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This article reports a significant outbreak of Clostridium difficile ribotype 027 infection in a residential care home in the UK. Five of six affected residents died within one month of diagnosis. Investigation of the facility revealed problems with hand hygiene and environmental cleaning. Affected residents had received a mean of 2.7 antibiotic courses in the two months preceding diagnosis. It is important to recognize that C. difficile outbreaks can occur in residential homes. There is a need for health- and social-care systems to work closely together to assure the safety of people in their care., (Copyright © 2014 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

This report describes an outbreak of Clostridium difficile infection (CDI) in a vascular surgery ward in 2009 caused by a high-level clindamycin-resistant ribotype 106. A case of CDI was defined as a patient with diarrhoea, positive for C. difficile toxin and negative for other enteric pathogens. Cultures were sent to the Scottish Salmonella Shigella and Clostridium difficile Reference Laboratory (SSSCDRL) for PCR ribotyping, antibiotic susceptibility testing and PCR detection of ermB. The mean age of the nine patients was 73 years (range: 38-90 years). All had received clindamycin and ciprofloxacin. All cases were typed as PCR ribotype 106 and they showed high-level resistance to clindamycin. Five of these isolates were tested by PCR for the presence of the ermB gene and no amplification was detected. This strain has rarely been isolated from patients on this ward. The outbreak was controlled successfully by closure of the ward with terminal cleaning, reinforcement of infection control precautions and the introduction of a new antibiotic policy. It is notable that this outbreak was caused by a strain with high-level clindamycin resistance not mediated by ermB. It also re-emphasizes that outbreaks of CDI can be caused by C. difficile PCR ribotypes other than 027. The outbreak was most likely associated with the use of clindamycin and ciprofloxacin cross-infection with spores in this environment. Implementation of strict infection control precautions, antimicrobial stewardship and enhanced environmental cleaning are key components in managing such an outbreak successfully. The number of meticillin-resistant Staphylococcus aureus acquisitions also fell substantially after these interventions., (Copyright © 2011 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

The recent data for hospital-acquired infections suggest that infection rates for meticillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile are beginning to decrease. However, while there is still pressure to maintain this trend, the resistance of C. difficile spores to standard detergents continues to present a problem for many UK hospitals trying to prevent its spread or control outbreaks. Alternative disinfection technologies such as gaseous decontamination are currently being marketed to the healthcare sector as an alternative/supplement to manual disinfection, and have been shown to be effective in reducing environmental contamination. When used correctly, they offer a complementary technology to manual cleaning that increases the probability of an effective reduction in viability and provides a comparatively uniform distribution of disinfectant. Three gaseous decontamination technologies are examined for their suitability in reducing environmental contamination with C. difficile: gaseous hydrogen peroxide, chlorine dioxide and ozone. Air decontamination and UV-based technologies are also briefly described. We conclude that while there is a role to play for these new technologies in the decontamination of ward surfaces contaminated with C. difficile, the requirement for both a preclean before use and the limited 'in vivo' evidence means that extensive field trials are necessary to determine their cost-effectiveness in a healthcare setting., (Copyright © 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.)

The prevention and control of healthcare-associated infections (HCAIs) requires a tripartite partnership between clinicians and carers, managers and government/Department of Health (DoH) across the whole health and social care community. Mandatory surveillance of meticillin-resistant Staphylococcus aureus bacteraemia and Clostridium difficile infection has shown a significant fall from peak numbers in 2003/04 and 2006, respectively, and there is now a zero tolerance approach to preventable infections and poor practice. Success so far has been based on senior management commitment, enhanced real-time surveillance, implementation of clinical protocols (high impact interventions, prudent prescribing), improved hand hygiene and environmental cleaning, and training and audit, backed up by a heightened performance management focus through targets and legislation (Code of Practice). DoH improvement teams have supported National Health Service trusts in implementing change. Responsibility for managing HCAI is a combination of managerial responsibility based upon compliance assurance that procedures and protocols are being implemented and personal professional responsibility of all clinicians and other healthcare workers.

