Clostridium difficile Support

[chrismc]

http://www.telegraph.co.uk/health/healthnews/6494359/C.diff-cases-may-be-twice-as-high-as-tests-miss-infection.html
By Rebecca Smith, Medical Editor
Published: 7:15AM GMT 04 Nov 2009

There are around 3,000 cases of Clostridium difficile reported in hospitals in England each month but the true figure could be much higher as the current testing methods miss between 20 per cent and 80 per cent of cases, according to microbiologists.

New, more expensive tests should be brought in, but hospital managers would need reassurance that any apparent rise in cases found by the new methods should not be seen as poor patient care, they said.

Prof Gary French, consultant microbiologist at Kings College London and Guy's and St Thomas' Foundation Trust, has carried out research showing that the current test only correctly identifies around 38 per cent of cases of C.diff. Other trials have suggested about half of cases are found.

The research, which is due to be published in the Journal of Hospital Infection, suggests new methods using two-stages, one to screen for the presence of C.diff and if positive another more sophisticated test to establish if the bug is producing the toxins which cause symptoms or is lying dormant.

C.diff is a bacterium that can be found naturally in the gut of some people without causing problems but in others it can produce toxins which trigger diarrhoea. Vulnerable elderly patients and those who have been on antibiotics in hospital are more susceptible and the disease can prove fatal in some cases.

The results from current tests used in NHS hospitals can take several days.

Prof David Persing, consulting professor of pathology at Standford University in California and chief medical officer of Cepheid, a company which produces pathology tests, said his research has shown that the tests only found about 50 per cent of positive C.diff cases.

"The data was quite surprising. The tests are not doing anywhere near as well as we thought. For some strains they are only picking up about 20 per cent of the infections that are there. The vasst majority of patients who are infrected with some of these strains are being missed and are not being put in isolation. There is no attempt to even treat the patient if the test comes back negative," he said.

He said for strain 106, which is common in Britain, the current test only detected around 20 per cent of cases but for the more virulent 027 strain the tests found 80 per cent of cases.

The new tests are more accurate and faster, he said, but they can be three time more expensive. However, by finding positive cases faster, NHS hospitals could cut their infection rates and reduce duplicate tests to save money in the long run.

Prof French also found that the current tests are 'inadequate' and called for new methods to be employed. But he added that patients with symptoms are isolated and treated accordingly without waiting for test results and they may continue to be treated even if the result is negative.

He said: "From our paper and other studies, we show that the present tests are not as reliable as they should be... I think that these tests are really not good enough. We need recommendations to move to a new system and this should be debated."

Prof French said that although new tests may find more cases it should not be taken as a rise in C.diff prevalence but would be the result of more accurate testing. He said the downward trend in C.diff cases shown by mandatory reporting of cases to the Health Protection Agency is probably still the case.

He said: "The hygiene improvements across the board, shown by the dramatic reduction in MRSA rates, means I am convincted taht the reduction in C.diff rates is a true phenomenon.

"If we go to a new test that is more sensitive we are bound to see an increase in reported cases. That will not be a result of poor practice but the result of better testing."

The latest C. difficile figures show that there were 6,855 cases reported in patients aged two years and over during the April to June 2009. This is a drop of 37 per cent on the same period last year.

Dr Christine McCartney, Executive Director for the Health Protection Agency's Healthcare Associated Infection and Anti-Microbial Resistance Programme, said: “Studies have suggested that different tests have better efficacy rates depending on the strain of Clostridium difficile.

“The Agency works closely with the Department of Health to ensure all infection control guidelines take any new strains of health care associated infection into account to ensure health care settings have the most up to date evidence and research possible to help combat healthcare associated infections.”

Brian Duerden, Inspector of Microbiology and Infection Control at the Department of Health said: "Accurate test results are essential for good patient care. In March this year we issued advice on a two-stage testing approach and reminded trusts that patients should be isolated and treated as Clostridium difficile patients if they were symptomatic, even if they tested negative.

"We will be evaluating the results of this study, along with other studies currently underway, as part of a review into healthcare acquired infection testing. We will continue to work tirelessly to tackle these infections."

Testing methods will be discussed at a symposium at Guy's and St Thomas' Hospital.
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The very first requirement in a hospital is that it should do the sick no harm - Florence Nightingale

[Annie]

Graziella and I attended this symposium today. Although some of it was very high tech, it's clear that the testing issue is going to be an extremely difficult issue to resolve and they are some way away from doing that.

[Catherine M]

Apart from you two (Go Girls!) who else attended? Did you get to see a delegate list?

[Annie]

It was a well attended event - about 120 people from all over the country (and some from USA). We do have a delegate list, mostly very senior positions (Consultants, scientists - mainly associated with Infection Control and Microbiology).

The speakers were Brian Duerden (Chief Microb), Dr Bharat Patel (HPA), Prof Ian Poxton (Uni of Edinburgh), Prof Ed Kuijper (Netherlands), Dr Tim Planche (Cons Microb St George's Hosp), Prof Mark Wilcox (Leeds) and some others speaking about the specifics and experiences surrounding testing.

Most of what was said is actually covered in the 'How to deal with the problem' guidance. There was a lot of explanation about the epidemiology and how, geographically, they are able to trace the spread of the various strains that have emerged. Pretty early in the day, one of the speakers had put up a slide from an outbreak in N Manchester General Hospital in 1991. He stated that the recommendations from that outbreak were still valid today. (How frustrating is that!)

A very interesting day and I learned a lot too.

[chrismc]

Hi Annie,
I and am sure many others here would appreciate an insight in what you learned, would it be any more than available on the forum?
Christine X
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The very first requirement in a hospital is that it should do the sick no harm - Florence Nightingale

[chrismc]

Would be interested to know if any mention made of Lactoferrin Stool WBC Test.
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The very first requirement in a hospital is that it should do the sick no harm - Florence Nightingale

[Annie]

Chris, I have contacted the organisers to see if there is a transcript available. I don't think I would be confident enough to post up my notes in case I have completely misunderstood something. I don't recall that testing method being discussed, it was very fast paced and some of it very 'sciency'. (We missed one of the sessions where that may have been discussed.)

One thing that was interesting was one of the experts views on the danger of producing lists of 'high risk' antibiotics. Since the guidance was issued to reduce the use of fluoroquinolines and cephalosporins, it then emerged that in 2008/9 the antibiotic most associated with C.diff infection was co-amoxiclav. His view was that if you re-wrote the list of 'high risk', then fluoroquinolines would now appear in the 'medium' risk group.

Annie

[roy]

Annie
Even if there are some errors in your notes it would be informative if you did post a bit more about what was discussed at the symposium!
Perhaps a,
THE WAY I UNDERSTOOD IT type of post would be appropriate?
(sorry to give you so much work but something like this is so important to us "long termers")

Roy
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GETTING THERE !!
I am not a medic anything in my posts is my own opinion and from what I have learnt. A doctors advice should always be sought before following any advice.