Author's response

As the authors rightly pointed out, Clostridium difficile infection (CDI) can cause not only toxic megacolon, but also other conditions such as antibiotic-associated diarrhoea and pseudomembranous colitis. The answer to Question 7 is indeed ‘all of the above’ not ‘toxic megacolon’ alone as stated in our paper. We assure the readers of the Annals of The Royal College of Surgeons of England that we have taken the correct answer into account when we analysed the results. This was an error and we sincerely apologise for this mistake.

With regards to the issue raised by the authors about the gold-standard test for the diagnosis of pathogenic CDI, we acknowledge that the gold-standard test for CDI would be to test for both cytotoxin A and B, as sometimes only one of these may be positive in CDI, and apologise for being less than totally rigorous in our question. The purpose of this question was to test healthcare workers' knowledge of the principle behind the test, and in particular that this was not a microbiological ‘culture and sensitivity’ test, rather than exploring their understanding of detailed biochemistry. It seems unlikely that the overall response to the question would have been very different had both toxins been included in the question as perhaps they should.

The conclusions we have reached are still valid and it is very clear from the results that there was a significant lack of knowledge about CDI amongst healthcare professionals particularly among consultants and nurses at the time of the study. Since then, there has been much publicity about hospital-acquired infections and all hospitals have been required to take measures to increase the awareness of their staff about CDI; this is reflected in the nationally reduced incidence of hospital-acquired CDI.¹