Refining Our Approach to Clostridium difficile Prevention

Laura A. Stokowski, RN, MS; L. Clifford McDonald, MD

Disclosures

March 21, 2012

In This Article

C difficile: Success in Prevention

Medscape: The CDC just reported on a CDI prevention program[1] in 3 states that had some amazing results: a reduction in hospital-onset CDI of 20% over 21 months. How did these hospitals accomplish this, and what can we learn from them?

Dr. McDonald: The engagement of leadership at participating hospitals was a key factor, along with the organizational support of state health departments and their patient safety partners. In very large organizations, it takes a concerted effort not just within a facility, but across facilities, to share information and coordinate regional efforts to prevent CDI. For example, the risk for C difficile transmission is high when patients are transferred from one healthcare facility to another -- from hospital to nursing home or rehabilitation facility and back again.

If these facilities aren't working together and notifying each other that a patient has, or has had, CDI, then the appropriate precautions aren't taken. The CDC recommends that a standardized transfer form, such as the CDC's Inter-Facility Infection Control Transfer Form be used by all facilities for patient transfers, especially transfers between facilities.

Many different strategies were used in these prevention programs, and these strategies varied somewhat from hospital to hospital. (A sample C difficile prevention bundle is shown in the Table.)

Table. Strategies Used in the New York Clostridium difficile Prevention Bundle[3]

  • Soap and water for hand hygiene

  • Contact precautions upon suspicion of C difficile infection

  • Monitoring of signage and availability of personal protective equipment

  • Dedicated rectal thermometers

  • Patient placement hierarchy

    • Private room vs cohorting vs shared

  • Bathroom hierarchy/prioritization

    • Dedicated vs shared vs commode

  • Transport precautions

  • Environmental cleaning

    • Hypochlorite-based disinfectant

    • Checklist for daily and terminal cleaning

One hospital (Advocate Christ Medical Center in Chicago, Illinois) took the unusual -- but ultimately quite effective -- step of combining environmental services and infection prevention into the same department, with the same director. This elevated the status of environmental services by emphasizing the infection prevention goals of their work.

A team concept was used by another Chicago facility, Swedish Covenant Hospital, which assigned dedicated environmental service staff to each hospital unit to foster interaction and teamwork among the unit staff. The efforts of these 2 hospitals were highlighted in a video, Not Just a Maid Service, which illustrates the point of view of front-line staff.

Antibiotic stewardship was a minor component of the prevention programs to date. The core efforts in the participating hospitals revolved around adherence to infection control precautions: hand hygiene, isolation, and environmental cleaning.

Medscape: Let's talk about each of these. What are the unique hand hygiene issues with CDI?

Dr. McDonald: We get a lot of questions about the hand hygiene issue with respect to CDI. We know that the alcohol-based (hand sanitizer) gels don't kill C difficile spores, nor do they reduce them. Essentially, hand gels don't do anything to these spores. So, some people have said that we should return to handwashing in healthcare facilities and eliminate hand gels. In one way, that makes sense. Handwashing, with soap, water, and friction, is better than alcohol-based hand sanitizers for C difficile, because of dilution and physical removal -- getting the spores off of the hands.

However, alcohol-based hand sanitizers have probably saved thousands of lives through the prevention of countless infections. Not only are they, on the whole, more effective than handwashing for a huge range of usual pathogens that do not form spores (eg, methicillin-resistant Staphylococcus aureus [MRSA], Escherichia coli), the ability to achieve higher levels of compliance in busy healthcare settings should not be overlooked. Thus, we need to think carefully about overall patient safety and not think about only 1 pathogen in devising our strategies.

C difficile is probably transmitted primarily between patients on the hands of healthcare personnel who are transiently contaminated after contact with symptomatic patients or their surrounding environment. Once C difficile spores are on a healthcare provider's hands, they are hard to remove, even with handwashing. Our ability to kill common pathogens, such as MRSA or E coli, on hands using an alcohol gel is at least an order of magnitude greater than our ability to wash C difficile spores off our hands with soap and water. It is much better to avoid getting them on your hands in the first place, and therefore gloves are the first and best line of defense. If you have a known patient with CDI, or even suspected CDI, wearing gloves is the most important thing to do to prevent hand contamination.

