The document summarizes healthcare-associated infection surveillance data from England in 2008-2009. It found dramatic decreases in several infections like MRSA and C. difficile compared to previous years. For example, there was a 35% drop in C. difficile infections. However, infections still occur so continued prevention efforts are needed. The data comes from mandatory reporting schemes and helps target control measures.

1. Healthcare-Associated Infections in England:
2008-2009 Report

3. Christine McCartney
Executive lead for the
HPA Healthcare-Associated Infection and
Antimicrobial Resistance Programme
Foreword – Christine McCartney
Healthcare-associated infections (HCAIs) are ‘everyone’s responsibility’ and so
all those involved in reducing HCAIs are to be congratulated as this annual
report highlights dramatic decreases in HCAIs reported through the mandatory
surveillance scheme. Encouraging though this is, patients continue to contract
meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia, Clostridium
difficile, and other HCAIs that may not have such a high profile, so we can not
afford to be complacent. Working towards zero tolerance of preventable
infections the Health Protection Agency remains vigilant gathering timely
surveillance data, providing diagnostic and reference microbiology services to
assist the NHS, providing expert proactive advice and support at local,
regional and national levels, as well as participating in and shaping research
and development.
Highlights
• Dramatic decreases in HCAIs reported through the mandatory
surveillance scheme.
• Launch of norovirus surveillance in December 2008.
• Growth of the Clostridium difficile Ribotyping Network (CDRN).
• Successful conference and launch of the DVD An introduction
to infection control in care homes.
Headlines
There were 36,097 Clostridium difficile infections reported in England in
2008/09 (patients aged two years and over), which represents a 35% fall on the
55,499 total for 2007/08. There is CDRN evidence that this decrease is due in
particular to successful control of ribotype 027.
Figures on MRSA bloodstream infections showed there were 2,933 cases
reported in England in 2008/09. This represents a 34% fall on the 4,451 total
for 2007/08 and a 54% fall on the 6,383 cases reported in 2006/07.
There have been statistically significant reductions in the rate of inpatient and
readmission surgical site infections between 2004 and 2008 in hip prosthesis
(1.6% to 0.7%), knee prosthesis (0.9% to 0.5%), open reduction of long bone
fracture (2.5% to 1.3%) and hip hemiarthroplasty (4.4% to 2.3%).
These figures are national statistics collected on behalf of the Department of
Health and published on the HPA website (www.hpa.org.uk).

4. Mandatory surveillance of MRSA bacteraemia
In September 2008 the HPA published results showing the NHS had met its
50% reduction target as compared with the 2003/04 baseline levels. Since
the start of MRSA bacteraemia surveillance in April 2001 there has been a
62% decrease in the cases of MRSA bacteraemia reported to the HPA
(comparison based on April to June 2001 vs January to March
2009 data).
Data for the past year continues to show these infections mainly afflict the
elderly (mean patient age is 69 ± 20 years), men (65% of patients), and
those with either predisposing morbidities (e.g. renal failure, diabetes,
immunosuppression) or medical procedures (e.g. surgical interventions,
central or peripheral intravenous lines). Patients attending for elective
medical procedures are estimated to account for less than 10% of all
affected patients.
Since October 2005 when the HPA introduced a web-enabled data capture
system to collect MRSA bacteraemia data on a patient basis (previously,
cases were reported at an aggregate acute trust level), the largest decline
among the three patient populations has been the 69% reduction in the
number of cases diagnosed three or more days after presentation at
hospital (Figure 1). From October to December 2005 this patient
population accounted for 65% of MRSA infections, but now (January to
March 2009) accounts for just 52% of MRSA infections. However, there have
also been substantial decreases of 47% and 45% respectively among
patients diagnosed within two days of admission and those diagnosed at
non-acute trust facilities during this time period.
The HPA introduced patient record tracing in March 2009. Further research
may be warranted into identifying predisposing risk-factors and MRSA
strains among patients suspected of being infected at non-acute
trust facilities.
Figure 1. MRSA bacteraemia, by patient presentation
2,500 Three or more days after admission
Within two days of admission
Non-acute cases
2,000
Reports of MRSA bacteraemia
1,500
1,000
500
0
Oct/05- Apr/06- Oct/06- Apr/07- Oct/07- Apr/08- Oct/08-
Mar/06 Sep/06 Mar/07 Sep/07 Mar/08 Sep/08 Mar/09

