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Combating healthcare-associated infection

Steve Titmarsh
14 May, 2015  

A meeting co-hosted by CDI Europe and HOPE at the European Parliament raised awareness of healthcare-associated infection and highlighted the need for action to combat and prevent the problem

Steve Titmarsh

Freelance Medical Writer

UK

Healthcare-associated infection (HAI), including Clostridium difficile infection (CDI), is estimated to kill at least 37,000 hospital patients in the European Union (EU) each year,1 Karin Kadenbach, MEP and member of the Group of the Progressive Alliance of Socialists and Democrats, told the meeting she hosted at the European Parliament in Brussels in December 2014.

It is estimated that HAI costs the EU €5.5 billion each year,2 but many of the infections are preventable. However, a study showed that on one day in 482 participating hospitals across 20 European countries, a mean of 74 inpatients with CDI were not tested for CDI and a further 34 patients received a false negative result  for CDI.3 Hospitalised patients with CDI are 2.5-times more likely to die within 30 days than those without diarrhoea.4

Political progress

Patient care and patient safety is a key focus for Ms Kadenbach’s work at the European Parliament as a member of the Committee on the Environment, Public Health and Food Safety. Investing in the health literacy of patients – helping them navigate health systems – will be a key part of the strategy to combat issues such as HAI, she said. Standardising data collection and reporting across Member States will be important in establishing minimum standards of care across the EU. A resolution on patient safety adopted in 2013 by the European Parliament stressed the importance of strategies to prevent and control HAIs.2

In answer to a question from the audience, Ms Kadenbach said that her next step would be to table a question in the European Parliament about HAI. That way the Parliament would have to say what its plans would be and that would lay the foundation for an action plan to tackle the problem.

Thanking Ms Kadenbach for her comments and her support, Professor Mark Wilcox, Consultant Microbiologist, Head of Microbiology and Academic Lead of Pathology at the Leeds Teaching Hospitals, UK, who chaired the meeting, declared clinical intervention alone is not enough. It is only with the help of policy makers that we will make an impact on this problem, he said. And that chimes with the objectives of CDI Europe, an expert-led initiative focussed at the healthcare policy level with the aim to translate research on CDI into meaningful policy responses, to help:

  • Raise awareness of CDI
  • Improve and standardise disease surveillance and reporting
  • Promote a better standard of care for CDI management across Europe (including diagnostic testing, therapy, infection control and prevention), and, ultimately,
  • Improve patient outcomes.

Herta Adam, from the European Commission, said that HAI is taken very seriously in the Commission and that surveillance for CDI will begin across Europe from 2015. In addition, a second point prevalence survey is due to take place in European acute care hospitals in 2016–17, and the ECDC directory of online resources for HAI and antimicrobial resistance (AMR) has also been recently updated (see: ecdc.europa.eu/en/healthtopics/Healthcare-associated_infections/guidance-infection-prevention-control/Pages/guidance-prevention-control-infections-caused-by-multidrug-resistant-bacteria-and-healthcare-associated-infections.aspx5). However, she explained that it is the Member States themselves that are ultimately responsible for the health and safety of their citizens. The Commission cannot force EU Member States to implement specific strategies, but it can support them in doing so by passing resolutions, making recommendations and reporting on what Member States are actually doing.

Impact of CDI

CDI is a leading gastrointestinal infection in European hospitals, typically causing diarrhoea.6–9 The infection can be life-threatening because it is associated with severe bowel inflammation and shock,6 and approximately one in ten CDI cases causes (or contributes to) admission to an intensive care unit, death or leads to bowel surgery.6–8 Patients at greatest risk of CDI are those who have recently been treated with antibiotics, the elderly, and people with a chronic illness.8,10 CDI can extend hospital stays by one to three weeks.11–13 Worryingly, Professor Wilcox commented that recurrence rates with CDI are high at around one in four to one in five cases, ‘which is the last thing you need if you are a frail, elderly patient’.

However, Professor Wilcox explained that CDI can often be prevented and the local burden of CDI reflects weaknesses in diagnosis (disease awareness and laboratory testing), in hospital care – including antibiotic use, hand washing, barrier nursing, environmental decontamination, training and staffing – and in disease surveillance.

A report published by CDI Europe in 2013 highlighted deficiencies in CDI management which included diagnosis, treatment, infection control and prevention and patient empowerment. Correct diagnosis, prevention and treatment, backed-up by good surveillance, will make significant improvements in the rate of CDI and therefore be safer for patients, Professor Wilcox explained. This has been demonstrated in England, where the annual number of reported cases of CDI in patients aged two years and over fell from 55,498 in 2007–8 to 18,022 in 2011–1214 after a series of initiatives including laws requiring hospital directors to put infection control measures in place and mandatory surveillance and reporting by acute hospitals.

