Guide to the Elimination of Clostridium difficile in Healthcare Settings
Transcript of Guide to the Elimination of Clostridium difficile in Healthcare Settings
Guide to the Elimination of Clostridium difficile in Healthcare Settings
About APICAPIC’s mission is to improve health and patient safety by reducing risks of infection and other adverse outcomes. The Association’s more than 12,000 members have primary responsibility for infection prevention, control and hospital epidemiology in healthcare settings around the globe. APIC’s members are nurses, epidemiologists, physicians, microbiologists, clinical pathologists, laboratory technologists and public health professionals. APIC advances its mission through education, research, consultation, collaboration, public policy, practice guidance and credentialing.
An APIC Guide
2008
Look for other topics in APIC’s Elimination Guide Series, including:
• Catheter-Related Bloodstream Infections• Catheter-Related Urinary Tract Infections• Mediastinitis• MRSA in Long-Term Care
Copyright © by 2008 APIC
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission of the publisher.
All inquires about this document or other APIC products and services may be addressed to:
APIC Headquarters
1275 K Street, NW
Suite 1000
Washington, DC 20005
Phone: 202.789.1890
Email: [email protected]
Web: www.apic.org
Cover photo courtesy of CDC.Micrograph of the bacterium Clostridium difficile made from an impression smear of 72hr anaerobe blood agar (1980). ISBN: 1-933013-37-0
For additional resources, please visit www.apic.org/EliminationGuides.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY �
Table of Contents 1.Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.GuideOverview......................................................................5
3.PathogenesisandChangingEpidemiologyofClostridium difficileInfection(CDI). . . . . . . . . . . . . . . . . . 7
4.CDIinthePediatricPopulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
5.ModesofTransmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
6.Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
7.Surveillance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
8.FocusingonPrevention:ContactPrecautions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
9.FocusingonPrevention:HandHygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
10.FocusingonPrevention:EnvironmentalControl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
11.TieredResponsetoC. difficile. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38SummaryofC. difficileTransmissionPreventionActivitiesDuringRoutine
InfectionPreventionandControlResponses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38SummaryofAdditionalC. difficileTransmissionPreventionActivitiesDuring
HeightenedInfectionPreventionandControlResponses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
12.OtherPreventiveMeasures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
13.AntimicrobialStewardshipandClostridium difficile: APrimerfortheInfectionPreventionist . . . . . . . . 43
14.UsingaSystemsApproachtotheEliminationofClostridium difficileInfection(CDI) . . . . . . . . . . . . . . 49
15.GlossaryofTerms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
16.FrequentlyAskedQuestions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
17.References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Guide to the Elimination of Clostridium difficile in Healthcare Settings
� ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Acknowledgments
ThechallengesposedbyClostridium difficilerepresentsomeofthemostdifficultandalarmingissuesconfrontinginfectionpreventionandcontrol.Theelementsinvolvedinaddressingthisproblem,aswellasthechangingepidemiologyofC. difficile,havecollided,resultinginapreventionandcontrol“perfectstorm.”Thishasalreadyimpactedthehealthandsafetyofpatients,regardlessofwhethertheyreceivecareinahospital,long-termcarefacility,outpatientsetting,ambulatorycaresetting,oraphysician’soffice.
ThedifficultiespresentedbythisorganismserveasacatalystforincreasingcollaborationamonghealthcarepersonnelandprovidersasweworktogethertominimizetheimpactofC. difficileandmaximizepatientsafety.Theprevalenceofthisorganismhighlightstheneedtocontinuestrongrelationshipsbetweeninfectionprevention,themicrobiologylaboratory,andpharmacy.
ThisguideprovidescurrentinformationregardingC. difficileanditsimpactonthepatientandthecareenvironment,andintroducesatieredapproachthatinfectionpreventionistscanuseintheirownfacilities.Specifictoolshavebeenincludedtoenablethepreventionisttoaddresstheproblemwithintherealmofaparticularsetting.TheAssociationforProfessionalsinInfectionControlandEpidemiology(APIC)acknowledgesthevaluablecontributionsfromthefollowingindividuals:
AuthorsRuthM.Carrico,PhD,RN,CICLennoxK.Archibald,MD,PhD,FRCP(Lond),
DTM&HKrisBryant,MDErikDubberke,MDLorettaLitzFauerbach,MS,CICJulietG.Garcia,MS,MT(ASCP),CICCarolynGould,MD,MScBrianKoll,MDJennieMayfield,BSN,RN,MPH,CICXinPang,MDJulioA.Ramirez,MD,FACPDanaStephensRN,CICRachelL.Stricof,MT,MPH,CICTimWiemken,MPH,CIC
ReviewersKathleenMeehanArias,MS,MT,SM,CICCandaceFriedman,MT(ASCP),MPH,CICJeffKempterMichaelOttlinger,PhDJudyPotterWilliamRutala,PhD,MPHMarionYetman,RN,BN,MN,CIC
SpecialthankstoJuliaJ.Fauerbach,interiordesigner,ShandsHealthcarebusinessassociate,M.ArchandHealthcandidate,ClemsonUniversity2009,forherartistryandknowledgeregardingphysicalelementsanddesignofthepatientroom.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY �
Guide Overview
TheimpactofClostridium difficileInfection(CDI)hasbeenfeltacrosstheentirespectrumofhealthcareandisnowrecognizedasapathogencapableofcausinghumansufferingtoadegreematchingthatofMethicillin-resistantStaphylococcus aureus.Theseverityofdiseaseisincreasingandhasaffectedchildren,adults,andtheelderly.CDIisassociatedwithanincreasedlengthofstayinhealthcarefacilitiesby2.6to4.5daysandattributablecostsforinpatientcarehavebeenestimatedtobe$2,500to$3,500perepisode,excludingcostsassociatedwithsurgicalinterventions.IntheUnitedStates,theeconomicconsequencesrelatedtomanagementofthisinfectionexceeds$3.2billionannually.Sadly,CDIhasbeenassociatedwithanattributablemortalityrateof6.9%at30daysand16.7%atoneyear.1-6Clearly,preventingthedevelopmentandtransmissionofCDIshouldbeatoppriorityforinfectionpreventionistsinallhealthcaresettings.
AsratesofCDIcontinuetoincreasenationallyandinternationally,itisimportantthatinformationprovidedinthisguidestartatthebeginninginitsdescriptionoftheproblem,includeincrementalstepsthatidentifytargetedareasforintervention,andprovideclearguidanceforimplementation.
Theconceptsofintervention“bundling”anduseofatieredapproachrepresentanorganizedapproachtoaddresspreventionofC. difficiletransmissionapplicableinallhealthcaresettings.TheuseofatieredapproachisconsistentwiththerecommendationsfromtheHealthcareInfectionControlPracticesAdvisoryCommittee(HICPAC)andtheCentersforDiseaseControlandPrevention(CDC)regardingpreventionofmultidrug-resistantorganisms(MDROs).7
ConsiderthefollowingexamplesofCDIamongpatientsacrossthespectrumofhealthcare:
• 48-year-oldmale,treatedwithantibioticsforhealthcare-associatedinfection,developsCDIwhileaninpatientinanacutecarefacility
• 25-year-oldfemale,givenasingledoseofantibioticsassurgicalprophylaxis,developsCDIwithindaysafterreturninghome,followingasurgicalprocedureinanoutpatientsurgicalsetting
• 62-year-oldmale,developsCDIwhilearesidentinalong-termcarefacility• 51-year-oldfemale,developsCDIaftertakingacourseofantibioticsprescribedbyherprimarycare
provider• 12-year-oldfemale,developsCDIfollowingacourseofantibioticsprescribedduringtreatmentfora
chronicmedicalcondition
BeforetheincidenceofC. difficileincreasedandmorevirulentstrainsemerged,healthcareteamsoftenconsidereddiarrheaassociatedwithantimicrobialtherapyanuisance,andperhapsevenanacceptedoutcomeforpatientsreceivingantibiotics.Complacencytowardthishealthcare-associatedcomplicationcannolongerexistatanypointinthehealthcarespectrum,includingambulatorycare,acutecare,long-termcareandhomecare.TheseveremorbidityandmortalityassociatedwithC. difficileprovidestheimpetusforhealthcareproviderstointensifyeffortstowarddevelopingpreventionstrategiesthatcanbeconsistentlyappliedacrossthecontinuumofhealthcare.Althoughitisrecognizedthatfew“onesizefitsall”initiativeswork,thegoalofthisguideistobuildonevidencethat“bundling”ofactivitieshasbeeneffectiveinaddressingotherhealthcare-associatedinfections,ashasuseofatieredapproachforinterventionsguidedbyoutcomesinthespecifichealthcaresetting.
AbundledapproachtoC. difficilepreventionandcontrolattheUniversityofPittsburghincludededucation,enhancedcasefinding,expandedinfectioncontrolmeasures,theformationofaC. difficilemanagementteam,
Guide to the Elimination of Clostridium difficile in Healthcare Settings
� ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
andimplementationofanantimicrobialstewardshipprogram.8McDonaldanalyzedtheMutoandcolleagues’reportandconcludedthatthebundledapproachreflectedsuccessive,tieredinterventionsbasedondatafromtheirsurveillance.Thishighlightstheimportanceofusinglocaldatatodriveprioritysetting,andchoiceandtimingofinterventions.9AsanorganizationfocusesonCDIprevention,healthcarefacilitiesshouldevaluatetheirlocalsurveillancedataandselectappropriateinterventionsthataddresstheirparticularsituation.ElementsofaCDIbundleincludeactivitiessuchasthefollowing:
• EarlyrecognitionofCDI,throughappropriatesurveillancecase-findingmethodsandmicrobiologicidentification
• Implementationofcontactprecautions,inadditiontostandardprecautionsandpatientplacement• Establishmentandmonitoringofadherencewithenvironmentalcontrols• Handhygienemeasures• Patientandfamilyeducation• Evidence-basedmethodsforpatienttreatmentandmanagementofdisease• Antimicrobialstewardship• Educationofhealthcareworkers• Administrativesupport
Inthesectionsthatfollow,theseelementswillbediscussedatlength,followingareviewofthepathogenesisofCDI,itschangingepidemiologyandmodesoftransmission.Bundleelementsareorganizedinthesectionsoutliningroutineandheightenedinfectionpreventionandcontrolresponses.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY �
Pathogenesis and Changing Epidemiology of Clostridium difficile Infection (CDI)
TounderstandthechainofeventsinvolvedinCDI,itishelpfultobeginwithanoverviewoftheorganismandhowitaffectsanindividual.AreviewofthepathogenesisandthechangingepidemiologyofC. difficile provideinsightintopointswherepreventiveinterventionscanbestbetargeted.
