Policy responses and statements

Name of organisation:

Health Protection Agency

Name of policy document:

Clostridium difficile infection: how to deal with the problem – a board to ward approach

Deadline for response:

23 April 2008

Background: In the light of the increase in reported cases of Clostridium difficile infection (CDI) in the UK among patients of all ages, there was a need to update the working group report on prevention and management of CDI produced by the Department of Health (DH) and Public Health Laboratory Service (PHLS) in 1994. The DH approached the Health Protection Agency (HPA) Steering Group on Healthcare Associated Infections (SG HCAI ) in November 2006 to form a working group to comprehensively revise the report on CDI prevention and management.

The revised guidelines are based on a comprehensive review of the literature and expert opinion and identify best practice and key recommendations for the NHS to ensure the control of CDI.

This public consultation aimed to gather and take into account the views of partners, stakeholders, members of the public and other interested parties. Respondents were invited to make general comments on the document/comment on the recommendations for the management of C.difficile

COMMENTS ON
HEALTH PROTECTION AGENCY
CLOSTRIDIUM DIFFICILE INFECTION - HOW TO DEAL WITH THE PROBLEM – A BOARD TO WARD APPROACH

The Royal College of Physicians of Edinburgh is pleased to respond to this HPA document on following receipt of comments from interested Fellows.

Firstly, we note that this document is produced by the Health Protection Agency and is therefore both written and immediately applicable to the Department of Health in England and Wales.  However, we feel strongly that the content is equally relevant to other parts of the UK and this should be recognised by the Scottish and Northern Ireland Authorities.  In passing, we would also comment that in Scotland, the new Scot Marap (Scottish Anti-microbial Prescribing Group) is now in place, analogous to the AMT’s envisaged in this report.

It also a somewhat sad reflection that the essential recommendations of this report are the same as those published in 1994.  One must therefore question why this should be.  Several reasons for this are discussed on pages 6 and 7.  However, we consider that there are two other major causes which are not acknowledged or given insufficient prominence in the draft report.  Firstly, both the original recommendation and now those in this report do not discuss the very considerable financial and resource implications of their implementation (e.g. AMT’s, link Physicians, 7 day laboratory facilities, isolation facilities, multi disciplinary panel review teams); there will be both financial and protected time costs to execute properly the key recommendations.  Secondly, little acknowledgement is given to the very real pressure exerted upon Trusts to achieve DH targets which on occasions have profoundly influenced NHS managers in assessing the balance between patient throughput and quality of care. Whilst this latter is acknowledged in the extended report, it is buried within the plethora of detail, appearing as one paragraph (6.5, page 74) even though this was one of the clearest messages to come out of the reports on the Stoke Mandeville and Maidstone outbreaks.  We feel that much of the value of this report to deliver a very important message will lose credence if these two major problems are not acknowledged prominently and early within the report.  It is suggested that they are discussed at the end of page 7 and also included as a key recommendation.  A realistic assessment of the financial and resource implications of all recommendations should also be included. 

Aside from these two major reservations we find much to commend.  In particular, the SIGHT mnemonic should prove useful and widely applicable.  The treatment algorithms are clear and sensible and section 3 in both reports is most useful, particularly where other potential treatment modalities are assessed, but Appendix 4 could be included in this section.  As always, the length of document remains a problem.  The extended report is long and well referenced and this is probably justified for a reference document.  However, it will be difficult to ensure that a core document of 27 pages in length will reach all of the projected audience to achieve the desired effect.  A two page summary with the treatment algorithm and headed by the SIGHT mnemonic could be posted prominently in all relevant clinical areas.

The working group had little clinical representation.  It is therefore important that there is strong support from the clinicians and significant backing from the Royal Colleges, their Fellows and Members.  If the policy is perceived just as an imposition by health care management as a reaction to the current situation, it is likely to be received less favourably.

We feel that the aspiration to prevent as much CDI as possible is reasonable but would caution against suggesting that the measures described here will result in complete prevention and we feel that to state this would be unwise.  We note that measurements of compliance may be difficult and suggest that quality improvement methodology using the care bundle developed by HPS may prove a useful tool. 

Specific comments relating to the report are as follows:

1. Some respondents regret that STROBE methodology was not employed as it was felt that this would have added to the value of the report.

