Best Practices for Addressing CDI

ICT spoke with Ruth M. Carrico, PhD, RN, FSHEA, CIC, an assistant professor with the University of Louisville School of Public Health and Information Sciences and associate faculty with the Center for Health Hazards Preparedness, regarding best practices for Clostridium difficile elimination. With more than 30 years of experience in healthcare, Carrico has focused her practice toward issues dealing with infection prevention in the healthcare and public health sectors. She has received training specific for healthcare epidemiology and public health at the Centers for Disease Control and Prevention (CDC) in conjunction with the Rollins School of Public Health at Emory University in Atlanta and the Society for Healthcare Epidemiology of America (SHEA).

Q: What is the level of concern about CDI that you are seeing in hospitals today? Are levels of CDI incidence rising? What is contributing most to increasing C. diff rates?

A: The number of Clostridium difficile infection (CDI) cases is increasing across all healthcare settings in the United States. Nearly half a million Americans acquire CDI every year, and that number climbs by about 10 percent each year. Not only has the incident rate increased, but the death rate has increased, as well. C. difficile infection is associated with a 16.7 percent mortality rate at one year. Therefore, it is important for hospitals, and all healthcare facilities, to take an aggressive approach in order to prevent transmission.

Q: What practices seem to be contributing to CDI proliferation?

A: CDI is not a nationally reportable disease and the true incidence of infection is not known. We know that outbreaks occur due to the environmental hardiness of the bacteria, so it is important that healthcare facilities have the capabilities to quickly recognize an outbreak and implement more intense interventions.

CDI is transmitted from person to person through one of three methods: 1) contact with a healthcare worker with contaminated hands, 2) contact with a patient with CDI or, 3) contact with the contaminated environment and shared equipment. Since CDI is easily spread to others, if hospital staff do not diligently adhere to contact precaution protocols including frequent hand hygiene, the incident rate of CDI could increase.

Q: Inversely, what practices are the very best weapons against C. diff transmission?

A: Attention to hand hygiene, rapid identification of patients with CDI, quick response and isolation and meticulous attention to the cleaning and disinfection of the environment are essential steps in a CDI prevention program. It is also important to recognize that staff education and systems support are critical for a successful implementation. Effort must be devoted toward the development of a complete set of policies and procedures that identify individual and departmental responsibilities in the process. Specific activities, including the order of cleaning and disinfection, must be clearly outlined and monitored. Sharing results from practice monitoring is especially helpful in order to assist staff with performance improvement.

Q: Current best practices can sometimes be thwarted by evolving, mutating strains what are the special approaches being advocated in this case?

A: One of the primary challenges with C. difficile involves the dramatic changes in CDI epidemiology. Not only has there been an overall increase in the incidence of CDI, but outbreaks have increased in severity as well. This newer strain of C. difficile is commonly known as NAP1/B1/027 and may be referred to as the "toxigenic" strain of C. difficile. Due to the threat that this new strain has already posed for patients, activities have to be designed so early recognition, attention to environmental cleanliness, and adherence with isolation precautions are all part of usual practice.

Q: What are the misperceptions about what kills spores?

A: C. difficile spores are very hardy microorganisms that can survive on surfaces for several months at a time. Even the physical act of hand washing may not be enough to remove all CDI spores. Because of the resilience of these spores, it is important to routinely clean and disinfect surfaces to reduce the risk of transmission. It is also important for staff follow the disinfectant products label instructions to ensure the correct contact time is implemented. Daily environmental attention is vital to prevent C. difficile transmission.

When CDI is present, facilities may want to switch from a standard hospital germicide to a U.S. Environmental Protection Agency (EPA) registered 1:10 hypochlorite or bleach solution with proven efficacy against C. difficile spores. One example of such a product is Clorox® Germicidal Bleach. This product has a demonstrated effect against C. difficile and may be used to clean and disinfect the environment including many pieces of patient care equipment. It is also important that staff follow the product label instructions to ensure the correct contact time is implemented.

Q: What is your advice for tackling a C. diff outbreak?

A: There are four essential steps to dealing with a C. difficile outbreak: 1) attention to hand hygiene, 2) rapid identification of patients with CDI, 3) a quick response and isolation, and 4) meticulous attention to the environment.

Hand hygiene: The first step for prevention is vigorous monitoring of hand hygiene practices and heightened attention toward increasing hand hygiene rates. Educating staff and visitors of these practices is crucial to reducing the spread of CDI. Critical elements of an effective hand hygiene program include:

- Frequent washing of hands with soap and water, or alcohol-based products when soap and water are unavailable

- Ensure gloves are readily available and used by patient care providers as a means of preventing hand contamination

- Teach staff how to remove and discard gloves (and other pieces of personal protective equipment) in ways that minimize hand contamination during removal.

- Monitor practices of staff and intervene early if there is lack of adherence with best practices

- Remember to include families and visitors in hand hygiene education

Isolation and surveillance: Once a patient experiences symptoms that may be associated with a transmissible infection, such as diarrhea, they should be isolated immediately. An assessment should be performed to determine the cause. Patients with C. difficile should be placed in private rooms. If single rooms are not available, co-horting can be done with other C. difficile patients but each patient should have their own dedicated commode and other personal-care items.

Contact precautions: All staff entering the isolation environment should be instructed to wear the proper protective equipment. For C. difficile, this includes gowns and gloves. Visitors should also be educated and encouraged to frequently wash their hands and wear the protective gown and gloves when in the patient environment. Contact precautions should continue until diarrhea resolves but may be continued in outbreak situations or when ongoing transmission is present.

Environmental cleaning and disinfection: Cleaning the environment and using an appropriate disinfectant is critical to helping prevent the spread of pathogens that cause CDI and protecting the well-being of patients. The use of a product that is registered by the EPA for proven efficacy claims is crucial. Bleach is approved by the EPA to kill many types of problematic organisms including C. difficile spores. Using a 1:10 bleach solution as a disinfectant is also included in recommendations by the Association for Professionals in Infection Control and Epidemiology (APIC), the Society for Healthcare Epidemiology of America (SHEA) and the Centers for Disease Control and Prevention (CDC) to address the challenge of C. difficile.

Each of the aforementioned steps may seem like they are easy to implement, but ensuring consistent application of improvements and the rapid addressing of practice deviations take time and attention. Successful outcomes are dependent upon the involvement and commitment of everyone.