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Don't blame GPs for C. difficile rise

From Dr David Church, Machynnlleth

The poor quality of GP care hits the media again. This time, the fact GPs have been detecting MRSA and C. difficile diarrhoea in the community at a rate increasing faster than in inpatients, despite a reduction in antibiotic use, is clear proof that GPs' infection control procedures are negligent – except that it proves nothing of the kind in regard to GP care, and has more the opposite implication.

Increased detection rates in the community actually indicate:

• That causative organisms are being tested for more, and thus that GPs are considering such infections, rather than treating blind with antibiotics.• That hospitals' problem with control of these infections is now spreading rapidly to the community because of: 1. poor infection control and surveillance in hospital; 2. excessive use of broad-spectrum antibiotics in hospitals; and 3. patients being discharged too soon after heavy antibiotic treatments before they are fully recovered and back to normal health and commensals.• That resistant infections detected after discharge from hospital are wrongly classified as 'community acquired' because the patient was tested from their home or GP address, disregarding the fact that the causative treatment was received, and often the symptoms first developed, a couple of days earlier while an inpatient.

We can prove the latter point. Our local cottage hospital takes patients for rehab post-operatively from a district general hospital orthopaedic ward. These patients are tested for MRSA on admission to the orthopaedic ward at the DGH and are usually negative at the time.They are tested for MRSA on arrival at the cottage hospital because they are inter-hospital transfers. As they are tested immediately on arrival, any MRSA they carry must really have come from the orthopaedic ward at the DGH. Unfortunately, since the swab and request originate from the cottage hospital, it is clear proof to some that the infection must have been acquired after discharge from the DGH. This is dangerously wrong and unscientific thinking.In regard to C. difficile, although antibiotic-associated diarrhoea can be quite debilitating, especially in the elderly, the organism is part of the normal bowel flora of young children, and I suspect it is even more prevalent in normal bowel flora in rural livestock farming areas such as ours. Can we really blame GPs for the existence of organisms of normal bacterial flora?

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