Medscape: What are the proper isolation procedures for CDI? Is cohorting appropriate?

Dr. McDonald: Whenever possible, patients with CDI should be isolated in a single patient room. That's not always possible, especially in nursing homes and some other long-term care settings. Then it becomes key, if you can, to cohort patients -- to put patients who have CDI together in the same room. However, it also becomes critical to use a bedside commode so that people with CDI are not sharing the toilet.

Bedside commodes must also be cleaned with an approved sporicidal agent after use. Whenever possible, equipment should be dedicated to individual or cohort use (eg, electronic thermometers) and not taken from room to room. When not possible (as in the case of sinks or bathtubs), shared items must be cleaned after use. Gowns and gloves must be worn when entering isolation rooms, even briefly.

Medscape: What are the criteria for taking patients with CDI out of isolation?

Dr. McDonald: The recommendation right now is to continue isolation for the duration of diarrhea. The data suggest that patients with CDI can continue to shed organisms for up to 7 days after the cessation of diarrhea. We know these patients will continue to shed; it's the degree of shedding that is important. The important factor is diarrhea. Most shedding occurs while the patient has diarrhea. When diarrhea resolves, shedding diminishes. Many facilities routinely continue isolation for 2-3 days after resolution of diarrhea. If the infection is going to recur, it frequently recurs during that period. Some facilities maintain isolation for as long as 7 days, and others until discharge.

Nonetheless, the standard recommendation right now is to isolate for the duration of diarrhea. If your facility is experiencing high rates of CDI, and you have been doing everything else that you can but without success in preventing infections, then you should consider the supplemental recommendation, which is to extend the duration of isolation to one of the other time points (48-72 hours, 7 days, or duration of admission).

We don't recommend continuing isolation until the patient's C difficile test becomes negative. Patients remain colonized after infection, so their tests will continue to be positive, if the test used is sufficiently sensitive.

Medscape: What should facilities do if they are cohorting?

Dr. McDonald: With cohorting, there are some special considerations for taking patients who have had CDI out of isolation. When you cohort for MRSA or another organism, you usually cohort the patients for the remainder of the patient's hospitalization. With CDI, however, we are concerned about risk for recurrence. Therefore, our main recommendation is to isolate people when they have diarrhea -- that is clearly the time when they are most contagious. If you are cohorting and a cohort member's diarrhea resolves, it is probably important to get that patient out of the cohort, although we don't have a clear evidence base to make this recommendation.

Medscape: How can facilities ensure that environmental cleaning is being done properly? Is any particular method of monitoring the adequacy of cleaning recommended?

Dr. McDonald: An emphasis on environmental cleaning was a focus of the prevention programs that reduced CDI rates by 20%. Good physical cleaning should be accomplished, because this can lead to the physical removal of spores. This should be augmented with an EPA-approved spore-killing disinfectant, such as chlorine bleach. Standard EPA-registered hospital disinfectants are not effective against C difficile spores.

Engagement and empowerment of front-line staff, particularly those who work in environmental services, were critical to the success of the prevention programs. Hospital leaders motivated environmental service staff by educating them about their role in promoting patient safety, sharing data, and giving them credit for the facility's success. It can be challenging because of high turnover rates and, in some instances, language issues, but the hospitals involved in the prevention programs proved that it can be done.

We are often asked about how to monitor cleaning. Of course, just because something looks clean doesn't mean it is clean. We have a toolkit for hospitals to use in assessing the adequacy of environmental cleaning. In that toolkit, we discuss the different assessment methods available and provide template checklists and evaluation forms. As an example, a hospital in Illinois used fluorescent markers to evaluate the thoroughness of cleaning by environmental services staff. A fluorescent substance is applied to areas of the room that are often overlooked, and this substance shows up under a black light if cleaning was inadequate.

Medscape: Other than the hospital or long-term care facility, in what other settings has transmission of C difficile been problematic? For example, what about the home, for patients who are discharged while they still have diarrhea?

