COVID-19 Mitigation Efforts Helped Stonewall C. Diff at Hospital

Investigators at Mount Sinai Morningside in New York City wanted to find out if Clostridium difficile spiked during the COVID-19 surges that battered the health system in 2020. To their pleasant surprise it did not, according to a study unveiled today at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC). Investigators compared C. diff rates in March, April, and May of 2020 to the rates in the same 3 months in 2019. Barbara Smith, RN, BSN, MPA, CIC, an infection preventionist (IP) at the hospital and one of the authors of the study, says that she was pleasantly surprised by the results. “The other factor that we looked at was: Were people not testing the same amount?” Smith tells Infection Control Today®. “Maybe the doctors were just starting treatment without testing.” That wasn’t happening, either, says Smith. What was happening was a significant increase in hand hygiene compliance, going from about 84% in 2019 to well over 90% in 2020. However—and perhaps of concern to IPs—Smith has seen a slight drop-off in hand hygiene since the COVID-19 pandemic began to wane. However, COVID-19 created closer ties between Morningside’s infection prevention department and other departments, such as data management. That way IPs “can be out with the staff members, rather than stuck to being at a desk trying to calculate numbers.”

Infection Control Today®:Tell us a little bit about your study and what you found.

Barbara Smith, RN, BSN, MPA, CIC:During the first part of the wave, we really had to just focus on making sure the staff and the patients that were coming to the hospital were safe from COVID. And all of the resources and attention for the infection preventionists were devoted to that. When we were finally able to catch a breath, we did notice that some of the infections were on the increase. Most notably were the central line-associated bloodstream infections. And we could attribute some of that to the amount of care that the patients needed, the types of treatment like the antibiotics that they were receiving. Although it was alarming because the rates were higher

Barbara Smith, RN, BSN, MPA, CIC

than what we had successfully achieved in the past, it was understandable given the crisis situation and the condition of the patients. But the one interesting factor was we wanted to see what was going to happen with the C. difficile. You would think that with the amount of antibiotics these COVID patients received that that should have gone up the roof and it didn’t. We were very cautious about making any statements whether it was a valid result or not until a few months after [when] the pandemic slowed. We were able to more fully assess what was going on with their C. difficile rates. What we did was compare the three months in March, April, and May of 2020 which was—in New York City—the height of the pandemic, to the same three months in 2019. We looked at both the number of C. difficile cases per 10,000 patient days, which is the number that we calculate with NHSN all the time. And we also looked at the number of tests that were performed during those two periods.

Infection Control Today®: There was a statistically insignificant uptick between 2019 to 2020: 0.48% per 10,000 patient days in 2020 [days], right? Where in 2019 it was zero, right? That’s pretty impressive. Were you surprised?

Smith: Should I say I was relieved? Well, you didn’t need anything else to worry about. But we were a little surprised, to be honest. We would have been understanding if the rate had gone up. So, we were a little surprised that it did remain the same as compared to the prior year. The other factor that we looked at was: Were people not testing the same amount? Maybe the doctors were just starting treatment without testing. But that, too, was not found to be statistically significant. The volume of patients tested in 2019 was the same, or similar, as the volume in 2020. We didn’t feel like people were just missing the cases. The people that were diagnosed and that did need treatment we’re getting it. And the other thing we looked at … we have a PhamD who’s part of our program. She specializes in appropriate antibiotic treatment as part of the antibiotic stewardship group. She looked at how many people got oral Vancomycin, which is considered a treatment for C. difficile to see if it was valid. And of the people who got it, there was the one case in 2020 who had C. diff. So that was valid. There was another woman who had come in with C. diff. She was valid to receive that treatment. And all but one of the other ones had some significant reason for getting that treatment even without the C. diff—they had been tested for C. diff and found negative. And then the oral Vancomycin would be either stopped or continued because they had another medical reason for it. We did all of those things to make sure we weren’t missing any of the C. diff cases. And at the conclusion of our study, we did not feel like we had missed any cases.

ICT®: As you know, flu practically disappeared this year.

Smith: It’s true. That’s true.

