hibernating.

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.

UK NHS national policy on circumcision - rite or wrong ?

4 More News last night had a fascinating piece about male circumcision in the UK .NHS Direct (in page Last updated on 27 November 2007 ) says "In the UK, circumcision is only carried out on the NHS in cases where it is medically necessary. It is usually performed as a last resort when other types of treatment have been unsuccessful." Some fascinating pictures of the whole process here.

The policy is extremely clear ..."In England, ritual circumcisions are not carried out by the NHS. Primary Care Trusts (PCT) only perform circumcisions for medical reasons, as recommended by The British Medical Association (BMA).(There is no discussion on NHS Direct on female circumcision)

Which is clear enough .. quite where when and how this universal policy was established is a little unlcear - in the 40's and 50's circumcision of boys ran at about 30%. It is now recognised as medically unecessary - unlike for example in the US where male circumcision is prevalent.

In March 2007 the Center for Disease Control and Prevention stated that a National Health and Social Life Survey in 1992 revealed that 77% of men reported being circumcised including 81% of white men, 65% of black men, and 54% of Hispanic men. Since 1999, 16 states have eliminated Medicaid payments for circumcisions that were not deemed medically necessary. In 2006, two states—Hawaii and Vermont—introduced resolutions questioning the need for public funding of male circumcision. More here and here and the CDC have a current fact sheet here including discussion on HIV transmission in vaginal sex by circumcised / non-circumcised men.

Since 1975, the American Academy of Pediatrics' position on circumcision is that "there is no absolute medical indication for routine circumcision of the newborn." a position now supported the American College of Obstetricians and Gynecologists. Many groups both in the US and the UK regard the operation as a form of sexual assault on children.

4 More News has however discovered however that some Health Trust in areas with high levels of Muslims in the local population are now providing circumcisions free where it was undertaken simply for religious or "cultural" reasons.

The reasons and authority for the local change in a national policy are unclear, but the practice is defended ( and was defended by an embarassed NHS manager on the program) , as the refusal to perform the operation without requiring payment, would lead to "back street" circumcisions which might result in injury, disease and complications requiring orthodox medical treatment and NHS intervention .

We have just unearthed the bizarre finding (More Clostridium difficile deaths and infections in Northern Ireland but outbreak over (?) )that there is no national UK policy on rules for hospital visitors .Despite 8 years spent focussing on Hospital Acquired Infections, which unlike the choice for circumcision YES/NO ,is actually killing some 20,000 people a year. Every year.

Perhaps 4MoreNews ,this might have a slightly higher priority for further investigation.

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 ?)

Baron Mogg of East Park and OFGEM Chairman forced to retire

The Office for National Statistics , now more accurately and carefully collected , show recorded deaths in Sussex as a result of Clostridium difficile - 214 people died in 2007/8 up a staggering 49% from, 140 in the previous year.

(See Health Protection Agency (HPA) re Guidelines for interpreting these accelerated publication figures) C. difficile was mentioned on 8,324 death certificates last year in t5he UK compared with 6,480 in 2006 and 3,757 in 2005 – an increase of 28% in the last year alone. That is 670 preventable deaths per month - 2 full Jumbo jets crashing or 2.5 times the deaths on UK roads.

Brighton's prestigious Royal Sussex County Hospital hit the couuntry's Top Ten with 79 deaths in 2007/8 ,up 84% on the 34 deaths in 2006/7. They show on their website that the MRSA infection rate is 3.51 infections for every 10,000 bed days

Chichester's St Richard's Hospital saw deaths rise 200% from from 19 to 57 and Haywards Heath , Princess Royal Hospital deaths rose from 50% 9 to 14. They cover 210,000 patients with double the national average of people over the age of 65 (24%) and those over 80 years (8%).

Eastbourne District General Hospital (14 deaths both years) and Southlands Hospital in Shoreham (7 deaths both years) were unchanged. Consult private Care charges at Eastbourne General here . The Warren Browne Sexual care Clinic at Southlands sees around 9,000 patients a year and has recently extended it's openings to weekends to cope with local requirments.