Clostridium isananaerobic,gram-positive,spore-formingbacillus.WithinthegenusClostridium,thereareanumberofspecies,includingC. tetani, C. botulinum, C. perfringens and C. difficile.Alloftheseorganismsareassociatedwithsignificantdiseaseinhumans,butthefocusofthisguideinvolvesillnessassociatedwithC. difficile.Someproducenotoxin,someproducelowlevelsoftoxin,andsomearehighlytoxigenic.
Priortothemid-1970s,developmentofpseudomembranouscolitiswasrecognizedtooccurfollowingtheuseofsomeantibiotics,especiallyclindamycinandlincomycin.Pseudomembranouscolitisisaninflammatoryconditionofthecolonthatdevelopsinresponsetotoxinsthathavebeenproducedbymicroorganisms.Thisprocessoccurswhenthenormalfloraoftheintestinaltractisdisrupted(forexample,fromtheuseofantibiotics)andtheremainingfloraprovidesanopportunityfororganismsnotimpactedbytheparticularantibiotic(s)toproliferate.InthecaseofC. difficile,thisprocessenablesC. difficiletoattachtothemucosaofthecolonandsetsthestagefortoxinproductionandresultantmucosaldisease.Toxin-producingstrainsofC. difficilecancauseillnessrangingfrommildormoderatediarrheatopseudomembranouscolitis,whichcanleadtotoxicdilatationofthecolon(megacolon),sepsis,anddeath.Figure3.1providesgraphicdemonstrationofthetransmissionandimpactofC. difficile.
ThefirstreportsestablishingClostridium difficileasthecauseofantibiotic-inducedpseudomembranouscolitiswerepublishedin1978.10,11Sincethen,CDIhasemergedasthemostcommoncauseofantibiotic-associateddiarrheaandahighlyproblematichealthcare-associatedinfection.ThedevelopmentofCDImostcommonlyhastwoessentialrequirements:(1)exposuretoantimicrobialagentsand(2)newacquisitionofC. difficilesuchasthatoccurringviafecal-oraltransmission.WhilesomepeopleexposedtothesetwofactorswilldevelopCDI,otherswillinsteadbecomeasymptomaticallycolonized.Thus,athirdfactor,possiblyrelatedtohostsusceptibilityorbacterialvirulence,isthoughttobeanotherimportantdeterminantfordevelopingdisease.12
AcquisitionofC. difficileoccursbyoralingestionofsporesthatresisttheacidityofthestomach.Thesesporesgerminateintovegetativebacteriainthesmallintestine.AlterationofthenormalcolonicflorabyexposuretoantimicrobialsprovidesanenvironmentinwhichC. difficileisabletomultiply,flourishandproducetoxinsthatcausecolitis.TheprimarytoxinsaretoxinAandB,twolargeexotoxinsthatcauseinflammationandmucosaldamage.Anexotoxinisaproteinproducedbyabacteriumandreleasedintoitsenvironment,causingdamagetothehostbydestroyingothercellsordisruptingcellularmetabolism.AlthoughevidencehassuggestedthattoxinAisthemajortoxin,C. difficilestrainsthatproduceonlytoxinBhavebeenshowntocausethesamespectrumofdiseaseasstrainsthatproducebothtoxins.13
ThemajorriskfactorsforCDIareexposuretoantimicrobials,hospitalization,andadvancedage.14NearlyallantimicrobialshavebeenimplicatedinCDI,butcertainantimicrobialclasses,suchascephalosporins,clindamycin,andfluoroquinolones,seemtocausehigherriskfordisease.Thisisprobablyrelatedtothoseantimicrobials’propensityfordisruptingnormalcolonicflorainadditiontotheantimicrobialresistancepatternsofprevalentC. difficilestrains.InrecentCDIoutbreaks,fluoroquinoloneshavebeenthemajorclassofantimicrobialsimplicatedinCDI,15-17anassociationthathasbeenattributedtohigh-levelresistancetofluoroquinolonesofthecurrentepidemicstrain.18
Guide to the Elimination of Clostridium difficile in Healthcare Settings
8 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Despitethefactthatexposuretomultipleantimicrobialagentsandlongercoursesoftherapyappeartoincreaseanindividual’sriskofCDI,exposuretoevenasingledoseofantimicrobialsgivenforpreoperativeprophylaxishasbeenassociatedwithCDI.19-21Severalstudiessupportrestrictionofcertainantimicrobialagentsorformularychangespromotingtheuseofnarrow-spectrumantimicrobialstoreducetheincidenceofCDIandtocontroloutbreaks.22-26Theseactivitiesformabasisforantimicrobialstewardshipprograms.
TheincubationperiodofC. difficilefollowingacquisitionhasnotbeenclearlydefined.Althoughonestudysuggestedashortincubationperiodoflessthansevendays,28theintervalbetweenexposureandonsetofsymptomsmaybelonger.29Thus,manycasesofhealthcare-associatedCDImayhavetheironsetinthecommunityafterhospitalization.AccordingtoCDIdefinitionsdevelopedforthepurposesofsurveillance,community-onsetcaseswithsymptomonsetoccurringwithinfourweeksofdischargefromahealthcarefacility(acuteorlong-term)shouldbeattributedtothatfacility.30Specificsurveillancedefinitionswillbereviewedlaterinthisguide.
Changing EpidemiologyInrecentyears,theepidemiologyofCDIhaschangeddramatically,withincreasesnotedintheincidenceofdiseaseinternationally,andreportsofCDIoutbreakswithinhealthcarefacilitiesinNorthAmericaandEuropeinvolvingmoreseverediseasethanpreviouslydescribed.IntheUnitedStates,nationalsurveillancedataindicate
Figure �.1. Transmission and Impact of C. difficile. Source: Sunenshine RH, McDonald LC. Clostridium difficile-associated disease: New challenges from an established pathogen. Cleve Clin J Med 2006;73:187–197. Reprinted with permission. Copyright © 2006 Cleveland Clinic. All rights reserved.
Pathogenesis of C difficile-associated disease
Clostridium difficile is spread via the fecal-oral route. The organiism is ingested either as the vegetative form or as hardy spores, which can survive for long periods in the environment and can traverse the acidic stomach.
C difficile reproduces in the intestinal crypts, releasing toxins A and B, causing severe in�ammation. Mucous and cellular debris are expelled, leading to the formation of pseudomembranes.
Pseudomembrane
Toxins
Monocyte
Neutrophil
In the small intestine, spores germinate into the vegetative form.
Toxin A attracts neutrophils and monocytes, and toxin B degrades the colonic epithelial cells, both leading to colitis, pseudomembrane formation, and watery diarrhea.
In the large intestine, C difficile-associated disease can arise if the normal �ora has been disrupted by antibiotic therapy
C difficile
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY �
thatthenumberofhospitaldischargeswithCDIlistedasanydiagnosisdoubledbetween2000and2003,withadisproportionateincreaseforpersonsolderthan64yearsofage(Figure3.2).4
MorerecentstatisticshaveshownamorethandoublingofthenumberofhospitaldischargeswithCDIfrom2001-2005,increasingfromapproximately149,000casesin2001toover300,000casesin2005.31SimilarincreasesinratesofCDIper10,000dischargeswerealsonoted,indicatingthatthesteepriseinCDIdischargeswasnotsimplyduetoanincreaseinnumberofhospitaldischarges.CasesofCDIintheU.S.weregeographicallydistributed,withthehighestratesintheNortheast,followedbytheMidwestandSouthernregions.Personsolderthan65yearsofagehavebeenmostaffected,withthehighestincreasesindischargerateswithCDI,representingovertwo-thirdsofpatientswithCDI.31However,therecentchangingepidemiologyhasalsoinvolvedemergingreportsofCDIoccurringinpopulationspreviouslyatlowrisk,includingseverecasesamonghealthyperipartumwomen,andincreasingreportsinchildrenandotherhealthypeopleinthecommunitywithnorecenthealthcarecontactorantimicrobialexposure.32
DuringthistimeperiodofrisingincidenceofCDI,thereweremanyindicationsofincreasingseverity,withgreaternumbersofcomplicationsandmortalityrelatedtoCDI.ReportsofCDIoutbreaksinhospitalsinQuebec,Canada,andsubsequentlyintheU.S.,emerged,describingseverecasesassociatedwithhighernumbersofcolectomies,treatmentfailures,anddeathsthanwereeverbeforereported.15,18,27In2004,the30-dayattributablemortalityrateofnosocomialCDIinQuebechospitalswas6.9%,27comparedto1.5%amongCanadianhospitalsin1997.33AttributablemortalityistheamountorproportionofdeaththatcanbeattributedtoCDI.IntheU.S.,deathcertificatedatashowedthatmortalityratesfromCDIincreasedfrom5.7permillionpopulationin1999to23.7permillionin2004(Figure3.3).2
AhypervirulentepidemicstrainofC. difficilewasfoundtobeassociatedwiththeoutbreaksinQuebecandatleasteighthospitalsinsixU.S.states,andsubsequentlywithoutbreaksinEurope.18,27,34,35ThisepidemicstrainhasbeennamedBI/NAP1/027andproducesatypeoftoxinnotpreviouslyseeninhospitalstrains.36TheBI/NAP1/027/toxinotypeIIIstrainhasbeenfoundtoproduce16-foldhigherconcentrationsoftoxinAand23-foldhigherconcentrationsoftoxinBinvitrothantoxinotype0strains.34Anotherfeatureofthisstrainistheproductionofatoxincalledbinarytoxin,theroleofwhichisnotyetdefined;however,strainsthatproducebinarytoxinmaybeassociatedwithmoreseverediarrhea.37ThecauseoftheextremevirulenceoftheBI/NAP1/027strainmaybeacombinationofincreasedtoxinAandBproduction,binarytoxin,orotherunknownfactors.