ICT®: Many medical experts say that happened because the things we did to protect ourselves against COVID-19—hand hygiene, social distancing, masking—stopped the flu in its tracks. Now, as I recall from your study … I don’t know whether you came flat out and said this or perhaps just the implication was there. The reason that C. diff was held to such a low rate in 2020 was because the things health care professional were doing because COVID-19 helped to stop C. diff. Is that a fair assumption?

Smith: I think so. I think we’ve not only seen that but some…. There’s been a study out of Spain. It’s quoted at the end of our program and that does support that as well. I think one of the biggest things that we can demonstrate with data is that the compliance with hand hygiene certainly increased during that time period. It went from about 84% in 2019 to well over 90% in 2020 because people were concerned. The staff was nervous and worried about themselves. And probably two other factors that might have impacted on it was people were using more gloves and gowns. So, they were better about personal protective equipment [PPE]. And finally, people were disinfecting more. We definitely had an increased volume of sanitary wipes, you know, disinfectant wipes that we were buying and using. We were fortunate at my facility and of course, my hospital system, as well, that we may not have always had our first choice of disinfecting wipes, but we always had something that was effective against C. difficile. Normally, you would think of it as a bleach wipe. I think those three factors combined probably helped keep the rate down.

ICT®: Will that continue as COVID-19 ends and goes away? Or will people let their guards down?

Smith: You’ve been in the business, I know, for a while, and you’ve often talked to people about compliance rates. So yeah, I think the hand hygiene has seen a little bit of a drop. People have been a little bit less faithful about doing their hand hygiene in and out of the rooms. I can’t say that’s a problem on the isolation cases; people that are on precautions. People are usually pretty good about washing when they come out of the room. But in general, from patients that you may not know about, they’ve been a little lax. And you may have heard the term PPE fatigue. It has more to do with people wanting to not use the mask anymore. That wouldn’t have as much impact C. difficile, but certainly would have an impact on COVID-19. We might be getting a little too relaxed on them.

ICT®: How has your job as an infection preventionist changed over the years in terms of controlling and preventing C. diff?

Smith: I think there are probably two factors that are both changing and also need to be addressed a little bit more. Having followed one of the Twitter accounts…. It’s a case where the mother died after getting antibiotics from a dental appointment and then developing C. diff. I think that we need to do a little bit more with the public in terms of antibiotic use in the community. So that they’re not at risk for C. diff for whatever reason later in their life. That’s one point that I know APIC has been working on in terms of infographics for antibiotic stewardship and what to tell your provider or what to ask your provider for when you might or might not need antibiotics. The other thing is in the in-hospital settings, not so much in nursing homes because of the cost. There are these other disinfection methods such as ultraviolet lights that have been proven in multiple studies to be effective at getting rid of the C. diff spores. Of course, it doesn’t eliminate the process of terminally cleaning the room the old-fashioned [way with] elbow grease. But as a supplemental factor, the ultraviolet lights and other types of touchless disinfection have really helped decrease the rates across inpatient settings. They haven’t really been mobilized in nursing homes yet. One because of the cost. Two, because the types of furniture that are in nursing homes are somewhat different, obviously, than what’s in hospitals.

ICT®: A two-part question for you. Do you think infection preventionists in general are part of the antimicrobial stewardship program? And are you specifically involved in the antimicrobial stewardship program where you are?

Smith: Oh, that’s a great question. I think that the role for the infection preventionist is still evolving in terms of antibiotic stewardship. And the best way to think of it is that we’re part of that interdisciplinary team that would help bridge between, let’s say, that licensed care provider, like the physician or the physician’s assistant, and the pharmacy staff that has the expertise. I think [at the] major academic centers, they’re realizing that the pharmacy, especially the PharmDs, have a wealth of knowledge that can help in this area. So as part of a team, the infection preventionist have a role there in terms of helping educate the online staff about the role of infection, the role of antibiotic stewardship. The other thing that all of us infection preventionists say: We’re in the business of preventing you from getting infection. It removes the need for an antibiotic. That’s our first role in terms of stewardship. In our facility, we do have a specific program about it. And one of the direct links that we have in terms of my department, myself, is helping with the antibiotic stewardship monitoring for surgical infections. Like if somebody does develop a surgical infection, we always try to look back to see was that antibiotic appropriate? And was it given in a timely fashion? I have to say the other collaboration that we have as part of the stewardship program is we involve the PharmD every time we do have a C. diff case in terms of: Could we have done something different? Could we have changed some of the other treatments? Like the other non-antibiotics that might influence somebody getting C. diff. Like laxatives, for instance?

