Date Published: 27 August 2005

UK Department of Health publishes data about clostridium difficile and glycopeptide resistant enterococci

The Department of Health and the Health Protection Agency (HPA) have published the results of the first ever mandatory surveillance schemes for Clostridium difficile associated diarrhoea and glycopeptide resistant enterococci (GRE) bacteraemias on Friday 26th August 2005.

Chief Nursing Officer, Christine Beasley, said:

" Clostridium difficile diarrhoea occurs in patients who have received broad spectrum antibiotics, particularly the elderly and debilitated, but most patients make a full recovery.
_ We have seen a rise in cases over the past decade, some of which is due to better reporting, but much of which is due to the increased number of patients with serious underlying illness who need antibiotics.
_ We added Clostridium difficile and glycopeptide resistant enterococci to the mandatory surveillance system to help the NHS establish the scale of the problem, and provide information to help improve infection control.
_ We have issued guidance on dealing with outbreaks, with advice on antibiotic policies and isolating patients - this is being reviewed and Clostridium difficile will now be included in Saving lives: a delivery programme to reduce healthcare associated infections including MRSA."

The data shows 44,488 cases of Clostridium difficile associated diarrhoea were reported in England between January and December 2004. For glycopeptide resistant enterococci, a total of 620 cases were reported for the year ending September 2004.

Summary facts about Clostridium Difficile

What is Clostridium difficile ?

Clostridium difficile is the major cause of antibiotic-associated diarrhoea and colitis, a healthcare associated intestinal infection that mostly affects elderly patients with other underlying diseases.

Its usual habitat is the large intestine, where there is very little oxygen. It can be found in low numbers in a small proportion (less than 5%) of the healthy adult population. It is kept in check by the normal, 'good' bacterial population of the intestine.

Although C. difficile was first described in the 1930s, it was not identified as the cause of diarrhoea and colitis following antibiotic therapy until the late 1970s.

What does it cause ?

C. difficile can cause diarrhoea, ranging from a mild disturbance to a very severe illness with ulceration and bleeding from the colon (colitis) and, at worst, perforation of the intestine leading to peritonitis. Generally, it is only able to do this when the normal, healthy intestinal bacteria have been killed off by antibiotics. When not held back by the normal bacteria, it multiplies in the intestine and produces two toxins (A and B) that damage the cells lining the intestine. The result is diarrhoea.

Do patients recover from C. difficile infection ?

Most cases of C.difficile diarrhoea make a full recovery. However, elderly patients with other underlying conditions may have a more severe course. Occasionally, infection in these circumstances may be life threatening.

Who gets C. difficile infection ?

Patients who have been treated with broad spectrum antibiotics (those that affect a wide range of bacteria, including intestinal bacteria) are at greatest risk of C. difficile disease. Most of those affected are elderly patients with serious underlying illnesses. Most infections occur in hospitals (including community hospitals), nursing homes etc, but it can also occur in primary care settings.

This infection will not affect the majority of people as this bacterium lives in the bowel. It only becomes a problem when the natural flora in the gut is unbalanced by antibiotic treatment.

How does it spread ?

Although some people can be healthy carriers of C. difficile, in most cases the disease develops after cross infection from another patient, either through direct patient to patient contact, via healthcare staff, or via a contaminated environment. A patient who has C. difficile diarrhoea excretes large numbers of the spores in their liquid faeces. These can contaminate the general environment around the patient's bed (including surfaces, keypads, equipment), the toilet areas, sluices, commodes, bed pan washers, etc. They can survive for a long time and be a source of hand-to-mouth infection for others. If these others have also been given antibiotics, they are at risk of C. difficile disease.

Prevention and control

Expert guidance issued by the Department of Health includes advice on antibiotic policies and isolating patients.

There are three important components to the prevention and control of C. difficile disease:

• Prudent antibiotic prescribing to reduce the use of broad spectrum antibiotics
• Isolation of patients with C. difficile diarrhoea and good infection control nursing eg; handwashing (not relying solely on alcohol gel as this does not kill all the spores); wearing gloves and aprons, especially when dealing with bed pans etc .
• Enhanced environmental cleaning and use of a chlorine containing disinfectant where there are cases of C. difficile disease to reduce environmental contamination with the spores.

How is it diagnosed ?

A sample of diarrhoeal faeces is tested for the presence of the C. difficile toxins. This is the main diagnostic test and gives a result within a few hours. In outbreaks, or for surveillance of the different strains circulating in the population, C. difficile can be cultured from faeces and the isolates sent to the Anaerobe Reference Laboratory (National Public Health Service, Wales; Microbiology, Cardiff) for typing and testing.

How common is it ?

When C. difficile was first recognised to cause antibiotic-associated diarrhoea and colitis in the late 1970s, laboratory diagnosis was difficult and the number of cases was not monitored. Since 1990 laboratories have reported the number of cases diagnosed to the Health Protection Agency in a voluntary system. The number of reports increased from less than 1,000 in the early 1990s to 28,000 in 2002, 35,000 in 2003 and 43,000 in 2004. Some of this was due to improved diagnostic tests and improved reporting by laboratories, but there has clearly been an increase in the number of cases. Since January 2004, C. difficile has been part of the mandatory surveillance programme for healthcare associated infections

How can it be treated ?

Standard treatment regimens involve the use of one of two antibiotics, metronidazole or oral vancomycin. Other treatments may be tried, including pro-biotic (good bacteria) treatments, with the aim of re-establishing the balance of flora in the gut.

Is this another hospital 'superbug' ?

The term 'superbug' usually refers to bacteria that have acquired drug resistance and are hence more difficult to treat because the treatment options are limited. Specific antibiotic resistance is not generally a problem for C. difficile

What is type 027 and why is it of concern ?

Type 027 produces much more of the toxins than most other types because a mutation has knocked out the gene that normally restricts toxin production. It causes a greater proportion of severe disease and appears to have a higher mortality. It also seems to be very capable of spreading between patients.

The typing system analyses part of the C. difficile DNA (chromosome) in a test called ribotyping. Over 100 types have been identified. Type 027 was rare in the UK; the first isolate was identified in 1999 and the second in 2002. Individual isolates were identified in 2003-05. When outbreaks at Stoke Mandeville and the Royal Devon and Exeter Hospitals were investigated in 2004-05, Type 027 was found to predominate in their cases. The same type has caused a large outbreak of severe disease in hospitals in Canada (Quebec) and North-eastern USA since 2000.

The mandatory reporting also includes a structured sampling programme in which all laboratories save toxin-positive stool samples obtained from any age group for a week each year in rotation; C. difficile is cultured at the Regional HPA laboratory and the isolates are sent to the Anaerobe Reference Laboratory (Cardiff) for typing to detect changes in strain epidemiology. In addition, hospitals noticing an increase in the severity of disease associated with C difficile will send samples to Cardiff for testing.

What are glycopeptide-resistant enterococci ?

Glycopeptide-Resistant Enterococci (GRE) are bacteria that are resistant to glycopeptide antibiotics (vancomycin and teicoplanin). GRE were first detected in the United Kingdom (UK )in 1986 and have subsequently been found in many other countries. GRE are sometimes also referred to as VRE (Vancomycin-Resistant Enterococci).

GRE can cause wound infections, occasionally bacteraemia (blood poisoning) and infections of the abdomen and pelvis. GRE may also occasionally cause infections in the bile duct (cholangitis), heart valves (endocarditis) and the urinary tract.

GRE are not particularly virulent bacteria, but they are difficult to treat because of limitations in the range of antibiotics which are effective against them. Antibiotics linezolid and synercid are usually used in treatment.

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