Silent menace

Commonly known as C. difficile or C. diff, Clostridium difficile may lead to one of the most common health care-associated infections to plague U.S. health care facilities and their patients.

Nearly half a million Americans acquire C. difficile infection (CDI) every year. That number climbs by about 10 percent each year, according to an article on WebMD titled "C. diff Epidemic: What you must know," which can be accessed at http://bit.ly/7o3y61.

Not only has the incident rate increased but the death rate as well, according to the Association for Professionals in Infection Control & Epidemiology (APIC) 2008 "Guide to the Elimination of Clostridium difficile in Healthcare Settings".

CDI is associated with a one-year mortality rate of 16.7 percent, the APIC guide adds.

What's C. difficile?

C. difficile is a bacterium that causes inflammation of the large intestine or colon. Symptoms include diarrhea, fever and abdominal cramps. CDI cases range in severity from mild to serious, and in some cases it can cause death.

The infection is found most frequently in hospital and nursing-home settings and is increasingly common among older adults. People who currently take antibiotics also are more likely to develop CDI because the antibiotics may kill good bacteria in the large intestine as well as the disease-causing bacteria, thus allowing C. difficile to multiply and become a primary organism in the intestine.

In some situations, C. difficile infection easily can be spread from person to person. The infection is most commonly spread through one of three following methods:

• Contact with a health care worker with contaminated hands;
• Contact with a patient with C. difficile infection;
• Contact with the contaminated environment and shared equipment (e.g., light switches, door knobs, trays and patient-care items).

Fighting the spread

C. difficile infections are linked to increased lengths of stay in health care facilities by 2.6 to 4.5 days. The estimated patient care cost per case of C. difficile is $2,500 to $3,500.

In the United States, the cost related to managing this infection is more than $3.2 billion annually, states the APIC C. diff guide. This means that eliminating and preventing the spread of C. difficile should be a primary concern for health care facilities and infection preventionists.

It is important that hospitals and other health care institutions adopt a comprehensive C. difficile prevention program. The 2010 "Clinical Practice Guidelines for Clostridium difficile Infection in Adults," provided by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) outlines specific control measures that include hand hygiene, surveillance, use of contact precautions and private rooms, and environmental cleaning and disinfection. It can be accessed at http://1.usa.gov/kV4b6J.

Hand hygiene. Hand hygiene is one of the cornerstones of an effective infection-prevention program, but low compliance with best practices continues to plague infection-prevention programs.

The ability to maintain clean hands is of special importance to a C. difficile-prevention program, and some of the mainstay hand-hygiene activities may need additional attention and staff education.

Alcohol-based hand-hygiene products have been viewed as a breakthrough for increasing compliance, but they may have limited effectiveness when hands are contaminated with the C. difficile spore. Mechanically washing with soap and water is more effective in physically removing the organism from hands.

This does not mean that alcohol-based hand rubs should be removed from patient care areas where C. difficile has been identified, however. Instead, vigorous monitoring of hand-hygiene practices and heightened attention toward increasing hand-hygiene rates should be among the first responses.

Critical elements of an effective hand-hygiene program include the following:

• Frequently washing hands with soap and water or alcohol-based products when soap and water are unavailable;
• Ensuring gloves are readily available and used by patient care providers;
• Teaching staff how to remove and discard gloves in ways that minimize hand contamination during removal;
• Monitoring staff practices and intervening early if there is lack of adherence with best practices;
• Remembering to include families and visitors in hand-hygiene education.

Conducting surveillance. Hospitals and other health care facilities also should perform surveillance to quickly identify known or suspected cases of C. difficile infection. Standardized case definitions should be used and surveillance should at least be conducted for health care facility-onset C. difficile as a means of detecting outbreaks and monitoring patient safety, according to the SHEA/IDSA clinical practice document.

Contact precautions. Once patients with C. difficile are identified, they should immediately be placed on "contact precautions." Health care personnel must utilize protective equipment, including gowns and gloves, as a means of preventing transmission.

Patients with C. difficile should be placed in private rooms. If single rooms are not available, C. difficile patients can share a room, but each patient should have his or her own dedicated commode and other personal care items. Contact precautions should continue until diarrhea resolves, but may be continued in outbreak situations or when ongoing transmission is present.

Cleaning and disinfection. Effective use of cleaning and disinfection is another important addition to prevention. The role of the environment in infection transmission never has been more important.

Microorganisms are demonstrating a hardiness that allows them to survive on environmental surfaces for extended periods of time. In fact, C. difficile spores can survive on surfaces for several months.

Because of the resilience of these spores, it is important to clean and disinfect surfaces routinely to reduce the risk of transmission. Daily environmental attention is a must if C. difficile transmission is to be prevented.

Health care facilities may elect to change from their routine hospital germicide to one that has a demonstrated effect against C. difficile spores. Switching to an Environmental Protection Agency (EPA)-registered disinfectant such as a sodium hypochlorite (bleach) solution is an important consideration, especially during an outbreak or to address increasing C. difficile rates.

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 included in recommendations by APIC and SHEA as well as the Centers for Disease Control and Prevention to address the challenge of C. difficile.

Selecting appropriate disinfectants and ensuring that staff are properly trained to use them may make a difference in the well-being of the patients. It is important to recognize that staff education and systems support are critical for 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 outlined clearly and tested.

Overcoming obstacles

Like so many professions today, the skills and knowledge required to be a health care professional are not what they were 10 years ago. These days, nurses and other health care staff need training and education so they develop competencies in infection prevention, modes of disease transmission, critical thinking, problem solving, leadership, interpretation of data, implementing change and in understanding systems approaches to care.

Each step may seem as though it is easy to implement, but ensuring consistent application of improvements and the rapid addressing of practice deviations take time and attention. Recognizing that everyone has a stake in improving activities and ideas for successful and sustainable implementation should come from those involved in the process.

Attention to hand hygiene, rapid identification of patients with C. difficile, quick response and isolation, and meticulous attention to the environment are essential steps in a C. difficile-prevention program. Success depends upon involvement and commitment by everyone.

Ruth M. Carrico, Ph.D., R.N., FSHEA, CIC, is 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. She can be contacted at rmcarr04@louisville.edu.