Figure �.2. Rates of discharges from U.S. short-stay hospitals of patients with C. difficile-associated disease listed as any diagnosis by age.4
Source: McDonald LC, Owings M, Jernigan DB, 2006.
450
400
350
300
250
200
150
100
50
01996 1997 1998 1999 2000 2001 2002 2003
Dis
char
ges
per
100,
000
popu
latio
n
15–45 years46–64 years
>64 years
Guide to the Elimination of Clostridium difficile in Healthcare Settings
10 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Asidefromitsincreasedvirulence,anotherfeaturethatmayaccountfortheproliferationofthisstrainisitshigh-levelresistancetothefluoroquinoloneclassofantimicrobials.18AlthoughBI/NAP1/027isolatesexistedpreviously,historicstrainswerelessresistanttofluoroquinolones,andtheywerenotassociatedwithoutbreaksofdisease.TheBI/NAP1/027strainhadbeendetectedinatleast38U.S.statesasofNovember2007(seewww.cdc.gov/ncidod/dhqp/id_Cdiff_data.html)(Figure3.4),insevenCanadianprovinces,38andhasledtooutbreaksintheUnitedKingdomandotherpartsofEurope.34,39
Figure �.�. States with BI/NAP1/027 strain of C. difficile (n = 38), November 2007. Source: CDC, (www.cdc.gov/ncidod/dhqp/id_Cdiff_data.html).
Figure �.�. Yearly C. difficile-related mortality rates per million population in the U.S. 1999 to 2004.2
Source: Redelings MD, Sorvillo F, Mascola L, 2007.
25
20
15
10
5
0
1999 2000 2001 2002 2003 2004
5.7
7.38.2
12.2
16
23.7
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY 11
CDI in the Pediatric Population
Atpresent,thereismuchwedonotknowaboutCDIinchildren,butwedoknowthatCDIismuchlesscommoninchildrenthaninadults,andthatfrom2%to70%ofinfantsmaybeasymptomaticallycolonizedwithC. difficile,includingcolonizationwithtoxigenicstrains.40,41Ratesofcolonizationdecreasewithage,fallingtoabout6%atagetwoyears,whileinchildrenolderthantwo,colonizationratesaresimilartothoseinadults(approximately3%).Infantsmayacquirecolonizationearlyinthefirstweekoflife.42StudiesexaminingriskfactorsforC. difficilehavefailedtoshowaconsistentassociationbetweenmodeofdeliveryorreceiptofformulaversusbreastmilk.However,nosocomialacquisitionoftheorganismiswell-describedinNeonatalIntensiveCareUnits(NICU),andC. difficilecontaminationoftheNICUenvironmenthasbeendemonstrated.43
Moststudieshavefailedtoshowanepidemiologicassociationbetweencolonizationanddiseaseininfantslessthanoneyearofage.Forexample,inoneSwedishstudy,C. difficile wasisolatedwithequalfrequencyinhealthychildrenoneweektooneyearofage(17%)andinchildrenlessthansixyearswithdiarrhea(18%).44Inastudyofoutpatientchildren,C. difficilewasisolatedfrom7%ofpatientswithdiarrheaand15%ofhealthycontrols.ChildrenwithC. difficile wereyoungerthanchildrenwithouttheorganism(meanage8.2to9.8months);priorantibioticexposurewasnotedinonly22%.59Inanotherstudy,toxinBwasidentifiedin4.2%of618childrenwithdiarrheaandinanequivalentnumberofhealthycontrols.46
SimilarfindingshavebeennotedinmostcontrolledstudiesofNICUpatients.C. difficiletoxinwasrecoveredfromthestoolsof55%ofpatientsinoneNICU,butsignsofentericdisease,includingnecrotizingenterocolitis,occurredwithequalfrequencyinbothtoxin-positiveandtoxin-negativeinfants.47SporadiccasereportssuggestthatsevereCDIoccasionallyoccursininfants,especiallythosewithunderlyingintestinalpathology.
TheaccuratediagnosisofCDIinyoungchildreniscomplicatedbythefactthatcommonlyusedtestssuchastheenzymeimmunoassay(EIA)fortoxinAandBmaylackspecificityinthisagegroup.Between2004and2006,ahospitalinGeorgianotedanincreaseinC. difficiletoxin-positivestoolsinprematureinfants.Fiveinfantswerediagnosedwithnecrotizingenterocolitis.Retestingof26frozenstoolspecimensbyEIAattheCentersforDiseaseControlandPrevention(CDC)confirmedtoxininonlyfivespecimens.C. difficilecouldnotbeisolatedincultureinanyspecimen,althoughotherClostridiaspecieswerefoundin50%ofsamples.(L.CliffordMcDonald,CDC,personalcommunication).
YoungchildrenwhoarecolonizedwithC. difficilewithoutsymptomsneverthelessrepresentareservoirfortransmissionofdiseasetoothers.A19-year-oldwomandevelopedCDIintheimmediatepost-partumperiod.Althoughhersymptomsresolvedwithmetronidazoletreatment,shedevelopedthreerecurrences.HerasymptomaticinfantwasacarrieroftheidenticalstrainofC. difficileisolatedfromthemother, suggestingtheinfantwasthesourceofthemother’srecurrentdisease.48
TheemergenceofB1/NAP1/027maybechangingtheepidemiologyofCDIinchildren.B1/NAP1/027hasbeenassociatedwithseverediseaseinbothadultandpediatricpatientswithoutrecentexposuretohealthcarefacilities,andinsomecases,withoutrecentantimicrobialuse.In2005,theCDCreportedcasesofsevereCDIinpopulationspreviouslyatlowriskfordisease,includinghealthychildrenwithnorecentantibioticuse.32Afive-yearretrospectivestudyperformedatatertiarycarechildren’shospitalrevealedanincreaseinthenumberofchildrenseenintheEmergencyDepartmentwithcommunity-associatedCDI;43%lackedahistoryofrecentantibioticuse.49
Guide to the Elimination of Clostridium difficile in Healthcare Settings
12 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
ThereremaingapsinourknowledgeaboutthepathogenicityofC. difficileininfants,thespectrumofdiseaseinchildrenduetotheepidemicstrainB1/NAP1/027,andthemostappropriatediagnostictoolstoconfirmCDIinpediatricpatients.Judicioustestingandprospectivesurveillanceusingconsistentdefinitionsisessentialtobetterunderstandingthediseaseinthispopulation.
GuidelinespublishedbytheSocietyforHealthcareEpidemiologyofAmerica(SHEA)in1995discouragedtestingofstoolsfrominfantslessthanoneyearofageforC. difficile.TheNationalHealthcareSafetyNetwork(NHSN)surveillancedefinitionforCDIdoesnotdiscriminatebetweenadultandpediatricpatientsexcepttoexcludeNICUpatients.Otherpatientslessthanoneyearofagearenotspecificallyexcluded,althoughitremainsdifficulttodifferentiateincidentalcolonizationfromtrueCDIinthispopulation.Giventhechangingepidemiologyofdiseaseinotherpopulationspreviouslyatlowriskfordisease,additionalguidanceforcliniciansiswarranted.SystematicevaluationofCDIinyoungchildren,includingNICUpatients,isessentialtobetterunderstandingtheepidemiologyofdiseaseinthispopulation.
GuidelinesforthediagnosticevaluationforCDIinchildrenhavebeenproposed(L.CliffordMcDonald,AdHocClostridium-difficileSurveillanceWorkingGroup,personalcommunication).Pendingadditionalinformation,itseemsprudenttorestrictroutinetestingforC. difficileinchildrenlessthanoneyearofage.Whentestingisperformed,morethanonediagnosticapproachshouldbeutilized.Forexample,acultureand/ortoxintestingshouldbeperformedinadditiontoothertests.Retentionofmicrobiological,surgicalandautopsyspecimensforadditionaltestingbypublichealthauthoritiesorcenterswithspecialexpertisemaybeusefulforconfirmingthediagnosis,ordetectingepidemicstrains.Investigationofsuspectedclustersofinfectionsisessential.
Becauseasymptomaticcolonizationdecreaseswithage,testingforC. difficile shouldbeconsideredinchildrenonetotwoyearsofagewithdiarrheaandrecentantibioticexposure,especiallyaftermorecommonpathogenshavebeenexcluded.
Childrenolderthantwoyearsofagewithdiarrheaandahistoryofrecentantimicrobialusemaybetestedinthesamemannerasolderchildrenandadults.Becausediseasehasbeenconfirmedinhealthychildrenwithoutrecentantibioticexposure,testingforC.difficile maybeconsidered,butotherdiagnosesaremorelikely.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY 1�
Modes of Transmission
WhenconsideringthemodesoftransmissionforC. difficile,itisimportanttonotethesekeyconcepts:• C. difficilecansurviveinthehospitalenvironmentandonhospitalsurfaces.Astheorganismstrivesto
protectitselffromundesirableenvironmentalconditions,itassumesitssporeform.• Patientsand/orhealthcareworkerscantransmitand/oracquireC. difficilefromcontactwithcontaminated
surfaces,includingcontaminationwithbothvegetativecellsandspores.• Transmissionoccursviaafecal-oralroute,soanyactivitythatmayresultinmovementoftheorganisminto
themouthmustbeaddressedaspartofpreventionactivities.