5. Mandatory surveillance of Clostridium difficile
The mandatory surveillance of Clostridium difficile began in January 2004
for patients aged 65 years and over, and was ‘enhanced’ in April 2007 to
include patient-level data for all patients aged two years and over.
Since April 2007 there has been a 50% reduction in the number of cases of
C. difficile reported for all patients aged two years and over (comparison
based on April to June 2007 vs January to March 2009). The highest
reduction (54%) is observed among patients testing positive three or more
days after admission (Figure 2). Significant reductions of 41% and 47%
respectively have also been observed for patients testing positive within two
days of admission and patients testing at non-acute trust facilities.
There have been no changes this past year (compared with the previous
year’s data) in mean patient age (74 ± 17 years), with 80% of cases
affecting those aged over 64 years of age, and a majority of cases afflicting
women (58% of patients). Furthermore, the increased number of cases
observed between January and March 2009 as compared with the previous
quarter is consistent with the seasonality that was evident during the
previous year.
As over 40% of cases are observed among patients diagnosed within two
days of admission or diagnosed at non-acute trust facility, comprehensive
infection control should include initiatives by a range of non-acute trust
facilities. As part of a national strategy to reduce these infections by 30% in
financial year 2010/11, the HPA has been identifying affected patients’
responsible primary care organisations (PCO) to help these organisations
implement suitable infection control initiatives.
Figure 2. Clostridium difficile, by patient presentation (all patients aged 2 years and over)
12,000 Three or more days after admission
Within two days of admission
10,000 Non-acute cases
Reports of C. difficile
8,000
6,000
4,000
2,000
0
Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan-
Jun/07 Sep/07 Dec/07 Mar/08 Jun/08 Sep/08 Dec/08 Mar/09

6. Surveillance of surgical site infection
Surgical site infections (SSIs) account for 15% of all HCAIs, are associated
with considerable morbidity and estimated to at least double the length of
hospital stay. There is evidence that the care provided before and after the
operation is critical in minimising the risk of SSI and that feeding back data
on rates of SSI to the surgical team contributes to reductions in rates of
infection. The HPA established the SSI Surveillance Service (SSISS) in 1997 to
enable hospitals to compare their rates of SSI against a benchmark rate and
to use the data to improve the quality of patient care. Hospitals are able to
choose from 14 categories of surgical procedures. Basic demographics are
collected on each patient who has a procedure in the category under
surveillance. Patients are then followed up during their hospital stay for SSIs
that meet the standard case definitions and, since July 2008, SSIs that
occur in patients readmitted to hospital. SSISS is currently undertaking a
study to evaluate methods of post-discharge surveillance.
During 2008, 251 hospitals collected data on 94,750 surgical procedures.
These included 196 NHS and 55 independent sector hospitals. A total of
1,191 SSIs were detected, with readmission SSIs comprising 30% of this
total. The proportion of SSIs detected in readmissions is higher in those
procedures with a shorter length of post-operative stay. The rate of SSI
varies between categories, reflecting differences in likelihood of microbial
contamination at the operative site. In over 4,500 SSIs reported since 2004
Staphylococcus aureus was the causative organism for 38% of all SSIs, of
which 59% were due to a methicillin-resistant strain.
Since the mandatory surveillance of SSI following orthopaedic surgery
started in April 2004 the rate of SSI has decreased significantly (p<0.001) in
hip prosthesis, knee prosthesis and hip hemiarthroplasty.
Figure 3. Rate of SSI (detected during inpatient stay and at readmission)
by surgical category, with number of operations shown above each bar, 2008
12%
Readmission SSI 2,499
10% Inpatient SSI
% operations infected
8%
396
6%
348
4% 1,614
4,212
3,089
6,184 904
2% 1,354 765 1,261
34,702
37,422
0%
Knee prosthesis
Hip prosthesis
long bone fracture
Spinal surgery
Abdominal
hysterectomy
femur
Reduction of long
bone fracture
Hip
hemiarthroplasty
Coronary artery
bypass surgery
Vascular surgery
Limb amputation
Small bowel
surgery
Large bowel
surgery
Open reduction of
Repair of neck of