Dr. McDonald: Hospitalized patients who have active CDI, who are still being isolated, might be sent home before their diarrhea is resolved. Although in the home setting, the risk for transmission is much lower, we recommend that people in the community consider not sharing a bathroom (if possible) until their diarrhea has resolved. Some studies suggest that one risk factor for community-associated CDI is having someone in the home with active CDI.[4] Although a small proportion of cases are transmitted this way, we recommend telling patients as they leave the hospital to use a separate bathroom at home or make sure it has been cleaned before someone else uses it.

With respect to other ambulatory settings, some very early data[5] that were presented recently suggest that when patients who have recently recovered from CDI enter outpatient settings, they are contaminating the ambulatory environment. We are going to do further research into that area to find out how much transmission is occurring in different types of outpatient settings. For now, the risk is probably higher in places where patients receive higher levels of intervention (such as a colonoscopy center or a surgery center) or where patients are more debilitated. Another example is the dialysis setting, where patients are often taking antibiotics and patients with diarrhea still have to receive dialysis. In all these areas, we need to be more mindful of the importance of environmental cleaning and ask the patient: "Are you having diarrhea?" That's where it starts.

Medscape: Careful and judicious antibiotic prescribing is one of the primary steps in the prevention of CDI. Was the "Get Smart About Antibiotics" campaign responsible for the plateau in CDI rate observed in the past 2 years?

Dr. McDonald: More likely, the plateauing CDI rate was from general awareness. We need to increase that awareness up a couple more notches so we can see the CDI curve going down. We have also been asked if the focus on MRSA over the past few years could have contributed to a slowing of the CDI rate, because of some overlap in prevention being applied to patients at risk for both infections. The answer is probably "yes." Many patients with MRSA are also at risk for CDI. Therefore, the precautions taken for MRSA might have played some role, as suggested by some data from a Veterans Affairs study.[6]

Initially, our "Get Smart" program focused on antibiotic prescribing in the community. Now, we have expanded this to "Get Smart for Healthcare," to optimize the use of antimicrobial agents in inpatient healthcare settings by focusing on strategies to help hospitals and other inpatient facilities implement interventions to improve antibiotic use.

Part of this is education of prescribers. There are 3 key steps:

  1. Always record the name; dose; intended duration of therapy; and, of importance, the reason for the antibiotic.

  2. Order the appropriate cultures before treatment with antibiotics is started.

  3. Take an antibiotic "time-out." Reassess the patient after he or she has taken antibiotics for a day or 2 -- does the patient still need it? Whenever possible, stop treatment with antibiotics that are no longer needed.

These things have to happen in hospitals, as well as in the community -- doctor's offices, nursing homes -- across the entire healthcare spectrum.

Medscape: Some facilities routinely give patients yogurt or probiotics to patients taking antibiotics who are at risk for CDI. What is your opinion of this practice?

Dr. McDonald: Although not a core CDC recommendation at this time, the idea of using probiotics to prevent CDI-associated diarrhea makes a lot of sense. It has been studied, but the data don't fully say that the probiotics that are currently available are effective in preventing CDI. At the same time, it probably won't hurt in most patients. The use of yogurt and use of probiotics is something people can try.

Medscape: Recent reports suggest that the use of proton-pump inhibitors (PPIs) might be a factor in the development of CDI. The CDC's new recommendations didn't mention avoidance of PPIs in patients at risk. Why?

Dr. McDonald: We fully support the US Food and Drug Administration in their decision to alert clinicians about the association between PPIs and C difficile.[7] It makes sense. Accumulating observational evidence suggests an association. At the same time, we are not aware of any prevention programs that have focused on PPI prescribing as means to prevent C. difficile, and therefore we are not focusing on it as a prevention strategy. In fact, from some of the data, it seems that the proportion of patients who take PPIs and have not also recently received antibiotics is quite small.

Meanwhile, evidence to suggest that these drugs might be working through the same pathway to increase risk for CDI is growing. So, changes in PPI prescribing may never have as big an impact on CDI rates as will improved antibiotic prescribing. That doesn't mean that we shouldn't be alerting clinicians to this concern. We just decided not to focus on it as a prevention strategy at this time.

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