Survival of C. difficile in the Healthcare EnvironmentClostridium difficileisafastidiousanaerobeandthevegetativecelldiesrapidly,generallywithin24hours,outsidethecolon.50,51ThiswouldleadonetobelievethatC. difficileisnotahighlytransmissibleorganism.However,C. difficileproducessporesthatcanpersistintheenvironmentformanymonthsandarehighlyresistanttocleaninganddisinfectionmeasures.50,51Thesporesmakeitpossiblefortheorganismtosurvivepassagethroughthestomach,resistingthekillingeffectofgastricacid,wheningested.Afteringestion,thesporescangerminate,producetoxinsandcausedisease.Therefore,boththevegetativeandsporeformsofC. difficileareimportantintermsofenvironmentalcleaninganddisinfection.
Transmission of C. difficile to Patients from the Healthcare EnvironmentThetwomajorreservoirsofC. difficileinhealthcaresettingsareinfectedhumans(symptomaticorasymptomatic)andinanimateobjects.Patientswithsymptomaticintestinalinfectionarethoughttobethemajorreservoir.52
TheleveltowhichtheenvironmentbecomescontaminatedwithC. difficile sporesisproportionaltotheseverityofdiseaseinthepatient.6However,asymptomaticcolonizedpatientsshouldalsobeconsideredasapotentialsourceofcontamination.56PatientcareitemssuchaselectronicthermometersandcontaminatedcommodeshavealsobeenimplicatedinthetransmissionofCDI.53
TransmissionofC. difficiletothepatientviatransienthandcarriageonhealthcareworkers’handsisthoughttobethemostlikelymodeoftransmission.ReductionofCDIratesassociatedwiththeuseofglovesprovidesstrongsupportfortheimportanceofhandcarriage.54AlcoholisnoteffectiveinkillingC. difficilespores,butCDIrateshavenotbeenfoundtoincreaseasuseofalcohol-basedhandrubs(ABHR)increase.IfahospitalisexperiencinganoutbreakorincreasinginfectionrateswithC. difficile,itcanbebeneficialforhealthcareworkerstowashtheirhandswithsoapandwaterexclusivelywhencaringforpatientswithknownCDI.55
Transmission Via Patient Care ActivitiesThereareanumberofpatientcareactivitiesthatprovideanopportunityforfecal-oraltransmissionofC. difficile.Someoftheseactivitiesinclude:
• Sharingofelectronicthermometersthathavebeenusedforobtainingrectaltemperatures(handlesmaybecontaminatedwithC. difficileeventhroughprobesarechangedandprobecoversused)
• Oralcareororalsuctioningwhenhandsoritemsarecontaminated• Administrationoffeedingsormedicationwithcontaminatedhands,foodormedication• Emergencyproceduressuchasintubation
Guide to the Elimination of Clostridium difficile in Healthcare Settings
1� ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
• Poorhandhygienepractices• Ineffectiveorinconsistentdisinfectionofpatientcareequipment• Sharingofpatientcareitemswithoutappropriatedisinfection• Ineffectiveenvironmentalcleaning
Theseexamplesservetoidentifythebroadarrayofactivitiesthatcouldresultinfecal-oraltransmissionofC. difficile. Therefore,whenpreventionstrategiesaredesigned,itisimportantthattransmissionopportunitiessuchasthesebeconsideredandobservationofpatientcareactivitiesbeperformed,inanefforttoidentifypreviouslyunrecognizedorunsuspectedpotentialmodesoftransmission.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY 1�
Diagnosis
C. difficileinfection(CDI)shouldbesuspectedinanypatientwithdiarrheaorabdominalpainwithrecentantibioticorhealthcareexposures.52SevereCDIhasalsorecentlybeenreportedin“low-risk”populations,forexample,peoplewithoutrecentantibioticorhealthcarefacilityexposures,andCDIshouldbeconsideredinanypatientwithdiarrhealastinglongerthanthreedayswithfeverorabdominalpain.32Reviewthesurveillancedefinitionsprovidedlaterinthisguide.CDIismostcommonlyconfirmedwithalaboratory-basedassay,andthereareadvantagesanddisadvantagesforalllaboratory-basedmethodsfordetectingC. difficile oritstoxins.Therefore,itisessentialtobefamiliarwiththemethodusedatyourfacility.
Who Should be Tested and How Frequently?ItisrecommendedtoonlytestforC. difficileinpatientswhoaresuspectedofhavingCDI,forexample,patientsexperiencingdiarrhea.52,57ItisrecommendedtoNOTscreenasymptomaticpatientsorperforma“testofcure”inpatientswhohaverespondedtotherapy.52,57Thereareseveralreasonsfortheserecommendations.Allnon-culturelaboratory-basedassaysfordetectingC. difficileoritstoxinshavebeendevelopedandvalidatedtodiagnoseCDIonlyinsymptomaticpatients.Therearenumerousreasonstobelievethesensitivity(thelikelihoodthatsomeonewiththediseaseorconditionwillhaveapositivetestresult),specificity(thelikelihoodthatsomeonewhodoesnothavethediseaseorconditionwillhaveanegativetestresult),andpositivepredictivevalue(thelikelihoodthatsomeonewhotestspositiveactuallyhasthediseaseorcondition)oftheseassaysarelowerinasymptomaticpatients,resultinginmorefalse-positiveandfalse-negativeresults.Inaddition,thisinformationprovidesnoclinicallyusefulinformationandmayresultinpatientharm.
ItisnotrecommendedtoplaceasymptomaticpatientscolonizedwithC. difficile inContactPrecautions.Thiscanleadtodecreasedpatientsatisfactionaswellasanincreaseinhealthcarecostsassociatedwithplacingthepatientinaprivateroomandtheunnecessaryuseofgownsandgloves.Somereportsquestiontheimpactofisolationonpatientsafety,duetootheradverseeventssuchasfalls,decreasedmonitoring,andmedicalerror.
PersistentlypositivetestresultsattheendoftreatmentarenotpredictiveofaC. difficilerelapse,andapositivetestresultinanasymptomaticpatientmayresultinunnecessarytreatmentwithantimicrobials,whichcanincreasethepatient’sriskofdevelopingCDIinthefuture.59Testingasymptomaticpatientsalsotakesnursingandmicrobiologytimetocollectandtestthestool,plusthecostofthetestitself.
Acommonquestionishowoftenapatientwithdiarrheashouldbetestediftheinitialtestsarenegative,duetoconcernsoflowsensitivityofthetests.Somestudieshavedemonstratedthatanadditional10%ofpatientswillhaveapositivetestifrepeattestingisperformed.52ItisimportanttonotethattheprevalenceofCDIislowerinpatientswithapreviousnegativetest.WhentheprevalenceofCDIdecreases,thepositivepredictivevalueofthetestdecreasesaswell,increasingthelikelihoodthatapositivetestwillbeafalse-positivetest.Theincreaseinfalse-positivetestsandlowyieldofadditionaltestingdoesnotsupporttheroutineuseofrepeattestingasacost-effectivemeasure.52Collection and Transport of Stool for C. difficile TestingOnlywateryorloosestoolshouldbecollectedandtestedtoestablishthediagnosisofCDI.Specimensshouldbesubmittedinaclean,watertightcontainer.Transportmediaisnotnecessary,andmayincreasethefalsepositiverateofsometests.59Specimensshouldbetransportedassoonaspossibleandstoredat2˚to8˚Cuntiltested.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
1� ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Storageatroomtemperaturedecreasesthesensitivityofsometests,presumablyduetotoxininactivation.60Repeatfreezingandthawingofthespecimenshouldalsobeavoidedforthesamereason.60
Laboratory Tests for Diagnosing CDIAsCDIisatoxinmediateddiseaseandonlyC. difficileisolatescapableofproducingtoxinareabletocauseCDI,mostdiagnostictestsinvolvethedetectionofC. difficile toxinAand/ortoxinB(Table6.1).Thecellcytotoxicityassay,whichdetectsthecytopathiceffectoftoxinBonculturedcelllines,isconsideredthegold-standardclinicallaboratoryassayforthediagnosisofCDI.52However,somehavereportedasensitivityofthisassayaslowas67%comparedtocultureforC. difficile.52TheprimaryadvantageofthisassayisitismoresensitivethanimmunoassaysfortoxinAand/orB.Disadvantagesofthisassayincludeaprolongedturn-aroundtimeof48to72hours,andthatitisnecessarytobeabletomaintaincellculturesinorderforalaboratorytoperformthisassay.
Enzymeimmunoassays(EIA)fortoxinsAand/orBhavebecomethemostwidelyusedlaboratory-basedmethodsfordiagnosingCDIintheUnitedStatesbecauseoftheirlowcost,easeofuse,andrapidturn-aroundtime.SomeassaysdetectonlytoxinA,whereasothersdetectbothtoxinsAandB.Thisisanimportantdistinction.TherearesomestrainsofC. difficilethatproduceonlytoxinB.ThesestrainsarecapableofproducingthesamespectrumofillnessasstrainsthatproducebothtoxinsAandB.52ThesestrainsaremissedbyEIAsthatonlydetecttoxinA.AlthoughthereareseveraladvantagesofEIAscomparedtocellcytotoxicityassaysasmentionedabove(lowercost,easeofuse,andrapidturn-aroundtime),thesensitivityoftheseassaysrangefrom63%to94%,withaspecificityof75%to100%comparedtocellcytotoxicityassays.52
Glutamatedehydrogenase(GDH)isaproteinproducedbyC. difficile,andassaysareavailabletodetectGDHinstool.Initially,itwasthoughtthatthisassaywasspecificforC. difficile, butitwassubsequentlydemonstratedthatotherbacterialstrainscancross-reactwiththisassay.52Theseassaysarerelativelylow-costandrapid.NewerassaysforGDHhaveasensitivityof85-95%andspecificityof89-99%.62ThisassayisnotspecificforC. difficileand
Laboratory Test Advantages Disadvantages
Toxinenzymeimmunoassay(EIA) Inexpensive.Rapid.
Lesssensitivethancellcytotoxicityassay.SomeonlytestfortoxinA.
Cellcytotoxicityassay MoresensitivethantoxinEIAassays.