Despite record resource being devoted to the control of healthcare-acquired infection (HCAI), rates have never been higher. Although the discovery of the contagiousness of puerperal sepsis by Alexander Gordon heralded the golden era of bacteriology and antibiotics, this led to a belief that infection was beaten. This in its turn may well have led us into a false sense of security and an over-reliance on antibiotics. Modern medicine has built many of its advances on a need for antibiotics, but their very success has led to huge over-use and resulting problems of resistance. Compounded by the absence of a good antibiotic pipeline we are now being forced to address the paradox of antibiotics; namely that they may actually be causing many HCAIs. Not only Clostridium difficile infection, but many others such as those caused by meticillin-resistant Staphylococcus aureus, are more or less completely contingent on antibiotic prescribing. Control of prescribing would probably be just as effective a measure in our fight against HCAI as conventional infection control measures. Arguably, traditional infection control is akin to fire-fighting and antibiotic stewardship to prevention.

Summary: Clostridium difficile infection (CDI) is the most common cause of hospital-acquired diarrhoea. It is estimated that 15-20% of patients experience recurrence of CDI. A limited number of studies have looked at the risk factors for recurrent CDI. We conducted a meta-analysis of observational studies and randomised controlled trials (RCTs) to assess risk factors for recurrent CDI. Studies were identified using the PubMed database and search terms 'Clostridium difficile associated diarrhoea' or 'pseudomembranous colitis'. Both observational studies and RCTs were included. In all, 1215 studies were identified of which 48 met the inclusion criteria. Twelve studies involving 1382 patients with CDI met the complete eligibility requirements. Odds ratios and information on study quality were abstracted by two investigators independently. To be included in the analysis, each risk factor was required to be evaluated by at least three separate studies. Continued use of non-C. difficile antibiotics after diagnosis of CDI (OR: 4.23; 95% CI: 2.10-8.55; P<0.001), concomitant receipt of antacid medications (OR: 2.15; 95% CI: 1.13-4.08; P=0.019), and older age (OR: 1.62; 95% CI: 1.11-2.36; P=0.0012) were significantly associated with increased risk of recurrent CDI. Significant prognostic risk factors were identified as risk factors for CDI recurrence. Additional or novel interventions may be required for these patients to prevent CDI recurrence.

Identification of a population at high risk for Clostridium difficile infection (CDI) would enable CDI prevention strategies to be designed. The purpose of this study was to create a clinical risk index that would predict those at risk for CDI. A CDI risk index was therefore developed, based on a cohort of hospital patients given broad-spectrum antibiotics, and divided into a development and validation cohort. Logistic regression equations helped identify significant predictors of CDI. A scoring algorithm for CDI risk was created using identified risk factors and collapsed to create four categories of CDI risk. The area under the receiver operating characteristic (aROC) curve was used to measure goodness-of-fit. Among 54 226 patients, 392 tested positive for C. difficile. Age 50-80 years [odds ratio (OR: 0.5; P<0.0116)], age >80 years (OR: 2.5; P<0.0001), haemodialysis (OR: 1.5; P=0.0227), non-surgical admission (OR: 2.2; P<0.0001) and increasing length of stay in the intensive care unit (OR: 2.1; P<0.0001) were significantly associated with CDI. A simple risk index using presence of significant variables was significantly associated with increasing risk for CDI in both development (OR: 3.57; P<0.001; aROC: 0.733) and validation (OR: 3.31; P<0.001; aROC: 0.712) cohorts. An OR-derived risk index did not perform as well as the simple risk index. This easily implemented risk index should allow stratification of patients into risk group categories for development of CDI and help fashion preventive strategies.

Clostridium difficile causes serious healthcare-associated infections. Infection control is difficult, due in part to environmental contamination with C. difficile spores. These spores are relatively resistant to cleaning and disinfection. The activity of a dry mist hydrogen peroxide decontamination system (Sterinis) against environmental C. difficile contamination was assessed in three elderly care wards. Initial sampling for C. difficile was performed in 16 rooms across a variety of wards and specialties, using Brazier's CCEY (cycloserine-cefoxitin-egg yolk) agar. Ten rooms for elderly patients (eight isolation and two sluice rooms) were then resampled following dry mist hydrogen peroxide decontamination. Representative isolates of C. difficile were typed by polymerase chain reaction ribotyping. C. difficile was recovered from 3%, 11% and 26% of samples from low, medium and high risk rooms, respectively. In 10 high risk elderly care rooms, 24% (48/203) of samples were positive for C. difficile, with a mean of 6.8 colony-forming units (cfu) per 10 samples prior to hydrogen peroxide decontamination. Ribotyping identified the presence of the three main UK epidemic strains (ribotypes 001, 027 and 106) and four rooms contained mixed strains. After a single cycle of hydrogen peroxide decontamination, only 3% (7/203) of samples were positive (P<0.001), with a mean of 0.4 cfu per 10 samples ( approximately 94% reduction). The Sterinis hydrogen peroxide system significantly reduced the extent of environmental contamination with C. difficile in these elderly care rooms. This relatively quick and user-friendly technology might be a more reliable method of terminally disinfecting isolation rooms, following detergent cleaning, compared to the manual application of other disinfectants.