Worthing Hospital (32 down to 22) and Conquest Hospital in St Leonards (25 down to 21) saw modest declines. where deaths fell from 25 to 21. Worthing's Mayor will open the refurbished £360,000 (with £50,000 from the League of friends.) High Dependency Unit tomorrow

The HPA summary says that nationally there was a 9% decrease in reported infections o Clostridium difficile in 2007 compared to 2006, with a decrease in rate from 2.5 to 2.3 cases per 1000 bed days. A rule of thumb currently applied in the UK is that about 1 in 10 of over 65's with C diff infection dies.

The recently ennobled Brighton resident Baron Mogg of East Park, OAP , is now swelling the ranks of the over 65's on the South Coast. He has been the worthless (but very highly paid) Chairman for years and years of the toothless, useless OFgem (Protecting energy consumer interests). Let's hope he will have no need of any of these facilities when his forced retirement is announced at the same time as the OFgem "urgent" report/ review into the rapacious and out of control UK energy industry is introduced shortly. "

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.”

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.

New soap dispenser to help in battle against Clostridium difficile infections

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.

"Failed top brass in the NHS are on a jobs merry-go-round at taxpayers' expense"

Barry Monk brings our attention to the happy circumstance that Ruth Harrison landed a £52,000 short-term contract which started in December 2007 to head a review into maternity and children's services at Epsom and St Helier Hospital in Surrey - a review which it is feared will lead to ward closures.

Ruth Harrison was the £130,000 p.a. Chief Executive of Stoke Mandeville Hospital, Bucks, who was paid off in 2006 with a £140,000 golden goodbye - she left the trust to do an MSc at London University.

This was the day before a damning report was published, citing serious faults in her leadership.

Under her tenure 33 patients died and 334 became seriously ill with the highly infectious stomach bug Clostridium difficile.

The Healthcare Commission, which carried out the investigation into the outbreak between October 2003 and June 2005, said the trust "compromised the safety of patients by failing to make the right decisions" and that it "rejected the proper advice of their own experts". Last Updated: Thursday, 15 November 2007, 10:24 GMT

The Health and Safety Executive ruled there was not enough admissible evidence to prosecute Stoke Mandeville Hospital bosses in Buckinghamshire.

Sandra Caldwell, HSE director of field operations said they launched the investigation into Stoke Mandeville because there was the possibility that serious criminal offences had been committed.

She added: "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."

Its report said: "The Healthcare Commission considers there were significant failings on the part of the leadership at the trust and has recommended that the leadership change."

Apparently there is some disquiet among patient rights campaigners at Epsom and St Helier Hospital . Geoff Martin, from campaign group Health Emergency, called on the trust to halt plans to bring in Ms Harrison, adding that the move was "a disgrace".

He said: "Failed top brass in the NHS are on a jobs merry-go-round at taxpayers' expense, where they can jump from one highly-paid post to the next, regardless of the wreckage they have left behind."

This has lead to the announcement in the Health Service Journal today to her "stepping down" from the position.

"She made the decision after all the press interest," said an Epsom and St Helier spokesman. "She was concerned her involvement would be a distraction."

Ms Harrison will be replaced by fellow Durrow employee Nick Relph, former chief executive of Thames Valley strategic health authority.

Andy Black has a curious self serving Press Release at the Durrow website....who have a very impressive client list of hospitals no doubt they obtained a large take up on their New Year study tour in Miami this year.

Dying in Hospital - Adverse Drug Events in UK Hospitals - Controlling costs to control disease

Colin Norris, 32, a nasty arrogant staff nurse murdered four elderly patients with lethal injections of insulin at Leeds General Infirmary and St James's Hospital in Leeds ("Jimmy's" of TV fame) hospitals and has been given a 20 year sentence.

Dying in hospital is not an unusual event. It is a fate we all fear.

Dying or illness induced by the maladministration of medicines in a UK is not at all unusual. You don't need to meet a Colin Norris or a Beverley Allitt to die from an adverse drug event - events which have to be recorded by statute.

1 in 10 patents entering NHS hospitals will experience an “adverse event”, and 1 in a 100 will die as a consequence wrote the Editor of the British Medical Journal 0n the 8th April 2004.

