Contribution of a government target to controlling Clostridium difficile in the NHS in England

Abstract

The introduction of mandatory surveillance of Clostridium difficile infection (CDI) in 2004 showed the scale of the challenge: cases in patients >64 years old reached 55,681 in 2006. The first type 027 outbreaks had been in 2005 and CDI was a headline issue. The prevention and control of CDI requires a tripartite partnership between clinicians, health service managers, and the government/Department of Health which needs to set standards, ensure that CDI is a priority, set targets and monitor outcome. Government can also legislate; the Health Act 2006 introduced a statutory Code of Practice for infection prevention and control for the NHS and extended to all independent health and care settings in 2010. In 2008, a national target was set for a 30% reduction in CDI by 2010-11 (baseline 2007-8). It was population-based and set a standard (ceiling) rate/10,000 in each area, within which acute hospitals had a target/1000 admissions (diagnosed after day 3). In the first year (2008-9), a 35% reduction was achieved from 55,499 to 36,079 cases in all ages and in 2009-10 the total was 25,604, a 54% reduction from 2007-8. However, in 2009, cases >64 years old were 29% down from 2008 but only 9% down in the 2-64 year old group; also, by this stage, cases in acute hospitals and in other settings were almost equal. Death certification showing CDI fell for the first time in 2008 and in 2009 there were 3550 total mentions (7816 in 2007) of which 1510 (42%) were as underlying cause (3875, 49%, in 2007). The reductions in CDI have been achieved by a raft of measures. Crucially, the targets focused management emphasis on infection prevention and control. This was supported by enhanced surveillance. Clinical practice protocols were implemented through the high impact interventions (care bundle) approach, and there was a major emphasis on cleanliness and hygiene (particularly hand washing for clinical staff and environmental cleaning and disinfection in patient areas). Achievement of the target is not the end of the road; it is to be transformed into an objective (benchmark) for 2011 and beyond based on median rates to maintain pressure for reduction.