Antibiotic-associated Clostridium difficile diarrhoea may complicate recovery from surgery for proximal femoral fracture. We undertook a four-year case-control study to evaluate a change in antibiotic prophylaxis in our department. During the period January 2003 to January 2005, patients received three doses of prophylactic cefuroxime (1.5g). We then introduced a new regimen, comprising of one single dose of cefuroxime (1.5g) with gentamicin (240mg) at induction. Prior to the change in prophylaxis, 912 patients underwent surgery for neck of femur fracture, and from March 2005 to March 2007, 899 patients had surgery under the new regimen. Thirty-eight patients developed C. difficile infection (4.2%) in the initial group, compared with 14 patients (1.6%) in the group with the new regimen (P=0.009). The incidence of C. difficile infection increased throughout the rest of the hospital over the same time period. Patients with C. difficile infection had a statistically significant increase in antibiotic exposure, inpatient stay, morbidity and inpatient mortality. The main challenges regarding prophylactic antibiotic selection are infection due to meticillin-resistant Staphylococcus aureus (MRSA) and C. difficile-associated diarrhoea. We advocate the use of the new regimen as an alternative to multiple-dose cephalosporin antibiotics for the prevention of C. difficile infection in this group of high-risk patients.

A survey of adult patients was conducted in February 2006 to May 2006 in acute hospitals across England, Wales, Northern Ireland and the Republic of Ireland to estimate the prevalence of healthcare-associated infections (HCAIs). A total of 75 694 patients were surveyed; 5743 of these had HCAIs, giving a prevalence of 7.59% (95% confidence interval: 7.40-7.78). HCAI prevalence in England was 8.19%, in Wales 6.35%, in Northern Ireland 5.43% and in the Republic of Ireland 4.89%. The most common HCAI system infections were gastrointestinal (20.6% of all HCAI), urinary tract (19.9%), surgical site (14.5%), pneumonia (14.1%), skin and soft tissue (10.4%) and primary bloodstream (7.0%). Prevalence of MRSA was 1.15% with MRSA being the causative organism in 15.8% of all system infections. Prevalence of Clostridium difficile was 1.21%. This was the largest HCAI prevalence survey ever performed in the four countries. The methodology and organisation used is a template for future HCAI surveillance initiatives, nationally, locally or at unit level. Information obtained from this survey will contribute to the prioritisation of resources and help to inform Departments of Health, hospitals and other relevant bodies in the continuing effort to reduce HCAI.

We determined prospectively the frequency, persistence and molecular epidemiology of Clostridium difficile environmental contamination after detergent-based cleaning in side rooms used to isolate patients with C. difficile diarrhoea. Approximately one-quarter of all environmental sites in side rooms sampled over four-week periods were contaminated with C. difficile. The overall side room prevalence of environmental C. difficile declined from 35% initially, to 24% in week 2, 18% in week 3, and 16% in week 4. The bed frame was the most common site from which C. difficile was recovered, although the floor was the most contaminated site in terms of total numbers of colonies. C. difficile was recovered significantly more frequently from swabs plated directly on to C. difficile selective media containing lysozyme than from enrichment broth (P< 0.001), emphasizing the benefit of lysozyme supplementation. The great majority of C. difficile isolates (87% of all isolates, 84% of patient isolates) was indistinguishable from the UK epidemic strain (PCR ribotype 1). It thus could not be determined whether environmental contamination was a cause or a consequence of diarrhoea. Our findings highlight the need for improved approaches to hospital environmental hygiene, and call into question current UK guidelines that recommend detergent-based cleaning to remove environmental C. difficile. In particular, improved cleaning of frequently touched sites in the immediate bed space area is required., (Copyright 2001 The Hospital Infection Society.)

Clostridium difficile infection is a common and potentially lethal complication of antibiotic usage. Since the aetiology of antibiotic-associated colitis was discovered 14 years ago, two antibiotics in particular, metronidazole and vancomycin, have been used to treat C. difficile infection. Studies comparing the efficacy of these antibiotics are reviewed. It is now apparent that many of the so-called 'relapses' of C. difficile infection following antibiotic treatment are, in fact, re-infections. Such findings have major infection control implications.