7. Clostridium difficile Ribotyping Network (CDRN)
The Clostridium difficile Ribotyping Network (CDRN, formerly the CDRNE)
has expanded to eight regional laboratories in England and Northern Ireland.
CDRN provides ribotyping and enhanced DNA fingerprinting to identify
cross-infection, reduce transmission, optimise management of outbreaks
and determine the epidemiology of C. difficile.
In 2008/09 CDRN processed 4,682 faecal samples from 190 healthcare
facilities (~100% increase over 2007/08) about one out of every eight or nine
C. difficile cases in England were examined by CDRN. Marked changes in
ribotype prevalence in 2008/09 occurred, with a striking decrease in C. difficile
027, and ‘compensatory’ increases in the other main types (Table 1). There
were clear regional differences in ribotype prevalence e.g. ribotype 027 was
the commonest in each region except the North East (ribotype 001, 20.0% vs
ribotype 027, 12.6%; p<0.001). Figure 4 demonstrates shifting ribotype
prevalences since CDRN(E) was introduced. There was a significant association
between all cause mortality and ribotype 027 (OR = 1.9; p<0.001).
Notably, there was an increase from 9.6% to 12.5% in the proportion of (toxin
positive) faecal samples that are C. difficile culture-negative. This may reflect
more false positive samples that have tested locally as ‘toxin positive’ (see HPA
guidance at www.hpa.org.uk). Susceptibility testing of over 1,000 C. difficile
isolates has shown more evidence of emergence of reduced susceptibility to
metronidazole with some institutional clustering.
Table 1. Changing prevalence of most common Clostridium difficile Figure 4. Prevalence of 10 most common ribotypes in
ribotypes detected by CDRN in 2007/08 and 2008/09 England by quarter (April 2007 to March 2009)
Riboty pe 07/08 (n,%) 08/ 09 ( n,%) Prevalenc e Prevalence of 10 most common ribotypes in England by quarter
change (%)
(Apr 2007 - Mar 2009)
027 1152 (55.3%) 1468 (36.1%) - 19.2% 700
106 270 (13.0%) 517 (12.7%) - 0.3% 027
600 106
001 181 (8.7%) 297 (7.3%) - 1.4%
500 Sporadic
Number of ribotypes
002 57 (2.7%) 231 (5.7%) + 3.0%
014/020* 57 (2.8%) 218 (5.4%) + 2.6% 001
400 002
015 50 (2.4%) 215 (5.3%) + 2.9%
015
078 37 (1.8%) 144 (3.5%) + 1.7% 300
078
005 29 (1.4%) 118 (2.9%) + 1.5%
200 005
023 21 (1.0%) 109 (2.7%) + 1.7%
023
026 5 (0.2%) 87 (2.1%) + 1.9% 100
014
The top 10 most prevalent ribotypes are shown i.e. those
0
with >2% prevalence in 2008/09. In 07/08 and 08/09, 7.2%
9 41 43 45 47 49 51 01 03 05 07 09 11 13 15 17 19 21 23 25 0 1 2 3 4 5 6 7 8 9
and 8.1%, respectively, of all isolates were designated as
Weeks
sporadic i.e. these were not one of the commonly recognised Quarter (April 2007 - March 2009)
ribotypes.
* Data for ribotypes 014 and 020 are combined.

8. Surveillance of norovirus
Norovirus is the commonest cause of cases and outbreaks of gastrointestinal
disease in the UK. The majority of outbreaks of norovirus reported to the HPA
occur in healthcare-associated settings such as hospitals and residential care
homes. A prospective study of gastrointestinal disease outbreaks in three NHS
hospital trusts in the county of Avon in 2002/03 found that 63% of the
outbreaks were confirmed due to norovirus. Resulting staff absence due to
illness and bed-days lost due to ward closures was estimated to cost the NHS
around £115 million in that year.
For 2009, the HPA launched a new surveillance scheme called Hospital
Norovirus Outbreak Reporting. Infection control teams in acute hospitals enter
and access data directly via a secure web enabled database at
www.hpa-bioinformatics.org.uk/noroOBK/.
Reporting to the scheme is voluntary; therefore the reported figures are an
underestimate of the true number of outbreaks of norovirus in hospitals in
England and Wales. To encourage participation the system was designed to be
a resource for infection control staff and to provide real-time local outbreak
information. The system supplements the data collected as part of routine
laboratory report surveillance (Figure 5).
From January to March 2009 there were 262 outbreaks reported from 43
trusts (Table 2). A total of 82% of outbreaks resulted in some form of ward
closure, with 2,814 patients and 747 staff reported to have been affected as
part of these outbreaks, and over 4,000 bed-days were lost.
Table 2. HPA Hospital Norovirus Outbreak Reporting: Figure 5. Seasonal comparison of laboratory reports
preliminary data, January to March 2009 of norovirus (England and Wales)
500 2002/2003
I 2,499
Trusts reporting (N) 43 450 2003/2004
Outbreaks (N) 262 2004/2005
January 107 400
2005/2006
February 89 350
Laboratory Reports
396 2006/2007
March 66 300
Ward closed 215 2007/2008
(82%) 348 250 2008/2009
1,614
Laboratory confirmed 4,212 181 200
6,184 904
3,089 (69%) 150
65 1,261
Total Median (Range)
Patients affected 2814 10 (2-34) 100
Staff affected 747 2 (0-21) 50
Spinal surgery
Abdominal
hysterectomy
femur
Reduction of long
bone fracture
Hip
hemiarthroplasty
Coronary artery
bypass surgery
Vascular surgery
Limb amputation
Small bowel
surgery
Large bowel
surgery
Repair of neck of
Bed days lost (N – 161) 4136 10 (0-173) 0
27 29 31 33 35 37 39 41 43 45 47 49 51 01 03 05 07 09 11 13 15 17 19 21 23 25
Weeks