Notalllaboratoriesabletoperformthetest.48-72hoursforresults.
Glutamatedehydrogenaseassay Rapid.Inexpensive.Sensitive.Canbeusedasinitialscreen.
Notspecific(detectsnon-toxigenicC. difficileandotherbacteria).
StoolcultureforC. difficile Mostsensitivetest.ProvidesC. difficileisolates.
Notspecific(detectsnon-toxigenicC. difficile).Laborintensive.Cantakemorethan72hoursforresults.
Table �.1. Comparison of different laboratory-based diagnostics tests for CDI.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY 1�
detectssomestrainsofC. difficile thatdonotproducetoxin(andareunabletocausedisease);thereforethisassayshouldnotbeusedalonetodiagnoseCDI.52
BecauseofthehighnegativepredictivevalueofGDHassays,severalinvestigatorshavestudiedtheGDHassayasascreeningtest.61,62,63StoolwithanegativeGDHassayisreportedassuchandnofurthertestingisperformed.StoolpositiveforGDHisthentestedfortoxinwithacellcytotoxicityassay.StoolpositivebythecellcytotoxicityassayisdiagnosticforCDI;stoolnegativebythecellcytotoxicityassayisreportedasnegative.Thetwo-stepapproachisabletorapidlyidentifypatientswithoutCDI(negativeGDHassay),whileutilizingthemoresensitivecellcytotoxicityassaytoidentifypatientswithCDI.Thisapproachmayalsobemorecost-effectivethanuseofthecellcytotoxicityassayalone.63
Undertheproperconditions,stoolcultureisthemostsensitivelaboratorymethodfordetectingC. difficile.However,becauseoftheexpenseandtimerequiredforculture,itisrarelyperformedintheU.S.CharacteristiccolonymorphologyandgramstainappearanceareoftensufficientforidentifyingC. difficile.C. difficile isolatesshouldbetestedfortoxinproductiontoestablishthediagnosisofCDIbecauseasmanyas25%ofC. difficileisolatesdonotproducetoxinandareincapableofcausingCDI.52Stoolcultureisnecessarytoperformmolecularfingerprinting,andisthereforeausefultoolinevaluatingoutbreaks,sourcesofinfectionandcontrolmeasures.
Molecular TypingThereareseveralmoleculartypingtechniquesforC. difficile,butthesearenotroutinelyavailableoutsideofresearchlaboratories.Duetotherelianceontoxinassays,culturesforC. difficilearenotroutinelyperformedtodiagnoseCDI,andisolatesareinfrequentlyavailableformoleculartyping.Whilemoleculartypingisnecessaryforin-depthepidemiologicalstudiesofC. difficile andishelpfulwhenchangesinCDIepidemiologyoccur,itisnotnecessaryforroutinepatientcare.
Non-laboratory Based TestsCDIisthecauseofmorethan90%ofcasesofpseudomembranouscolitis(PMC)andcanbediagnosedwithdirectvisualizationofpseudomembranesbysigmoidoscopyorcolonoscopy.SomepatientsmaynothavePMCidentifiedbydirectvisualization,buthaveevidenceofPMConhistopathology.AlthoughconsidereddiagnosticforCDI,PMCisidentifiedinonly50%ofcasesofCDI.64
AbdominalCTscansarehelpfultosuggestthediagnosisofCDIifcolitisisidentifiedinapatientwithabdominalpainorileus.However,thesescansshouldnotbereliedupontoruleinorruleoutthediagnosisofCDIduetotheirpoorsensitivityandspecificity.65,66AbdominalCTscanfindingsalonealsodonotcorrelatewithseverityofCDI.65,66
Guide to the Elimination of Clostridium difficile in Healthcare Settings
18 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Surveillance
Surveillanceisdefinedastheongoing,systematiccollection,analysis,interpretationanddisseminationofdataregardingahealth-relatedevent,usedtoreducemorbidityandmortalityandtoimprovehealth.Surveillancemayinvolveprocessmeasures(e.g.,handhygiene,adherenceratestospecificprotocols,etc.)oroutcomemeasuressuchasinfectionrates,deathrates,lengthsofstay,orcostsofcare.Outcomemeasuresareparticularlyimportanttoevaluatetheeffectivenessofinfectionpreventioneffortsandidentifyingindicationsforchange.7
Theessentialcomponentsofahealthcaresurveillancesystemare:• Standardizeddefinitions• Identificationandmonitoringofpopulationsatriskforinfection• Statisticalanalysis(calculationofratesusingappropriatenumeratorsanddenominators,trendanalysis
usingcontrolchartstoidentifyhigh-incidenceareasandtomonitortrends)• Feedbackofresultstotheprimarycaregivers7
• Feedbacktomanagers,directors,andtoseniorleadership,includingadministratorsandeventheboardofdirectorsortrustees
Ataminimum,everyhealthcarefacilityshouldhavetheabilitytoidentifyclustersofinfections,knowhowtoconductasystematicepidemiologicinvestigationtodeterminecommonalitiesinpersons,placesandtime,anddevelop,implementandevaluatepreventionmeasures.ForC. difficile,thiscanbeaccomplishedthroughmonitoringofclinicaldisease,orbyusingaproxymeasure,laboratory-basedsurveillanceindicator.
Case Definitions for Clinical CDI SurveillanceStandardizedcasedefinitionsarecriticaliftheinformationisgoingtobeusedtocompareoneunitorfacilitywithanother,tomonitortrendsovertime,ortoevaluatetheeffectivenessofinterventionstoreduceinfections.30ThedefinitionsproposedbyMcDonaldetal.aresummarizedhereandrecommendedforsurveillancepurposes.30Itisimportanttorememberthatsurveillancedefinitionsarenotnecessarilythesameasclinicaldefinitionsandmaynotbeappropriateforclinicaldecision-makingandtreatment.
AcaseofCDIisdefinedasanindividualpatientwiththesymptomofdiarrhea(unformedstoolthatconformstotheshapeofaspecimencollectioncontainer)ortoxicmegacolon(abnormaldilationofthelargeintestinedocumentedradiologically)withoutotherknownetiologyinwhich:
1. thepatienthasadiarrhealstoolsamplepositiveforC. difficiletoxinAand/orB,oratoxin-producingC. difficile
OR2. pseudomembranouscolitisisfoundduringsurgeryorendoscopically OR3. pseudomembranouscolitisisseenduringhistopathologicalexamination.30
Healthcare Facility-onset, Healthcare Facility-associated CDIAhealthcarefacilityisdefinedasanyacutecare,long-termacutecareorotherfacilityinwhichskillednursingcareisprovidedandpatientsareadmittedatleastovernight.30
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY 1�
Apatientclassifiedashavinghealthcare facility-onset, healthcare facility-associated CDIisdefinedasapatientwhodevelopsdiarrheaorCDIsymptomsmorethan48hoursafteradmissiontoahealthcarefacilityandfulfillscriterion1,2,or3definedabove.30TheNationalHealthcareSafetyNetwork(NHSN)hasfurtherclarifiedthistobethethirdcalendardayafteradmission.
Healthcarefacility-onset,healthcarefacility-associatedCDIisalso defined as a patient who develops diarrhea or CDI symptoms less than 48 hours after discharge from a healthcare facility and fulfills criterion 1, 2, or 3 defined above.
Community-onset, Healthcare Facility-associated CDIApatientclassifiedashavingcommunity-onset, healthcare-facility associated CDIisdefinedasapatientwithCDIsymptomonsetinthecommunityor48hoursorlessafteradmissiontoahealthcarefacility,providedthatsymptomonsetwaslessthanfourweeksafterthelastdischargefromahealthcarefacility.30
Community-associated CDIApatientclassifiedashavingcommunity-associated CDIisdefinedasapatientwithCDIsymptomsonsetinthecommunity,or48hoursorlessafteradmissiontoahealthcarefacility,providedthatsymptomonsetwasmorethan12weeksafterthelastdischargefromahealthcarefacility.30
Indeterminate or Unknown CDIApatientwhodoesnotfitanyoftheabovecriteriawouldbedefinedashavingindeterminate or unknown CDI.30
Recurrent CDIApatientwithrecurrentCDIisdefinedasonewithanepisodeofC. difficilethatoccurseightweeksorlessaftertheonsetofapreviousepisodethatresolvedwithorwithouttherapy.Table7.1showstheseorganizeddefinitions.
Case Type Definition
Healthcarefacility-onset,Healthcarefacility-associated(HO-HCFA)
CDIsymptomonsetmorethan48hoursafteradmission(thirdcalendarday).
Community-onset,healthcarefacility-associated(CO-HCFA)
CDIsymptomonsetinthecommunity,orwithin48hoursfromadmission,providedsymptomonsetwaslessthanfourweeksafterthelastdischargefromahealthcarefacility.
Community-associated(CA-CDI)
CDIsymptomonsetinthecommunity,orwithin48hoursafteradmissiontoahealthcarefacility,providedsymptomonsetwasmorethan12weeksafterthelastdischargefromahealthcarefacility.
Indeterminateorunknownonset CDIcasepatientwhodoesnotfitanyoftheabovecriteria.
RecurrentCDI EpisodeofCDIthatoccurseightweeksorlessaftertheonsetofapreviousepisode,providedthesymptomsfromthepriorepisoderesolved.
