Noble's Hospital Isle of Man

16th Infection Prevention & Control Conference

First Do No Harm

Monday 30th January 2012

Derek Butler and Maria Cann attended Noble's Hospital Infection Prevention and Control Conference on the Isle of Man. Derek was a guest speaker and spoke of the challenges that everyone faced, and how this impacts on patients and their families.  The Minister for Health, the Hon Mr D M Anderson MHK, opened the conference. Being from a farming background he was knowledgeable about infection prevention and control. 

The conference had an international flavour, with shared experiences from all care settings, including hospitals, care homes and the community. 

David Killip, Chief Executive Officer, Department of Health, Isle of Man was pleased to attend his ninth conference and introduced Professor Mark Wilcox, Leeds General Infirmary, who presented "Clostridium difficile infection - how to find treat and stop"

Professor Wilcox is the lead on Clostridium difficile infection for the Health Protection Agency Regional Microbiology Network in England.  He is a member of the Department of Health's Antimicrobial Resistance and Healthcare Associated Infection Committee, and is an advisor to the Medicines and Healthcare products Regulatory Agency, the Health Technology Assessment programme on Healthcare Associated Infection, and the European Centre for Disease Control.  He is a member of UK, European and US working groups on Clostridium difficile infection. His research projects include several areas of healthcare associated infection, in particular Clostridium difficile infection, staphylococcal infection, and the clinical development of new antimicrobial agents. He is a Member of Council of the British Society of Antimicrobial Chemotherapy Scientific Advisory Board and a member of the Wellcome Trust. 

The title of Professor Wilcox's presentation reflected the move to new guidance which will help to target patients with tests that will be able to find those patients who will be vulnerable to the toxigenic type of disease that is more likely to cause severe illness and higher mortality.  

Lab detection is fundamental to tackling Clostridium difficile infection, yet research has shown that there can be a 43-fold variation in testing. It is therefore important that the best test was used to give the patient the best chance of overcoming the illness, and to help to control the risk of cross-infection. 10-20% of adults aged over 65 can be colonised with the bug that might produce toxins. Colonisation will last 4-6 weeks in 56% of patients in an environment where Clostridium difficile infection is endemic.

There will be new guidance issued by the Department of Health which will specify who to test and when, which tests will be used and which positives will be reported. This will give a clearer picture of the disease as there is too much variation in testing currently.

Toxin positive patients are more likely to die, it's important to identify potential Clostridium difficile carriers.

Metronidazole and Vancomycin are currently used to treat Clostridium difficile. Patients with a raised white cell count, which is one of the symptoms of more severe disease, do better on Vancomycin.

Fidaxomicin will be licensed for use in the UK from June 2012 trials show the recurrence of Clostridium difficile infection is less frequent with Fidaxomicin than with Vancomycin. Fidaxomicin costs one and a half thousand pounds for a 10 day course, so there will be a need to assess which patients are at higher risk of recurrent C diff. The frail elderly are more likely to benefit. Resistance has not been detected, although there was a need to increase levels during trials. We need surveillance to check this is not a clinical problem as it will be 4-5 years minimum before a fourth and fifth antibiotic for the treatment of Clostridium difficile will be available.

There was no sound evidence for the Department of Health to recommend probiotics, but there were two studies ongoing. Interventions to combat the disease include:

- Isolate within 2 hours of unexplained diarrhoea 

- Early warning system

- Route cause analyses

- Appropriate care pathways

- Use of HPA fingerprinting to test if there is cross infection.

The deadlier strain 027 has significantly reduced, and 027 has kept others at bay, 078 is increasing and there are similar risks associated with this strain that we need to resolve before patients start dying.

Environmental and air sporicidal spread is significant.

Toilet facilities in healthcare settings vary widely, but patient toilets are commonly shared and do not have lids. When a toilet is flushed without the lid closed, aerosol production may lead to surface contamination within the toilet environment.

In tests C. difficile was recoverable from air sampled at heights up to 25 cm above the toilet seat. The highest numbers of C. difficile were recovered from air sampled immediately following flushing, and then declined 8-fold after 60 minutes and a further 3-fold after 90 minutes. Surface contamination with C. difficile occurred within 90 minutes after flushing, demonstrating that relatively large droplets are released which then contaminate the immediate environment. The mean numbers of droplets emitted upon flushing by the lidless toilets in clinical areas were 15-47, depending on design. C. difficile aerosolisation and surrounding environmental contamination occur when a lidless toilet is flushed.

Lidless conventional toilets increase the risk of C. difficile environmental contamination, and the research suggests that their use is discouraged, particularly in settings where CDI is common.

"Potential for aerosolisation of Clostridium difficile after flushing toilets: the role of toilet lids in reducing environmental contamination risk.

Best EL, Sandoe JA, Wilcox MH. J Hosp Infect. 2012 Jan;80(1):1-5. Epub 2011 Dec 2"

Patients are infectious for about a week after infection symptoms subside. Less than a quarter can be matched to other cases, there is little evidence of long term ward transmission.

New guidance talks of importance of diagnosis at the right time.

Left to right: Judy Potter Lead Nurse, DIPC, Royal Devon & Exeter Foundation Trust; Dr Naomi Baldwin, Senior Infection Prevention & Control Nurse, Antrim Hospital, Belfast; Derek Butler, Chair, MRSA Action UK; Mr Phillip Howard, Dr John Wardle, Consultant Medical Microbiologist / DIPC, Noble's Hospital, Isle of Man and Keynote Speaker Professor Mark H Wilcox

Mr Phillip Howard, Consultant, Antimicrobial Pharmacist, Leeds General Infirmary followed the presentation with his talk on Antimicrobial Stewardship, and Judy Potter, Lead Nurse / DIPC, Royal Devon & Exeter Foundation Trust, spoke of the challenges of managing large outbreaks of Norovirus in Devon.  The south west region has highest incidence of Norovirus in the UK.  It affects staff as well as patients and in 2009/10 4,409 calendar days were lost to staff sickness. Interestingly C.diff was lower when there was a higher prevalence of Norovirus. Route cause analysis showed outbreaks stemmed from missed outbreaks on admissions wards - there are now frequent reviews of admissions ward. Early closure of entire wards and waiting 72 hours before reopening (more than national guidance) has resulted in a significant fall in the numbers of patients now affected.  

If you or someone you care about has been affected by a healthcare associated infection and you wish to discuss this with us, please contact us at

The information on this website is for general purposes only and is not a substitute for qualified medical care, if you are unwell please seek medical advice.

(c) MRSA Action UK 2012