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Clostridium Difficile

Health care associated infections- illnesses one can acquire during a stay in hospital or a long term care facility - are not new. In recent years, however, the infections have reached epidemic proportions in hospitals and nursing homes in Ireland and around the world. One of the most widespread and potentially serious of these infections is caused by the bacterium, Clostridium difficile often known as C-diff.

In March and April of 2007 an outbreak of C-diff occurred in Ennis General Hospital which prompted the National Directors Population Health and National Hospital's office to commission a report to review the infectious disease protocols and procedures in the hospital.

The report, published on the 10th April 2008, highlighted serious deficiencies in the Hospital's infection control practices and procedures. It also made important recommendations for Ennis General Hospital, as well as for the HSE and the Department of Health and Children regarding matters of infection control and hygiene.

The report examined the circumstances surrounding an outbreak of the C-diff super bug at Ennis General Hospital which involved 50 episodes of the disease. Forty six, mainly elderly patients were infected - 39 women and 7 men.

Twenty two of the episodes occurred on the Female Medical Ward which at the time was suffering from overcrowded conditions. Of those patients affected, 15 died within 30 days of being diagnosed with C-diff. None of the 15 Death Notification Forms for these patients recorded that the deaths were directly caused by C-diff. Eight of the 15 Death Notification Forms contained C-diff as an antecedent cause or significant condition of death. Nine patients' notes mention the C-diff was a contributing factor to death.

In 4 of these 9 cases there was no mention of C-diff on the death notification form. A further 6 persons died in the months after their C-diff infection were diagnosed.

The investigation undertaken in relation to Ennis General Hospital outlined the following weaknesses in both the Hospital and the national health care system which put patients at an unreasonable risk for infection:

• The Infection Prevention and Control Committee of Ennis General Hospital which should have been monitoring the threat of the super bugs was "in abeyance" for 15 months - from September 2006 until December 2007.
• The Infection Prevention and Control Committee does not have input from either a Consultant Medical Microbiologist or an Infectious Disease Consultant.
• A particularly virulent strain of C-diff was circulating in the Hospital at the time when there was overcrowded occupancy levels reaching 105.9% - a level which would leave patients at a risk from cross-contamination.
• There were ongoing concerns regarding the hygiene levels at the hospital. This was particularly the case in the Female Medical Ward where some 22 patients became infected with C-diff.
• The absence of the 3 key Infection Control employees contributed significantly to the delay in taking definitive action in relation to the increase in cases of C-diff and as such the situation was not declared an outbreak and the Outbreak Control Team was not convened.
• The following persons were absent from the hospital:
  The Director of Nursing was absent from the Hospital on special assignment from March until October 2007.
  Female Medical Ward Manager was on sick leave from April 2006 until April 2007.
• Infection Control Nurse who was on annual leave from 9th - 23rd of April.
• Due to patient overcrowding, the hospital staff were forced to put up additional beds in the female wards which impeded access to hand basins in one of the rooms.
• The hand basins in the rooms are standard domestic fittings and are not clinical hand hygiene facilities.
• The report also details that toilet facilities for the A&E Department are limited and across the corridor from the Department.
• There is also no facility to isolate a patient with diarrhoea (main C-diff contagion) in the A&E Department or the Intensive Care Unit.
• The distance between the beds is less than recommended for good infection control practice and additional hand hygiene facilities are required.
• Bed pans were being washed by hand because of difficulties with the bed pan washer which broke down and required maintenance and repair call-outs.
• Hospital staff adherence to Infection Control Protocols were "patchy" with practical difficulties in implementing patient isolation, adhering to antibiotic prescription guidelines and poor attendance by hospital staff at Infection Control Training Sessions.

In short, it appears that Ennis General Hospital had a substantial lack of Infection Control management personnel during the time of the outbreak. Furthermore, it seems that despite Infection Control Protocols being in place at the Hospital, there was no HSE or Department supervision or review to insure that said Protocols were being adhered to on an effective and consistent basis.

The absence of proper management and non-compliance with infection control standards is extremely serious in a healthcare environment given that C-diff is highly contagious through the faecal-oral routes.

Further compounding the problem is that despite C-diff a potentially life-threatening and extremely contagious super bug, it is not a notifiable disease for the purpose of Infection Control. This has only recently been changed in that C-diff will become a notifiable disease from May 2008 and will thereby put an obligation on the Doctors and Health Staff to officially report all suspected cases.

Further, although there is a national MRSA reference laboratory in existence, a similar reference laboratory for C-diff has not been established. This makes the identification of strains and other infection control issues relating to C-diff very difficult. The absence of such a reference lab is significant since C-diff is likely to be even more prevalent than MRSA because it is more contagious.

The Report also offers recommendations that should be implemented on the national level, including:

• Implementation of the Healthcare Associated Infection and Antimicrobial Resistance National Action Plan to include public education, standard setting and audits, Healthcare worker education and training, improving personnel and physical infrastructure.
• National guidelines should be developed for surveillance, case definition, prevention and control of C. diff infections.
• Said guidelines need to be implemented across the entire Health Care System including acute hospitals, community facilities, nursing homes and general practice.
• A systematic, standardized format for reporting adverse incidents associated with infection should be implemented and monitored both at a local and national level.
• A C-diff reference laboratory should be established
  Actions plans must be developed for compliance with national hygiene standards and infection control prevention and control standards.
• It should be noted that Health Minister Mary Harney was warned about the infection risk to patients at Ennis General Hospital two years before the C-diff outbreak that infected and contributed to the deaths of these patients.

The Irish Independent reports that consultant Terry Hennessy wrote to the Health Minister in April 2005 and warned her that the overcrowding at Ennis General Hospital which he asserted were reaching 120% was posing a risk of cross-contamination. Some 7 other consultants contacted the Minister and voiced the same concerns.

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