Nothing has changed since then. Which is the reason that people like Norris - and don't think he is unique - can thrive in the NHS culture.

The unwillingness of the medical establishment, consultants, doctors, nursing staff, pharma companies and the NHS managing bodies, trusts and their elected and un-elected representatives to examine this dark secret within the health services is understandable, if regrettable.

Complacency and inertia well dosed with a wish to leave the washing of the medical profession's laundry in private is a powerful force.

It is even more regrettable that it is only after 60 years of the National and “free at the point of delivery” Health Service (NHS), which was apparently, until recently, “the envy of the world” are the “adverse” effects of hospital treatment being identified and studied.

Especially since Ivan Illych in the early 1970's in his book Medical Nemesis alerted the world to the problems of iatrogenic illness, that is, illness caused by medical treatment. In the UK efforts to quantify and cost these effects in monetary and wasted use of staff, time and resources. Only now are we shuffling towards framing sensible, rational plans to deal with these skeletons in the medical cupboard. Unlike say, the Netherlands where constant monitoring, high levels of isolation of affected patients and rigorous controls have almost completely removed the problem from hospital wards of Hospital Acquired Infections (HAI). A lesson we persist in refusing to learn.

Medical mistakes, misdemeanours, misunderstandings and resulting confusions and cockups are an apparently irredeemable consequence of organisations such as the NHS, the biggest employer in Europe. Plenty of studies on both sides of the Atlantic have shown the varying extent of dishonesty, incompetence and plain stupidity, the costs of which, both in health and money are exacerbated by the introduction of the legal process.

This has led to excessive litigation, overpaid greedy lawyers, fed and funded by obtuse thick skinned and bone headed bureaucrats unwilling to accept the realities of the world, anxious to both conceal and cover-up their organisation's mistakes and errors. Their medical colleagues meanwhile have continued to peddle the popular myths of modern medical practice with it's much publicized store of hi-tech wizardry, golden bullets and glamorous “brilliant” surgeons, fresh from their glitzy tours of the TV studios.

Staphylococcus infections, have been present for decades in UK hospitals, they frequently accelerated death for patients with terminal conditions, and consequently obtained the medically neutral and apparently benevolent description as “the old man's friend”. The problem was trivialised and ignored, a factor affected by changes in hospital management more anxious to control costs than disease. Resistant Staphylococcal aureus strains emerged (MRSA).

Strains appeared in hospitals world wide, often resulting from the use of massive doses of antibiotics, to control wound infections, increasingly because of the use of novel and extensive invasive surgical procedures, especially organ transplants, bio-mechanical implants and more recently the widespread use of very much improved dialysis methods as well as unnecessary catheterization of incontinent patients to relieve nursing care, reduce bed changes and control costs. There is broad agreement that 50,000 patients are affected each year in the UK with 5,000 deaths in hospital (at least) from HAI (not including deaths after discharge which are unknown but must occur).

To MRSA and the more recent epidemic of Clostridium difficile must now be added Multiple Drug Resistant TB (MDRTB) of which there have been (to date) a few isolated outbreaks and deaths which will increase due to in an increase hospitalised HIV / TB patients, especially of infected immigrants from Africa and increasingly Eastern Europe and the new EU states such as Estonia and Slovakia. There is reason to believe that MDRTB is where MRSA was 20/30 years ago – therefore effective prompt action is essential. Care costs for a single patient of MDRTB can be in the hundreds of thousands of pounds and an outbreak in millions.

A DRUGS DOWNER IN LIVERPOOL

Dr Munir Pirmohamed and colleagues in Liverpool reported in 2004 the consequences of admitting patients suffering from adverse drug reactions (ADR) in 2 Liverpool hospitals (BMJ Vol 329 3.7.04. p. 15-19). They studied 18,820 patients admitted over a 6 month period in 2001 over 16 years old, excluding all patients with deliberate or intentional overdosing and women with obstetric or gynaecological problems, a total of 1225 admissions.