The current situation is summarised in a study published recently in Lancet Infectious Diseases, in which the authors estimate that, in 482 hospitals that took part in the study, across 20 European countries, an estimated 40,000 cases of CDI are missed each year.4 Professor Wilcox commented that the reason cases were not being diagnosed was that either testing was not being requested (because in many European countries C. difficile testing was carried out only when requested by a doctor) or the wrong test was being performed.

Recognition of the impact of HAI and the need to take action has been growing steadily in Europe. This is evidenced by a number of initiatives, starting with the Council recommendation in 2009 that Member States should implement/ enhance HAI prevention/control, and develop/strengthen surveillance (regional, national and institutional),15 to the European Commission Implementation Report in 2012,16 which noted gaps in staff education/training, patient empowerment and information, and the decision on cross-border health threats in 2013, which urged Member States to share data on epidemic surveillance for HAI.17

Then followed the European Parliament Resolution in 201318 calling for Member States to set national targets for HAI reduction, and for EU and Member States to reinforce measures to reduce HAI and invest more in research, including studies on CDI. In 2014, the European Commission’s second report to the Council on the implementation of Council Recommendation 2009/C 151/01 on patient safety, including the prevention and control of healthcare-associated infections,19 said greater efforts were needed, particularly on infection control staff numbers and isolation capacity. And most recently, in December 2014, came the Italian Council conclusions on patient safety and HAI.

Nevertheless, despite increasing C. difficile testing and growing awareness of the problem of HAI, there is still a large burden of undetected cases across Europe, which is likely to hamper control measures. As a result, CDI Europe wants to see:

  • Gaps in CDI diagnosis, treatment, control surveillance addressed 
  • CDI measures made integral to HAI prevention/control
  • Support for innovation to improve CDI detection/management to improve care quality
  • CDI considered as a routine indicator of care quality/patient safety and mandatory reporting of rates encouraged
  • HAI policies prioritised as integral to care quality and patient safety programmes.

Measures CDI Europe feels are necessary to achieve these objectives include:

1. Professional education: All healthcare staff should receive training on CDI to increase diagnosis rates and improve compliance with treatment and infection control guidelines

2. Laboratory testing: Healthcare systems must offer appropriate C. difficile testing services, and testing should be performed for all patients with healthcare-associated diarrhoea

3. Public education: Patients and caregivers should receive information on CDI so that they can play their part as true partners in CDI prevention/control

4. Surveillance: All Member States should institute mandatory, publicly reported national surveillance of hospital-acquired CDI. In 2013, only 13 EU Member States had implemented national CDI surveillance.

Professor Franz Allerberger (Institute for Medical Microbiology and Hygiene and Head of Public Health Division, Austrian Agency for Health and Food Safety) said cases of CDI have been rising in Austria with the emergence, as in other Member States, of the hypervirulent 027 ribotype. CDI is also becoming more common in the community, with 14% of cases across Europe being community associated.8,20 Residents of nursing homes are also at risk. For example, a quarter of residents in nine homes in the Netherlands were found to have CDI.21

Interventions including reducing the use of antibiotics, such as moxifloxacin, and giving patients information about CDI have an immediate impact to decrease CDI rates, Professor Allerberger explained.22 He echoed Professor Wilcox’s comments about testing, quoting the European Centre for Disease Prevention and Clostridium difficile Control (ECDC), which concluded that in countries where no or very few cases of CDI were reported ‘this is more likely to be due to lack of diagnostic testing than to absence of C. difficile, because … [CDI] is expected to be responsible for a large proportion of healthcare-associated diarrhoea’.6

The role of hospitals

Silvia Bottaro, from HOPE, said healthcare managers need to prioritise HAI prevention and infection control at an organisational level which will involve resource allocation, design and planning of facilities, education and training and patient information.

Collaboration at a European level is important too, in particular sharing good practice. One example is the European Union Network for Patient Safety and Quality of Care (PaSQ) database of good practices (http://pasq.eu/Wiki/

PatientSafetyandQualityofCare

GoodPractices.aspx)23 where details of programmes such as hand hygiene practices being implemented in different institutions in EU Member States can be found. Sharing this sort of information raises awareness and encourages the spread of good practice in infection control and prevention.

Patient power

However, it is not just clinicians and politicians who need to engage with the issue: patients have a central role to play. Cristina Padeanu (European Patients’ Forum (EPF)) explained that approximately 3.2 million patients acquire an HAI in the EU each year, of which 20–30% are considered preventable.24,25 

The Council of European Union has endorsed the idea of empowering and informing citizens and patients by inviting Member States to: ‘Encourage the participation and empowerment of patients, families and their informal caregivers, as well as patient organisations, through evidence-based and unbiased provision of information and education, and promote patients’ participation in decision making in the healthcare process in order to contribute to the prevention of adverse events.’26 

Patients want information, guidance and empowerment so they can have a genuine partnership in the healthcare system, Ms Padeanu explained. Key elements needed to help patients and carers include better communication about patient safety, the ability to report side effects formally and better information about patients’ rights and their enforceability.