ICT®: How do you contain C. diff once it breaks out? Once you’ve discovered it in one patient?

Smith: Our objective is to keep them in the room by themselves. We generally don’t let them leave the room for anything other than a regular medical test. We would not encourage those people to go to the physical therapy area, for instance. And we of course don’t want them out in the lounge area, the common lounge. This is assuming that we don’t have COVID, right? Because all the rules changed during COVID. Nobody went anywhere then. And people that are entering the room can use a sanitizer to go in. They do wear full gloves and gowns. They should be removing that before they leave the room. And using soap and water when they exit the room. Because as you know the alcohol sanitizers don’t kill the spores. And, actually, neither does the soap and water. It just flushes it down the drain. One of our changes—I guess it’s probably two years [ago], it was pre-COVID—is that we made a different sign for our people that are on special contact precautions. There are a few other organisms like norovirus that would qualify for that one. And so, it’s brown, making the association with the symptom that’s most prevalent with this disease.

ICT®: Very nicely put. Your role as an infection preventionist. Obviously, you were much in demand during COVID-19. Do you see the demand for infection preventionists growing in hospitals? Is your department specifically going to add more infection preventionists? Are you trying to lure people from other health care professions—such as nurses—into the infection prevention department in your hospital?

Smith: It would be wonderful to say that we could get more staff. But at this point we’re not. We’re not able to hire anybody. But I think one of the things that we’re looking at from the APIC point of view is how do we create that pipeline for people? It does take a long time for somebody to…. Most people don’t come to this job with the experience. Even the educational experience or the practical experience. It does take more than a year before people actually feel comfortable making that transition because you need a certain amount of autonomy to become an infection preventionist. It can sometimes be challenging. APIC is one group that is trying to look for different ways to develop that pipeline, both in a formal academic setting, as well as an informal type of mentorship or internship program. In our facility … of course because I’m in New York, in Manhattan. And I think I can speak for both the acute care facilities and nursing homes. It is challenging to recruit because people don’t have that experience. And it does take a long rollup time.

ICT®: APIC came up with the system where you start as a novice and eventually become—I don’t know if they use the term “expert,” or not. But is that the system that you’re using there?

Smith: We have the traditional director, assistant director, that kind of thing. But we certainly have people within our system, because we’re an eight-hospital system, that we each feel like we’ve assigned ourselves at what level you feel comfortable at. So, across our system, I guess we have about 25 or 30 IPs, I don’t know the exact number. But we know the novices certainly feel comfortable reaching out to those of us that feel more proficient. And even within that group—and I think that this is an important distinction—somebody might feel like they’re a novice in one part of the field. Like they don’t know the operating room, but they feel like they’re proficient in things like the isolation practices for C. diff. You could be across two levels actually. The other part, I think that we're realizing both in my system, as well as across the country, is that other support services, such as data managers and data mining programs, can help support the role of the infection preventionist, so that we can be out with the patients, we can be out with the staff members, rather than stuck to being at a desk trying to calculate numbers. I see that as part of the future, too. Looking into a different variety of roles within an infection prevention department.

ICT®: Is there anything I neglected to ask you that you think is pertinent and that you want your fellow infection preventionists to know about regarding infection prevention in general, and infection prevention against C. diff in particular?

Smith: You covered all the bases that we would have talked about, so I appreciate that. I do think people should look at the APIC website. Even if you’re not a health care professional, there is a lot of community information there as well. And even within our members, we don’t have the time to see every…. We get emails directing us to what the new information is that’s coming out. But it’s hard to get to every piece of email that you see. It’s great to go back to the APIC website, which is APIC.org. And you can find a lot of things that you could use if, let’s say, you have to do a paper because you’re going back to school. There’s a lot of information there. Or even if your child needs some help with something that they’re preparing for school, I often send people to that [website] and say, “Don’t recreate the wheel. APIC has already done it for you.”

This interview has been edited for clarity and length.