This was the largest such study undertaken in the UK and showed that ;

Up to 6.5% of all admissions were related to ADRs, with a median age of 76 yrs compared with 66 yrs for all admissions and with a slight bias to females.

The median bed stay was 8 days or 4% of theoretical bed capacity (equivalent nationally, to seven 800 bed hospitals) involving, at average bed costs of £228 per day an annualised cost to the NHS of £466 Million.

1. 72% of the ADRs were by their definitions “avoidable”.
2. 2.3% of ADR patients died as a direct result of the ADR = 0.15% of all admissions, (broadly equivalent to reports of US experience.)
3. An annualised UK assessment indicates 5700 deaths of the 3.8 million acute hospital admissions per year. If ADRs subsequent to admission are added, this could indicate a total greater than 10,000 deaths per year. The authors indicate that deaths resulting from ADRs not admitted to hospital in primary care are probably equivalent in number. A possible total of 30,000 deaths per year in the UK.

The drugs responsible are in common and widespread use and are mainly basic drugs that have been in use a long time in general practice for many common conditions and include analgesics like aspirin and Non Steroidal Anti Inflammatory Drugs (NSAIDs) like diclofenac, diuretics, steroids such as prednisolene and blood thinning warfarin. Adverse effects may result from single use or in combination.

Besides the unsurprising call for more research, the authors conclude that it is incumbent on primary care prescribers to use the lowest dose necessary to achieve results, they identify evidence from others, that deaths related to aspirin (the cause of most problems and deaths of ADRs in the study, directly and in association with other drugs) could be reduced by 30% with a standard low dose of 75mg.

Funded by the Medicines and Healthcare Products Regulatory Agency (MHRA formerly Medicines Control Agency) the study highlights the needs for urgent action to reduce the burden on the NHS (presumably in money, wasted resource, and opportunity cost, and customer satisfaction), not to mention the anguish to patients and their families of illness, hospitalization and death. It is very good news that several of the authors sit on bodies and authorities who can pursue more research and effectively ensure that the necessary and urgent action is taken. Let us not forget that the initial report quantifying the costs of HAI from the NAO was published over 9 years ago.

What would be nice to report is that the pharmaceutical industry, to which antibiotics represent 2% of worldwide sales has produced a new antibiotic. It is 25 years since any antibiotic has been produced and there is not, nor is there any imminent possibility that a new and unexplored chink has been found in the biochemical pathways and metabolic systems of the major pathogens. These communicable diseases, TB, cholera, typhoid, malaria are now only ravaging the third world, which are set to increase with population growth and with increasing low cost international travel, legal and illegal immigration and the exodus of refugees from wars for resources.

Meanwhile the pharmaceutical giants are desperately seeking a new disease, called female sexual dysfunction, so they can double the market overnight for the lifestyle drug , sildenafyl citrate (Viagra / Cialis etc.,). The results so far, are disappointing. The lady really does have a headache. Lets hope she doesn't OD on the aspirin and end up as one more of the NHS ADRs and ends up boosting Dr Pirmohamed's revealing and alarming statistics.

See an earlier US study Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs. Research in Action, Issue 1. AHRQ Publication Number 01-0020, March 2001. Agency for Healthcare Research and Quality, Rockville, MD.

"Over 770,000 people are injured or die each year in hospitals from adverse drug events (ADEs),1-3 which may cost up to $5.6 million each year per hospital4,5 depending on hospital size. This estimate does not include ADEs causing admissions, malpractice and litigation costs, or the costs of injuries to patients. National hospital expenses to treat patients who suffer ADEs during hospitalization are estimated at between $1.56 and $5.6 billion annually.4-7."

Note also ESF-UB Conference in Biomedicine Pharmacogenetics and Pharmacogenomics:
Adverse Drug Reactions - Hotel Eden Roc, Sant Feliu de Guixols ,Spain - 27 June – 2 July 2008
Chair: Munir Pirmohamed, University of Liverpool, UK
See Program here "Adverse drug reactions are a major problem for healthcare services, the pharmaceutical industry and regulators. This has been highlighted recently with some high-profile drug withdrawals and regulatory decisions." One thinks of Vioxx....

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.

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.

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.

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.

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 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

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.