Table �.1. Surveillance definitions for C. difficile infection.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
20 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Figure7.1providesavisualtimelinethatmaybeofassistanceinapplyingthedefinitions.Casepatientswithsymptomonsetduringthewindowofhospitalizationmarkedbyanasterisk(*)wouldbeclassifiedashavingcommunity-onset,healthcarefacility–associateddisease(CO-HCFA),ifpatientwasdischargedfromahealthcarefacilitywithintheprevious4weeks;wouldbeclassifiedashavingindeterminatedisease,ifthepatientwasdischargedfromahealthcarefacilitybetweentheprevious4-12weeks;wouldbeclassifiedashavingcommunity-associatedCDI(CA-CDI),ifthepatientwasnotdischargedfromahealthcarefacilityintheprevious12weeks;ifsymptomonsetmorethan48hoursafteradmission;wouldbeclassifiedashaving,healthcarefacility–onset,healthcarefacility–associatedCDI(HO-HCFA).30
Forsurveillancepurposes:1. Asymptomaticpatientwithanadditionalpositivetoxinassaywithintwoweeksorlessafterthelast
specimentestedpositiveisacontinuationofthesameCDIcaseANDnotanewcase.2. Asymptomaticpatientwithanadditionalpositivetoxinassaywithintwotoeightweeksafterthelast
specimentestedpositiveisarecurrent CDIcaseANDnotanewcase.3. Asymptomaticpatientwithanadditionalpositivetoxinassaymorethaneightweeksafterthelast
specimentestedpositiveisanew CDIcase.30
Conducting SurveillanceDependingonthepurposesofsurveillance,alloronlysomeoftheaboveCDIcasedefinitionsmaybeappropriateforuse.30BecauseinpatientstayinahealthcarefacilityisarecognizedriskfactorforCDI,the initial purpose of surveillance in a healthcare facility should be to first track and compare healthcare facility-onset, healthcare facility-associated CDI.
Surveillanceshouldbefacility-wideandalinelistmaintainedinaretrievabledatabasefile,suchasMicrosoftExcel,MicrosoftAccess,SPSS(StatisticalPackagefortheSocialSciences),oranothersuchelectronicmeans.Thedatabaseshouldincludeatleastthefollowing:
• Patientidentification(nameoruniqueidentifier,suchasmedicalrecordnumber)• Dateofbirth• Admissiondate• Patientlocation(unitandroom)atthetimeofstoolcollection• CDIsymptomonsetdate(e.g.diarrhea)• Stoolcollectiondate• Dischargedate
Otherinformationmayalsobecollected,includingelementssuchasunderlyingdiagnosis,treatment(e.g.antibiotics),procedures(e.g.endoscopy,surgicalinterventions),oradditionalcircumstancesthatmayhaveled
Admission Discharge
48 h 4 weeks 8 weeksSymptom onset
(*) HO-HCFA CO-HCFA Indeterminate CA-CDI
Figure �.1. Timeline for definitions ofTimeline for definitions of Clostridium difficile infection (CDI) exposures.Source: Adapted from McDonald LC, Coignard B, Dubberke E, et al., 2007. Copyright © 2007, Society of Healthcare Epidemiology of America.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY 21
toexposureoracquisitionrisks.Inaddition,itmaybehelpfultonoteif/whenapreviousadmissiontookplace,residenceorlocationpriortoadmission(transferfromanotherhealthcarefacility,includinglong-termcarefacility),anddischargestatus(death,dischargetoextended/long-termcare,residence,etc.).
CDI RatesDenominatorforCalculationofCDIRates30
• Ratesshouldbeexpressedasnumberofcasepatientsperreportingperiod(usuallypermonth)per10,000patientdays.
• Thecalculationofthisrateis(numberofCDIcasepatientspermonth/numberofinpatientdayspermonth)x10,000=rateper10,000inpatientdays.
• Thisratereflectstheper-daypatientriskforCDIandisusefulacrossdifferenttypesofhealthcarefacilitieswithvaryinglengthsofpatientstay.
• Thisratecanbeusedforcomparingfacility-wideCDIrateswithotherorganizationsaswellasforcomparingdifferentunits,wardsand/orserviceswithinagivenhealthcarefacilityinwhichunit-specific/ward-specific/service-specificdenominatorsareavailable.
Expression of CDI Rates for Feedback to Caregivers and Comparative PurposesControl charts
ControlchartsmaybecreatedtodisplaythenumberofCDIcasesorratesfortheentirehealthcarefacility,and/orbyunit/ward/service.
• TheX-axisisthesurveillancetimeperiod(month).• TheY-axisisthenumberofCDIcasesorCDIrate.• Controlchartsareusefultodetermineiftherateofahealthcarefacilityand/orunit/ward/serviceisoutof
range,andtomonitortrends.• Controlchartscanbeusedtodemonstratedifferentaspectsofsurveillance,usingaseparatechart
foreachofthefollowing:healthcarefacility-onset,healthcarefacility-associated;community-onset,healthcarefacility-associated;community-associated;indeterminate;orrecurrentCDI.Theemphasisshouldbeonprovidinginformationandthemonitoringofoutcomesrelevanttothefacilityandthecommunity.
• Controlchartscanbepostedonindividualpatient-careunitsandusedduringeducationalin-servicessostaffcanunderstandwhatthechartsreflectandalsoseetheresultsofinterventionsputintoplacetoreduceCDIrates.AnexampleofacontrolchartisprovidedinFigure7.2.
• TheuseofcontrolchartsisavaluabletoolinmonitoringratesofCDIaswellasprovidingvisualrepresentationofwhenratesareinoroutofstatisticalcontrol.
UsingthecontrolchartshowninFigure7.2,whentherateofCDIexceedsthreestandarddeviations,thiscanbeatriggerforimplementationofheightenedinterventionsusingatieredapproach.Theappropriateuseofcontrolchartsandidentificationoftriggerstoguideinterventionsisanimportanttopicofdiscussionintheinfectionpreventionandcontrolcommittee.Forexample,aninitialuseofthreestandarddeviationsfromthemeanmaybetheplacetostartwithregardtothattrigger.Astimegoesonandratesmoveclosertozero,thecommitteemaychoosetoadjustthetriggersorelecttoexploreotherrulesforspecialcausemonitoring.
Formoreinformationregardingcontrolcharts,refertotheworkdonebyJ.C.BenneyaninICHEandareviewofstatisticalprocesscontrolbyAmininQuality Management in Health Care.67-69
Guide to the Elimination of Clostridium difficile in Healthcare Settings
22 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Other monitoring toolsTheinfectionpreventionistmayalsofindothertypesofchartsorfigurestobehelpfulwhenmonitoringratesaswellastemporaldocumentingofinterventions.Figure7.3demonstratesarun chartdevelopedusingEpiGraphics(availablefromAPIC).
Runchartsshowtherateovertime,andenabletheinfectionpreventionisttoaddtextboxesdescribingspecificinterventionsandwhentheywereperformed.Chartssuchasthiscanbeofhelpwhenprovidingacomprehensiveoverviewofactivitiesandoutcomestogroupssuchasmedicalstaff,administration,andaccreditationsurveyors.
Anepidemic curve(epicurve)canbeusedtopresentagraphicdepictionofthenumberofcasesofillnessbythedateofillnessonset.Anepicurvecanprovideinformationonthepatternofspread,magnitudeoftheevent,outliercases,andtimetrend.
Laboratory-based Surveillance for C. difficileLaboratory-basedsurveillancemayalsobeconsideredasasimplifiedoptionorproxymeasureratherthanconductingsurveillanceforclinicaldiseasewithchartreview.ThisshouldbeperformedsolelyinconjunctionwithlaboratoriesthatonlytestunformedstoolsamplesandlaboratoriesthatdonotperformscreeningculturesortoxinassaysforcolonizationwithC. difficile,allofwhicharediscouraged.
Figure �.2. Control chart example.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY 2�
Laboratory-basedsurveillancecanbeconductedfortheentirefacilityorbyspecificunit/location.Thedenominatorshouldbepatientdaysfortheentirefacilityorbyspecificunit/location,respectively.
Inanefforttoensurethatapatienthasbeeninthefacilityforaminimumof48hours,withoutreviewingthemedicalrecordfortheexacttimeofadmissionanddateandtimeofonset(asisdoneforclinicaldiseasesurveillance),acaseoflaboratory-basedhealthcarefacility-onsetdiseaseshouldbelimitedtothosepatientswithC. difficilefirstdetectedonoraftercalendardaythreeafteradmission(morethan48hoursafteradmission).
Bymaintaininganongoinglinelistofpositivepatients,incidentorrecurrentdiseasecanalsobeascertained.AneworincidentcaseisdefinedasanewpatientwithC. difficileoroneinwhomthelastpositivespecimenwasobtainedmorethaneightweeksafterapreviouspositive.Arecurrentcaseisdefinedasapatientwithapositivespecimenobtainedmorethantwoweeks,butlessthanorequaltoeightweeksafterapreviouspositivespecimen.Ifapatienthasanotherpositivespecimenwithintwoweeks,thisisconsideredacontinuationoftheinfectionandshouldnotbecountedagain.
IncidentcasesofCDIshouldbemonitoredfortheentirefacilityorbyspecificlocationstodetecttrendsandpossibleoutbreaks.Recurrentdiseaseshouldbemonitoredtoevaluatetheeffectivenessoftreatment.ControlchartscanbecreatedinthesamemannerasdescribedaboveforclinicalCDI,butshouldbeclearlytitledtoreflectthattheinformationisbaseduponlaboratory-basedsurveillancedata.
TheCentersforDiseaseControlandPreventionwillbeincorporatingalaboratory-basedC. difficilemoduleintotheNationalHealthcareSafetyNetworkforhospitalswantingtomonitorandcomparetheirC. difficilerates.
Figure �.�. Example of a run chart with text boxes noting interventions.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
2� ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Focusing on Prevention: Contact Precautions
Earlyrecognitionofpatientswhoaresuspectedtohave,orwhoarediagnosedwith,CDIisthefirststepinpreventingthespreadofthisepidemiologicallysignificantorganism.C. difficilecanbespreadbydirectandindirectcontactwiththepatientorthepatient’senvironment,andtherefore,patientswiththisorganismshouldbeplacedonContactPrecautionsasrecommendedintheHICPAC/CDCGuidelineforIsolationPrecautions.7AdherencetothecomponentsofContactPrecautionswillhelptobreakthechainofinfection.FecalincontinenceandanincreasedpotentialforextensiveandprolongedenvironmentalcontaminationmakepatientswithCDIasignificantthreatfordisseminationandtransmissionofthedisease.ThefollowingcomponentsofContactPrecautionsshouldbeobservedforallpatientssuspectedof,ordiagnosedwith,CDI.
