High profile outbreaks inform new guidance

In the introduction to the new guidance document, which examines the latest thinking on preventing Clostridium difficile and managing outbreaks from an evidencebased perspective, chief medical officer Sir Liam Donaldson, chief nursing officer Dame Christine Beasley, and Health Protection Agency CEO Justin McCracken, concede that, while the NHS is “working hard” to tackle healthcare-associated infections (HAIs), “they still present the service with a great challenge”. On a positive note, the document concludes that the “promising decrease” in the number of C. difficile infections (from April-June 2008 the NHS saw cases fall overall by 35% compared with the same quarter in 2007, while in the three months from July-September, 2008, case numbers were down on a similar quarter-to-quarter basis by 33%) is largely attributable to the “recent significant activity and focus” on the management and control of C. difficile infections. Nevertheless, with the risk of outbreaks still ever-present, the DH and HPA say they have received requests for advice on the most effective methods and prevention and the management of outbreaks. The result – the latest guidance – supersedes that given in 1994 in the DH and Public Health Laboratory Service paper, Clostridium difficile Infection: Prevention and Management.

Time for a review
Although the Department of Health says the basic premises of the prevention and control strategy for C. difficile set out in the 1994 guidance “remain appropriate in general terms”, policymakers felt it was clear the guidance should be reviewed “in the light of experience and evidence over the last decade and re-cast in a style that reflects the modern NHS”. The latest guidance, compiled by a working group established by the HPA’s Steering Group on Healthcare-Associated Infection at the DH’s request, also takes into account a national framework for clinical governance which did not previously exist – “a framework that gives significant weight to infection control as a matter of patient safety and highlights that all clinicians have a personal responsibility for infection prevention and control”.

Basis of the guidance
The guidance draws on the Healthcare Commission reports into the C. difficile outbreaks at Stoke Mandeville Hospital, the University Hopsitals of Leicester NHS Trust, and the Maidstone and Tunbridge Wells NHS Trust, and the joint HCC/HPA review (Health Protection Agency 2006). With the latter concluding that the 1994 guidelines “may not have been sufficiently prescriptive in their requirements to implement verified prevention and control practices”, the guidance builds on the earlier recommendations and “develops these guided by the three principles”:
 • C. difficile should be “managed as a diagnosis in its own right” (Healthcare Commission, 2007).
 • “The safety of patients cannot be compromised”, and is “at the centre of everything we do”. It thus “cannot be compromised by other strategic or financial objectives” (Commission for Healthcare Audit and Inspection, 2006; Healthcare Commission, 2007).
• Infection control, including Clostridium difficile infection, is “everybody’s business”. (Committee on Public Accounts, 2000; Healthcare Commission, 2007). It requires not only a “board to ward” approach in the hospital, but equally active engagement of primary care Trusts, health protection units, and strategic health authorities. The Operating Framework for the NHS in England 2008/2009 (Department of Health, 2008/09), and the Health Act 2006; Code of Practice for the prevention and control of healthcare-associated infections (Department of Health, 2008) also make clear that the DH “expects the NHS to implement effective infection prevention and control polices and procedures from board to ward”.