9. Providing specialist advice and support
The HPA has made a significant contribution to help trusts to control Clostridium
difficile. It has deployed multidisciplinary specialist advisory teams at the request of
acute trusts to improve patient safety by raising awareness, providing advice, support
and training, and using site visits to demonstrate good practice at local, regional and
national levels. This has been achieved through direct engagement with NHS trust
boards and executive groups, and frontline healthcare staff.
The roll out of the MRSA Standard Package of Charts for use by health protection units
and regions started in May 2008 and training for staff took place on 13 June 2008 in
London, 20 June 2008 in Leeds and 24 June 2008 in Birmingham. This standard
package, produced on a monthly basis, contains three data worksheets and 11 charts
within an spreadsheet and is used to inform dialogue with NHS trusts. There are four
types of charts that are automatically generated from the data entered into the three
data worksheets. These are a ‘raw’ time series, a guidance or statistical process control
chart, a cusum (cumulative sum) of differences from the trajectory, and a comparative
incidence density chart. The first three types have been produced for the monthly,
quarterly and annual data.
In February 2009 the HPA produced a DVD featuring a series of short films designed to
give care home staff an introduction to infection prevention and control. This training
resource was produced in conjunction with the Department of Health and the
Infection Prevention Society. It can be used to supplement existing infection control
training in care homes and provides practical assistance to help comply with the new
Department of Health code of practice.
To complement the launch of the DVD a one-day conference was held on 21 May
2009. The conference took place in London in partnership with the Infection
Prevention Society. The event was attended by 280 delegates from across the UK
including care home managers and owners, infection prevention and control
specialists, community nurses, representatives from primary care trusts and strategic
health authorities, leads on HCAI, regulators and health protection unit staff. Speakers
from the Department of Health, Care Quality Commission and the National Patient
Safety Agency highlighted the new code of practice and what it will mean for care
homes, including registration and compliance issues.

12. Health Protection Agency
Healthcare Associated Infection and Antimicrobial
Resistance Programme
7th Floor Holborn Gate
330 High Holborn
London WC1V 7PP
United Kingdom
Tel: +44(0)20 7759 2817
Fax: +44(0)20 8327 6633
Email: hcai@hpa.org.uk
Website: www.hpa.org.uk
Links to the data
Mandatory MRSA bacteraemia:
www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName
/Page/1191942169773
Mandatory C. difficile:
www.hpa.org.uk/web/HPAweb&HPAwebStandard/
HPAweb_C/1195733750761
CDRNE:
www.hpa.org.uk/webw/HPAweb&Page&HPAweb
AutoListName/Page/1208417851521?p=1208417851521
Norovirus:
www.hpa.org.uk/webw/HPAweb&Page&HPAweb
AutoListName/Page/1191942172974?p=1191942172974
Surgical Site Infection Surveillance Service:
www.hpa.org.uk/webw/HPAweb&Page&HPAweb
AutoListName/Page/1191942150156?p=1191942150156
Other useful links
PVL Staphylococcus aureus
www.hpa.org.uk/web/HPAwebFile/HPAweb_
C/1218699411960
Clostridium difficile infection: How to deal with
the problem
www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1232006607
827
Download the care homes DVD
www.hpa.org.uk/carehomesdvd
August 2009
c Health Protection Agency
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