C diff Remains a Challenge Even for Nation's Top Hospitals

Norra MacReady

September 30, 2016

Some of the nation's largest and most prestigious teaching hospitals now have a more dubious distinction: rates of Clostridium difficile infection that fall short of the national benchmark, according to a new survey published online September 27 in Consumer Reports. The survey evaluated 3100 hospitals, of which more than one third got low marks for C difficile infection control.

Among those were 19 renowned teaching hospitals, such as Baylor University Medical Center in Dallas, Texas; Cedars-Sinai Medical Center in Los Angeles, California; and Brigham and Women's Hospital in Boston, Massachusetts. All the teaching hospitals mentioned have at least 500 beds and had more than 200,000 patient days during the reporting period.

Many of these hospitals also fared poorly the last time the survey was conducted in March 2016.

The data come from the National Healthcare Safety Network, which is overseen by the Centers for Disease Control and Prevention (CDC) and is the nation's most widely used healthcare-associated infection tracking system. They cover the period between October 2014 and September 2015. "The CDC adjusts to account for factors such as the hospital's size, whether it's a teaching hospital, and how common C. diff is in the community around the hospital," author Jeneen Interlandi writes. Since 2013, hospitals have been required to report all C difficile infections that originate at that facility, except for locations with mainly infants.

C difficile is shed in feces, and any surface contaminated with feces can serve as a reservoir for the bacteria's spores. They are transmitted most often on the hands of healthcare workers who touch a contaminated surface and then care for another patient. The spores "can survive for weeks on a range of surfaces, including doorknobs and bed rails," Interlandi writes. More than 500,000 people contract C difficile infection, and 29,000 people die from it annually, usually in hospitals and other healthcare settings.

The tools for fighting C difficile are inexpensive and readily available: "soap, gloves, disinfectants, and the proper use of antibiotics." However, they must be used repeatedly and meticulously, which can be a challenge for large hospitals that treat thousands of patients. For example, a hospital room must be scrubbed with powerful germicidal agents such as bleach or other cleaners approved by the Environmental Protection Agency after every stay by an infected patient. Other measures such as wearing gloves and conscientious hand washing may seem simple, but are often forgotten by busy healthcare workers.

Judicious use of antibiotics is another important factor in controlling C difficile. At this time, as many as 50% of antibiotic prescriptions are unnecessary or inappropriate, Interlandi writes. Only 39% of US hospitals have antibiotic stewardship programs; the CDC is trying to increase that to 100% by 2020.

However, comparing hospitals requires some caveats, despite the adjustments used by the CDC, Susan Bleasdale, MD, told Medscape Medical News. "Many facilities have changed to nucleic acid amplification testing (NAAT), and there have been several studies that show there is a significant increase in the number of C. diff infections identified with NAAT compared to previous testing. Therefore, comparing facilities with different methods of testing may not be an equal comparison."

What is more, it may be misleading to compare large teaching hospitals that admit sicker, more complicated patients with smaller community hospitals where the patients are less challenging, said Dr Bleasdale, assistant professor and Infection Control Medical Director, University of Illinois at Chicago Department of Medicine Section of Infectious Diseases.

"Patients with complex medical problems often have a true indication for antibiotics, and the risk of C. diff does not outweigh the risk of complications from an untreated infection. In addition, needed chemotherapy and immunosuppressant medications for transplant patients also upset the bacterial balance in the colon, but cannot be withheld," she continued.

Dr Bleasdale also points out that stewardship programs exist in more than 55% of hospitals with at least 200 beds compared with 25% in smaller facilities "It does illustrate the need for more stewardship in smaller facilities and more support for all facilities to improve antibiotic stewardship." In 2014, the CDC and the President's Council of Advisors on Science and Technology published the National Strategy for Combatting Antibiotic Resistant Bacteria, which, among other things, advocated the use of evidence-based methods to enhance stewardship. The American Hospital Association, the Agency for Healthcare Research and Quality, the Centers for Medicaid and Medicare Services, and the Joint Commission all have developed standards on stewardship as well, which should bring it "to the attention of the C suites of facilities and require them to carve out resources and support structures for stewardship."

Physicians should urge hospital patients to be alert to the symptoms of C difficile infection so they can be diagnosed and treated quickly, said Dr Bleasdale, who is a member of the Clinical Affairs Committee of the Infectious Disease Society of America. "If you have diarrhea after getting antibiotics or during a hospital stay or after a hospital stay or procedure, ask your doctor if it could be C. diff. When your doctor prescribes antibiotics, ask why you need them and for how long. And ask your providers to wash their hands before they care for you. They should thank you for the reminder to protect you and all our patients."

Interlandi and Dr Bleasdale have disclosed no relevant financial relationships.

Consumer Rep>. Published online September 27, 2016. Abstract

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