1. Patient PlacementPatientsshouldbeassignedtoaprivateroomwithabathroomthatissolelyforusebythatpatient.Whenprivateroomsareoflimitedavailability,patientswhoarefecallyincontinentshouldpreferentiallybeassignedtothoseprivaterooms.Ifaprivateroomisnotavailable,theinfectioncontrolteamshouldassesstherisksandworkwiththepatientcareteamtodeterminethebestpatientplacementoptions(e.g.,cohortwithanotherpatientdiagnosedwithCDIandnootherdiscordantorganisms,orkeepingthepatientwithanexistingroommate).IfbothpatientshaveCDIandarecohorted,oncethediarrheastopsforoneperson,thatpatient,ifpossible,shouldbetransferredtoacleanroom.70
Inmanycaresettings,suchasrehabilitationprograms,long-termcareinstitutionsorresidentialsettings,privateroomsmaynotbeavailable.Thecareteamneedstodetermineifaroomshouldbeclosedofftootherpatients.Theteamshouldhaveadministrativesupporttotakethisadditionalprecautionarystep.Inthemulti-patientroomsettingwhereisolationinasinglepatientroomisnotpossible,otheractivitiesmaybeconsidered,includingtheuseofatleastathree-footspatialseparationbetweenbedstoreducetheopportunitiesforinadvertentsharingofitemsbetweentheinfected/colonizedpatientandotherpatients.Itmaybeprudenttodrawaprivacycurtainbetweenpatientstopromoteseparation.Somefacilitiesuseavisualqueue,suchascoloredtapeplacedonthefloor,inordertoidentifyareaswhererestrictedaccessanduseofadditionalprecautionsareneeded.
2. Personal Protective Equipment (PPE)Barrierprecautionsarecriticaltopreventtransmissionfromthepatienttothehealthcareworkerandthentoanotherpatient.PPEmustbedonnedbeforegoingintotheroomorcubicleanddiscardedbeforeexitingthepatient’sroom/cubicle.VisittheCDCwebsite(www.cdc.gov/ncidod/dhqp/ppe.html)foravideoandpostersillustratingproperPPEdonningandremovalprocedures,entitled“GuidancefortheSelectionandUseofPersonalProtectiveEquipment(PPE)inHealthcareSettings.”
a. GlovesGlovesmustbedonnedbeforeenteringtheroomandwornbyallhealthcareprovidersduringpatientcareandwhenincontactwiththepatient’senvironment.Glovesshouldalsobechangedaccordingtostandardrecommendationsforglovesutilization(e.g.,ifheavilycontaminatedortorn),andremoved/discardedasthehealthcareproviderleavestheroom.Contactwiththepatientandthepatient’senvironmentcanexposethehealthcareworkertovegetativeClostridium difficileanditsspores.High-touchsurfaces(e.g.,bedrails,lightswitches,faucets)areaknownsourceofC. difficilespores.C. difficilemayalsobefoundatmultipleskinsitesofpatientswithCDI,includinggroin,chest,abdomen,forearm,andhands,andcouldbetransferredtothecareprovider’shands.Thiscolonizationcanpersistafterthecessationofdiarrhea.71
b. GownsHealthcareworkersshoulddonandweargownsandgloveswhenenteringaroomtoprovidecaretoapersononContactPrecautions.Theuseofglovesalonemaybeaseffectiveinpreventingtransmission
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY 2�
astheuseofglovesandgownstogether.72However,untilconclusivedataisgenerated,gownsshouldcontinuetobewornwithglovesforallinteractionsthatmayinvolvecontactwiththepatient,contaminatedequipment,orpotentiallycontaminatedareaswithinthepatient’senvironment.
ProtectiveequipmentandpersonalitemssuchasclothinganduniformsmaybecomecontaminatedaftercareofapatientcolonizedorinfectedwithaninfectiousagentsuchasC. difficile.Althoughcontaminatedclothinghasnotbeenimplicateddirectlyintransmission,thepotentialexistsforsoiledgarmentstotransferinfectiousagentstosuccessivepatients,andinlightoftheseverityofCDI,liberaluseofPPEisappropriate.73
3. Patient Transport WhenapatienthasCDI,patienttransportationandmovementoutsidetheroomorcubicleshouldbelimitedtomedicallynecessarypurposes.Patientsshouldbetaughttoperformhandhygienepriortomovementfromtheirroom.Thesestrategiescanhelpcontainandlimitsheddingintotheenvironment.AccordingtotheHICPACIsolationGuideline,thetransportershouldremoveanddiscardcontaminatedPPEandperformhandhygienepriortotransportingpatientsonContactPrecautions.CleanPPEshouldbedonnedtohandlethepatientatthetransportdestination.Thepatient’sisolationstatusshouldbecommunicatedtothereceivingunitpriortotransport,sothatunitpersonnelareabletoaccommodatethespecialneedsofthatpatient.
4. Patient Care Equipment, Instruments, Devices and the Environment C. difficilecontaminatespatientcareequipmentanddevicesthroughfecalsheddingorthroughthecontaminatedhandsofpatientorhealthcareprovider.TheabilityofC. difficiletosurviveonenvironmentalsurfacesdemandsadherencetorecommendedmeasurestopreventcross-contamination.OngoingtransmissionofC. difficilemaybeamarkerforpooradherencetoenvironmentaldecontaminationandotherinfectionpreventionmeasures.Theinfectioncontrolteamshouldobservepersonnelandmeasureadherencetoappropriatehealthcarepractices,especiallywhenongoingtransmissionoccurs,inordertoidentifyanybreachesininfectionpreventionpractice.
C. difficilesporescanpersistformonthsinthehealthcareenvironmentandbetransmittedtopatientsduringthistime.Fecalcontaminationofsurfaces,devices,andmaterials(e.g.,commodes,bathingtubs,andelectronicrectalthermometers)55mayprovideareservoirfortheC. difficilespores,whichleadstotransmission.High-touchsurfacesandequipmentmustbethoroughlycleanedanddisinfectedtoremoveand/orkillspores.Useofanindividualbedsidecommodeforeachpatientreducestheriskoftransmissionofinfectiousagents.Whenabedsidecommodeisused,thestaffmustuseappropriatePPEandemptywasteinamannerthatpreventssplashing.Thecommodemustalsobecleanedanddisinfectedafterwasteisdiscarded.
Eachhealthcarecaresettingshouldhaveaplantocleananddisinfectsurfaceswhenfecalcontamination(e.g.,uncontrolleddiarrhea)hasoccurred.Personnelshouldbesuretocleananddisinfectallpatientcareequipmentthathasbeencontaminated.Reusableequipmentmustbecleanedanddisinfectedbetweenpatients.Wheneverpossible,eachpatientshouldbeassignedhisorherownequipmenttominimizecross-contamination.
5. Discontinuing Contact PrecautionsItiscurrentlyrecommendedthatContactPrecautionsmaybediscontinuedwhenthepatientnolongerhasdiarrhea.7Becauseofcontinuedenvironmentalcontaminationandpatientskincolonization,someexpertsrecommendcontinuingcontactprecautionsfortwodaysafterdiarrheastops.74ThisisoneexampleofheightenedresponseactivitiesandwillbediscussedinmoredetailinthesectionaddressingatieredapproachtoCDItransmissionprevention.
6. Assessing Adherence to Isolation PrecautionsAssessingadherencewithisolationprecautionsisanimportantelementinprevention.Figure8.1providesanexampleofatoolusedtomonitoradherence.Thistoolisalsoavailableatwww.apic.org/eliminationguides.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
2� ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Figu
re 8
.1. I
nfec
tion
Prev
entio
n an
d C
ontr
ol Is
olat
ion
Com
plia
nce
Che
cklis
t. So
urce
: Lor
etta
Litz
Fau
erba
ch, S
hand
s at
the
Uni
vers
ity o
f Flo
rida.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY 2�
Focusing on Prevention: Hand Hygiene
PreventionofCDIdemandsmeasurement,assessment,andevaluationofcurrenthandhygienepractices.C. difficiletrumpsallotherhealthcare-associatedinfectionsforthepolarizedapproachesregardingthebesthandhygienepracticestopreventtransmission.UnderstandingoftheincidenceofCDIinyoursetting,barrierstoperformanceofhandhygiene,andenvironmentalcleanlinesswillhelpyourteamselecttherightepidemiologically-driveninterventionstopreventtransmissionofthisorganism.
AccordingtotheCDCHICPAChandhygieneguidelines,healthcareproviderhandsarefrequentlycontaminatedwithC. difficile followingpatientcontact.WearingglovescansignificantlyreducethespreadofC. difficile inhospitals.Currentinformationontheneedtousetraditionalhandwashing,ascomparedtousingalcoholhandrubs,isconflicting.Commonantimicrobialagents(includingalcohols,chlorhexidine,hexachlorophene,iodophors,PCMX,andtriclosan)forhandwashingarenotactiveagainstspores.Thebenefitofhandwashingwithsoapandwateristhephysicalremovalanddilutionofsporesfromthehands,ratherthanthekillingofspores.54
Afterglovesareremoved,healthcareproviders’handsshouldbewashedwithanon-antimicrobialoranantimicrobialsoapandwater,ordisinfectedwithanalcohol-basedhandrub.76Hospitalsusingalcohol-basedhandrubsastheirprimarymeansofhandhygienehavenotseenincreasesintheincidenceofCDIassociatedwiththeirintroduction. TheincreasedincidenceofCDInotedinnumeroushospitalshasbeenattributedtotheintroductionoftheepidemicC. difficilestrainNAP1andnotduetoincreaseduseofalcoholbasedhandrubs.77However,duringoutbreaksorevidenceofon-goingtransmissionofC. difficile-relatedinfectionsinaninstitution,washinghandswithanon-antimicrobialorantimicrobialsoapandwaterafterremovingglovesandotherpersonalprotectiveequipment(PPE)isprudent.