To help facilitate greater patient involvement in safety issues EPF is planning to produce easy to understand information to raise awareness and support patient advocacy on safety, including HAI and antimicrobial resistance. In 2016, EPF plans to organise a conference on patients’ role in patient safety, including launching a process to develop core competencies in patient safety for patients and their families. And in collaboration with the working group on patient empowerment EPF wants to develop the concept of patient-centred care, advocacy and to produce an information toolkit for patient groups.

Professor Wilcox commented that it is incumbent upon healthcare professionals to facilitate patient involvement in decision making because it is a daunting prospect for many patients to question healthcare professionals and be part of the decision making process, particularly when they are ill. He also said, in response to a question from the audience, that patients should be told about what they can expect from the care they receive and be encouraged to report back on how they are feeling and progressing or whether they have concerns. Patients may be embarrassed about reporting they have diarrhoea, for example, which then makes it more difficult for healthcare professionals to provide optimum care.

Ms Padeanu said patients would feel more comfortable about asking questions and providing information if healthcare professionals simply wore a badge declaring ‘ask me’. ‘You will see an immediate change in the reaction of patients because they will really feel they can talk to that professional.’ It’s simple, but it works, she added.

The meeting was organised under the direction of the CDI Europe faculty and initiated and funded by Astellas Pharma EMEA. Support for the editorial development of this review has been provided by Astellas Pharma EMEA.

References

  1. European Centre for Disease Prevention and Control. www.ecdc.europa.eu/en/healthtopics/Healthcare-associated_infections/Page… (accessed 9 February 2015).
  2. European Parliament. pasq.eu/Portals/PaSQ/European%20Parliament%20Report%20on%20Patient%20Safety%20-%20Summary.pdf (accessed 9 February 2015).
  3. Davies KA et al. Underdiagnosis of Clostridium difficile across Europe:  the European, multicentre prospective, biannual, point-prevalence study of Clostridium difficile infection in hospitalised patients with diarrhoea (EUCLID). Lancet Infect Dis 2014;14:1208–19.
  4. Hensgens M et al. All-cause and disease-specific mortality in hospitalized patients with Clostridium difficile infection: a Multicenter cohort study. Clin Infect Dis 2013;56:1108–16.
  5. Directory of online resources for prevention and control of antimicrobial resistance and healthcare-associated infections. http://www.ecdc.europa.eu/en/healthtopics/Healthcare-associated_infectio… (accessed 9 February 2015).
  6. ECDC. Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals, 2012. 
  7. Debast SB et al. European Society of Clinical Microbiology and Infectious Diseases: update of the treatment guidance document for Clostridium difficile infection. Clin Micro Infect 2014;20 (Suppl 2):1–26. 
  8. Bauer MP et al, for the ECDIS Study Group. Clostridium difficile infection in   Europe: a hospital based survey. Lancet 2011;377;63–73. 
  9. Bauer MP et al. European Society of Clinical Microbiology and Infectious Diseases (ESCMID): treatment guidance document for Clostridium difficile infection (CDI). Clin Microbiol Infect 2009;15:1067–79.
  10. ECDC, European Centre for Disease Prevention and Control.
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  13. Wilcox MH et al. Financial burden of hospital-acquired Clostridium difficile infection. J Hosp Infect 1996;34:23–30.
  14. Annual results from the mandatory Clostridium difficile reporting scheme. http://webarchive.nationalarchives.gov.uk/20140714084352/http://www.hpa…. (accessed 9 February 2015).
  15. Council of the European Union (2009/C 151/01), 2009. 
  16. European Commission COM(2012) 658 final, 2012. 
  17. Decision No 1082/2013/EU on cross-border health threats, 2013. 
  18. European Parliament. Report on the report from the Commission to the Council on the basis of Member States’ reports on the implementation  of the Council Recommendation (2009/C 151/01) on patient safety, including the prevention and control of HAIs (2013/2022(INI)), 2013. 
  19. Commission’s Second Report to the Council on the implementation of Council Recommendation 2009/C 151/01 on patient safety, including the prevention and control of healthcare associated infections, 2014.
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  22. Wenisch JA, et al. Decreasing Clostridium difficile infections by an antimicrobial stewardship program that reduces moxifloxacin use. Antimicrob Agents Chemother 2014;58:5079–83.
  23. Prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals 2011–2012, ECDC, 2013. www.ecdc.europa.eu/en/publications/Publications/healthcare-associated-in… (accessed 9 February 2015).
  24. European Union Network for Patient Safety and Quality of Care database of good practices. http://pasq.eu/Wiki/PatientSafetyandQualityofCareGoodPractices.aspx (accessed 9 February 2015).
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