Killing C. diff can save lives

This initiative is funded by an unrestricted educational grant from Clorox Healthcare™.

Of all the multidrug-resistant organisms that can lead to health care-associated infections (HAIs), Clostridium difficile is among the most prevalent and serious threats to patient safety and most costly to hospitals. The numbers tell the story.

“The incidence, mortality and medical care costs of CDIs [C. diff infections] have reached historic highs,” the Centers for Disease Control and Prevention noted in its March 6 issue of Morbidity and Mortality Weekly Report. Among the report’s findings:

• In 2006 and 2007, an estimated 14,000 patients per year died from causes attributed to CDI, based on multiple cause-of-death mortality data. That’s a better than fourfold increase from 1999 to 2000, when an estimated 3,000 deaths per year were attributed to CDI. More than 90 percent of these deaths occurred in patients aged 65 or older, but nearly half of the C. diff infections occurred in people younger than 65. Similarly interesting, 75 percent of C. diff cases began in settings other than hospitals.
• The number of hospitalized patients with any CDI discharge diagnoses more than doubled to 336,000 between 2000 and 2009. The number of patients with a primary CDI diagnosis tripled, from 33,000 to 111,000 during this time.
• Recent data show that excess health care costs of hospital-onset CDI are estimated at between $5,042 and $7,179 per case. Nationally, this equates to between $897 million and $1.3 billion. “C. difficile harms patients just about everywhere medical care is given,” CDC Director Thomas R. Frieden, M.D., M.P.H., noted in the March report. “Illness and death linked to this disease do not have to happen.”

This last point is underscored in the CDC report, noting that hospitals should focus on four key areas to reduce CDIs: improving antibiotic stewardship, early and reliable detection of CDIs, isolation of symptomatic patients, and reducing C. diff contamination of health care environmental surfaces.

John Scherberger, CHESP, president of Healthcare Risk Mitigation Inc., Spartanburg, S.C., argues that clinicians, environmental services and infection prevention professionals together should take a more holistic approach to preventing the spread of C. diff. This will necessitate strict adherence to hand-washing protocols and donning appropriate personal protective equipment — steps he believes hospitals should consider expanding to visitors of C. diff patients. Finally, C. diff patient rooms and high-touch surfaces should be cleaned with an EPAregistered spore-killing hypochlorite disinfectant.

This latter point should not be overlooked, Scherberger counsels. “It’s required by the CDC and organizations such as the Joint Commission. The Centers for Medicare & Medicaid Services also requires that facilities use a hospital-grade sporicidal disinfectant. As C. diff spores grow, they build up a hard shell and only a few products will penetrate and kill the microbial bacteria inside the spore,” he explains.

Robert Orenstein, D.O., consultant on infectious diseases at the Mayo Clinic in Arizona, and several colleagues conducted a study aimed at reducing CDI incidence on two units at Saint Marys Hospital in Rochester, Minn., using germicidal bleach wipes. The study, published in the November 2011 issue of Infection Control and Hospital Epidemiology, found steep reductions in CDIs.

The units were selected because they were contiguous and had high endemic CDI rates. From Aug. 1, 2008, through Aug. 1, 2009, all rooms were cleaned daily and at discharge with a quaternary ammonium compound. The following year, housekeepers replaced the quaternary product with germicidal bleach wipes containing 0.55 percent active chlorine. During the intervention, identical cleaning protocols were employed for high-touch surfaces with both products. The results: In the year that germicidal bleach wipes were used, hospital-acquired CDI plummeted from 24.2 to 3.6 cases per 10,000 patient days — a nearly sevenfold decrease.

“The idea behind this project was that these two units had high endemic rates of C. diff — many were patients admitted with other GI tract diseases,” Orenstein says. “Because colonization pressure was high, we felt that targeting this unit for daily cleaning would reduce the environmental burden of C. diff and hence reduce disease transmission, which is exactly what we found.” Orenstein recommends ES team leaders focus on seven critical steps to reduce CDI rates.

1. Ensure that basic measures of contact isolation, hand hygiene and appropriate antimicrobial use are followed.
2. Teach ES staff about the local epidemiology of C. diff, i.e., which units, patients, etc., are at risk.
3. Apply this information through targeted interventions to those units at highest risk.
4. Work as a team with ES, infection prevention and the clinical staff on these units to identify the best solutions to C. diff problems.
5. Use sporicidal agents in rooms that have been cleaned effectively.
6. Deploy simple tools such as adenosine triphosphate testing to monitor cleaning thoroughness, audit periodically and provide feedback to ES staff to help improve their cleaning.
7. Empower ES staff so they understand the importance and value of their work in protecting patients.

Scherberger advises ES teams to use appropriate cleaning tools and disinfectants to prevent the spread of C. diff. “Sporicidal agents are just one step in the process. We have to understand the nature of the cleaning process and the products that we’re using,” he says. He notes that many ES teams continue to use cotton string mops and cleaning rags, which have proven ineffective in removing C. diff spores. Cotton fibers are much too large, Scherberger says, to capture and remove C. diff spores; instead, cotton products tend to move the bacteria around. Microfiber cleaning products have small enough fibers to grab and remove the microscopic bacteria from surfaces, he adds.

Lack of time is another critical issue for ES, infection prevention and clinical teams to address. Scherberger notes that ES staffs have been on the front line of employee cuts in recent years as hospitals focus on cost reduction. At the same time, many ES teams have found themselves responsible for an increasing amount of square footage for new and renovated facilities, ambulatory clinics and other assets that have been added to hospital campuses.

With this in mind, ES leaders need to ensure that staff follow industry standards from the Association for the Healthcare Environment for terminal cleaning and that they strictly follow disinfectant dwell times when cleaning.

“We have guidelines that say 45 minutes is minimum time for terminal cleaning. Once the room is terminally cleaned, it should take another 10 to 15 minutes to go through and disinfect the room with an EPA-registered sporicidal agent,” Scherberger says.

For ES teams, getting that full hour of cleaning and disinfection time in C. diff discharge rooms is running headlong into high patient census counts and demands to reduce admission times. But as with other areas of solving the C. diff challenge, Scherberger says it will take a collaborative effort among ES, infection prevention, clinical and administrative leaders to address this issue.

Resources

• Centers for Disease Control and Prevention, Vital Signs report on stopping C. diff infections
• Association for the Healthcare Environment, Best Practices in Environmental Cleaning and Surface Disinfection webinar
• Association for Professionals in Infection Control and Epidemiology: Clean Spaces, Healthy Patients webinars on the role of surfaces in the transmission of C. diff