2. At the bottom of page 9:  Surely Health Care Managers as well as individual doctors and nurses must share the responsibility?

3. Page 11-13:  Key Recommendations - the word Trust should be further defined. Presumably for paragraph 3 and 9 this should read: ‘Hospital Trusts’ and for paragraphs 5 and 10: ‘Hospital Trusts and PCT’s’.  Specifically, it needs to be recognised that there are major implications both financial and staffing in ensuring that isolation capacity matches demand.  The evidence base for using cohort wards as an alternative is not robust.  Because alcohol gel is not effective in also eradicating CDI, the requirement to return to soap and water hand cleansing will highlight the significant under provision of hand washing facilities in many hospitals.

   Key recommendation 3 – the capital investment and staffing resource of this recommendation are considerable.  A simple measure of cost would be helpful.

   Key recommendation 5 – we feel this recommendation should be balanced against published evidence that sepsis in the elderly is becoming both more common and serious.  We would not wish to reduce antibiotic treatment rates of complication at the expense of inhibiting appropriate antibiotic management for severely ill patients.

   Key recommendation 6 – it is suggested that responsibility should rest firmly at Trust Board level (either DPH or Medical Director).

   Key recommendation 7 – not only consultants but all doctors and practitioners should be held responsible; general practitioners also prescribe antibiotics and should not be excluded.

4. Paragraph 1.1, page 14: presumably this should read “… such as more than one episode” to fit with text elsewhere.  Definition of an outbreak is welcomed. 

5. Page 15, Paragraph 1.4 – the authors should provide more specific recommendations.

6. Page 18, paragraph, 3.6: (iii) <20,000 should be replaced by >.  In respect of sections (iv) and (v) perhaps ‘complicated’ and ‘life-threatening’ disease should be combined and their treatment unified.  This would apply also to the algorithm.

7. Page 19, paragraph 3.8: ‘Post-infectious non-specific causes’ would be more recognisable to clinicians as post-infective IBS and some would feel that a bulking agent such as Fybogel, would be as effective as an anti diarrhoeal – particularly with the latter’s potential to precipitate ileus/mega colon.

8. Page 21, paragraph 4.8:  We suggest that specific training is also provided at under graduate level.  Perhaps the simplest way for post-registration training to be provided would be to include it within PMET B training curricula.

9. Page 23: might be improved by emphasis at some point of the desirability of minimising transfers between wards.  We feel that this should apply generally and not just to CDI patients (see paragraph 8.6). 

   We are unaware of evidence for the absent risk of cross-infection during ambulance transport.

10. Page 27, paragraph 9.2:  We were unsure as to why the reason for the first sentence, it seems important to have this information.

11. Page 28, paragraph 9.10:  This should either be elaborated at this point or referred to in the extended report.

    Paragraph 9.11:  Some respondents were unhappy that this would be defensible.

12. Page 41:  We strongly support research recommendation 1.22.

13. Clinicians found section 3 (page 49 and following) particularly helpful.  No references are cited for high dose Vancomycin regimens, use of intravenous preparations of Vancomycin or tapered/pulse dose therapy.  The report is rather dismissive of probiotic therapy but recommends IV immunoglobulin, contradicting other guidance (e.g. produced by the British Infection Society) on the use of this potentially dangerous product. See above for other relevant comments.

14. Page 59, paragraph 4.2:  It is suggested that the naming of particular agents in this section would be less helpful than leaving the decision on antibiotic policy to the individual AMT and collaboration with their clinical colleagues.  This is primarily because there is limited evidence to suggest that any agents should be avoided altogether.

15. Page 64, paragraph 4.20 and following: there is unanimous support for the development of AMT’s (already suggested in Scotland under the Scot Marap scheme).  Some concern was expressed over the practicality of the AMT undertaking ward rounds in all areas where antibiotics are prescribed and an acceptable alternative suggested was for targeted ward rounds, audit and education as providing a better use of the team’s skills; this could be combined with the identification of senior clinical staff as a link person. Ward pharmacists are also seen as an important development and it was felt that this could be highlighted more forcefully.

16. Sections 7 and 10 were considered particularly helpful.

17. Page 95, section 11.6:  We feel this supports our general comment in respect of protected time and resources.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[23 April 2008]