Inanintensivecareunitstudythatcharacterizedhealthcareworkers’(HCW)encounterswithpatientsandcorrelatedthattotheirhandhygienecompliance,itwasnotedthathandhygienecompliancewasthelowestafterbriefencountersoflessthantwominutes.Theobserversnotedthatbriefencountersmadeupasubstantialportionofthecontactandhealthcareworkershadopportunitiesforhandhygieneduringallbriefencounters.TheauthorsconcludedthatHCWeducationandtrainingshouldincludespecialemphasisonthepotentialforhandcontaminationevenduringbriefencounters,andshouldstresstheimportanceofhandhygiene.InlightofhypervirulentstrainsandtheincreasingincidenceofCDIandotherepidemiologically-significantorganisms,thosemissedopportunitiespresentarealriskoftransmission.77
• SeveralresourcesforhandhygieneeducationalmaterialsareprovidedinTable9.1.AnexampleprovidedbyAPICisshowninFigure9.1.(Thesematerialsarealsoavailableatwww.apic.org/eliminationguides).
Teaching patient hygiene including hand hygiene and bathingFamilies,visitorsandpatientsshouldbepartnersinpreventingCDI.Therehavebeenseveralnationalinitiativesencouragingpatientstotakeanactiveroleintheircare.Aninformedpatientpromotesunderstandingoftheircare.Educationshouldinclude:
• ExplanationoftheinfectioncausedbyC. difficile• Reviewofthespectrumofdiseaseandre-occurrences• Discussionofhowtheorganismisspread• Descriptionofwhatthepatientcandotohelpreducethespreadofthedisease• EducationofpatientsandtheirfamiliesaboutvisitorswhomaybeathighriskforacquiringC. difficile, such
asindividualsonantibiotics,orwhoareimmunosuppressed,andhelpingthemdecideabouttheirvisitations
Guide to the Elimination of Clostridium difficile in Healthcare Settings
28 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft): A Summary. WorldHealthOrganization;2005.Availableathttp://www.who.int/patientsafety/events/05/HH_en.pdfandhttp://www.who.int/gpsc/tools/en/
IHI How-to Guide: Improving Hand Hygiene “A Guide for Improving Practicesamong Health Care Workers.” ThisguidewasacollaborateeffortbetweentheCentersforDiseaseControlandPrevention(CDC),theAssociationforProfessionalsinInfectionControlandEpidemiology(APIC),andtheSocietyofHealthcareEpidemiologyofAmerica(SHEA),andhasbeenendorsedbyAPICandSHEA.ValuableinputalsowasprovidedbytheWorldHealthOrganization’sWorldAllianceforPatientSafetythroughtheGlobalPatientSafetyChallenge.(Thisdocumentisinthepublicdomainandisavailableonwww.IHI.org.ItmaybeusedorreprintedwithoutpermissionprovidedappropriatereferenceismadetotheInstituteforHealthcareImprovement).
Hand Hygiene for Health Care Settings. OntarioMinistryofHealthandLong-TermCare/PublicHealthDivision/ProvincialInfectiousDiseasesAdvisoryCommittee;May2008.ToreviewtheHandHygieneFactSheetwithsupportingevidencegoto:http://www.health.gov.on.ca/english/providers/program/infectious/pidac/fact_sheet/fs_handwash_010107.pdf
APIC http://www.apic.org/AM/Template.cfm?Section=Search§ion=Brochures&template=/CM/ContentDisplay.cfm&ContentFileID=298http://www.preventinfection.org/Content/NavigationMenu3/InformationCenter/HandHygiene/default.htm
TheJoint Commissionhasbeenworkingwithleadinginfectionpreventionandcontrolorganizationsandhandhygieneexpertstodevelopaneducationalmonographtoguidethefieldinmeasuringadherencetohandhygieneguidelines.Themonographwillofferguidanceonsettingmeasurementgoalsandwillexploretheprosandconsofthethreemajorapproachestomeasuringhandhygiene.Themonographwillcontainextensiveresources,includingorganization-specificexamplesofmeasurementtoolsandlinkstohelpfulwebsites.Themonographisexpectedtobeavailableinfallof2008andwillbepostedontheAPICwebsite.
CDC’s Hand Hygienesitecontainspostersandeducationalprogramsaswellasaninteractiveeducationalprogram.http://www.cdc.gov/Handhygiene/
John Boyce and St. Raphael’ssiteprovidesaPowerPointpresentationforeducatingstaffandhandhygienemonitoringtools.http://www.handhygiene.org/
Henry the Handprovidescampaignslidesandprogramstouseindevelopingalocalhandhygienecampaignandincreasingcompliance.http://www.henrythehand.com/
Soap and Detergent AssociationEducationalmaterialsarepresentedonthissite.http://www.cleaning101.com/newsroom/2005_survey/handhygiene/
Table �.1. Resources for hand hygiene educational materials.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY 2�
Figure �.1. Sample hand hygiene educational material. Source: APIC.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�0 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
• DescriptionofhowtopreventtransmissionofC. difficile,includingContactPrecautions,StandardPrecautions,andhandhygiene
• Identifyingstepsthatpatientsandfamilycantaketocleantheirenvironmentathome
AsuccessfulpatientandfamilyeducationprogramcangaincooperationwithfollowingContactPrecautionswhileinthehospital.79Handhygiene,especiallyhandwashing,willbecriticalinminimizingthespread.Nursingstaffshouldassistthepatientinhandhygieneifthepatientcannotdoit,especiallyaftertoiletingandbeforeeating.Nursingstaffshouldeducatethefamilyabouttheriskfactorsfortransmission.
PatienteducationshouldincludetheimportanceofbothhandhygieneandshoweringtoreducethebioburdenofC. difficileontheirskin.Ifapatientisunabletoshower,bedbathsshouldbeperformed,withthestaffassistingasneeded.Acleanhospitalgown/clothingshouldbedonnedafterbathingorshowering.Freshbedlinensarealsoimportant,sincethepatientmaycontinuallyshedthebacteriaanditsspores,creatingheaviercontaminationonusedlinens.
Table9.2isasamplehandoutthatcanbeusedforpatient/familyeducationregardingC. difficile.(Thistableisalsoavailableatwww.apic.org/eliminationguides).
Patient and Family Education Regarding Clostridium difficile Infection (CDI)What is Clostridium difficile? Clostridium difficile is a bacterium that causes diarrhea as well as more serious intestinal conditions such as colitis, aninflammationofthebowel.
What is Clostridium difficile infection? Clostridium difficileisthemostcommoncauseofinfectiousdiarrheainhealthcarefacilities.Themainsymptomsincludewaterydiarrhea,fever,andabdominalpainortenderness.Clostridium difficile infectionmayoccurasanundesirableconsequencewhenantibioticsaretakentotreataninfection.Whentreatingthatinfection,someofyourgoodbowelbacteriaarealsokilledtherebyallowingthebacteriathatarenotkilledbytheantibioticstogrow.OneofthesebacteriathatareresistanttomanyantibioticsisClostridium difficile.WhenClostridium difficilemultiplies,itproducestoxinsorsubstancesthatcandamagethebowelandcausediarrhea.Clostridium difficileinfectionresultsindiarrhearequiringspecifictreatmentanditcansometimesbequitesevere.Inseverecases,surgeryresultinginremovalofaportionoftheintestinesmaybeneeded.
Who can develop Clostridium difficile infection? Clostridium difficile infection,alsoknownasCDI,usuallyoccursduringorafter theuseofantibiotics.Those individualshavingseriousillness,theelderly,orthoseinpoorgeneralhealthareatincreasedriskofdevelopingCDI.
How is Clostridium difficile infection diagnosed? Ifyouareonantibiotics,orhaverecentlytakenantibiotics,andyoudevelopwaterydiarrheaandfever,yourdoctormaysuspectClostridium difficileasacauseofthosesymptoms.Asampleofyourstool(feces)willbecollectedandsenttothelaboratoryforanalysis.ThelaboratorywilltestthestooltoseeifClostridium difficiletoxinsarepresent.Oneormorestoolsamplesmaybecollected.
How is Clostridium difficile infection treated? YourdoctormayprescribeaspecifictypeofantibioticthattargetsandkillsClostridium difficile.Treatmentusuallyconsistsofantibioticstakenforabout10days.
How do people get Clostridium difficile infection? Peopleingoodhealthusuallydon’tget C. difficile infection.Peoplewhohaveotherillnessesorconditionsrequiringprolongeduseofantibioticsandtheelderlyareatgreaterriskofacquiringthisdisease.WhenapersonhasClostridium difficileinfection,
Table �.2. Patient and family education.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY �1
thegermsinthestoolcansoilsurfacessuchastoilets,handles,bedpans,orcommodechairs.Whentouchingtheseitems,thehandsofthepatientaswellasthehandsofhealthcareworkersandfamilymemberscanbecomesoiledwithClostridium difficile.Thesesoileditemsandhandscanbeinvolvedinmovingtheorganismtoothersurfacesandotherpeople.ThisiswhyanindividualwithClostridium difficileinfectionisplacedinisolationwheninahealthcaresetting.
What type of isolation is used for Clostridium difficile infection? IfyouhaveClostridium difficilediarrhea,youwillbemovedtoaprivateroomuntilyouarefreefromdiarrhea.Youractivitiesoutsidetheroomwillberestricted.Everyonewhoentersyourroommustweargownandgloves.EveryoneMUST cleantheirhandsafterprovidingcaretoyouortouchingyourenvironment.Youshouldalsopayattentiontocleaningyourhandsregularlyandshoweringorbathingtoreducetheamountofbacteriaonyourskin.Yourroomwillalsobecleanedregularlyandallequipmentdisinfectedbeforeitisremovedfromyourroom.
What should I do to prevent the spread of C. difficile to others?Ifyouareinfectedyoucanspreadthediseasetoothers.However,onlypeoplethatarehospitalizedoronantibioticsarelikelytobecomeill.Forsafetyprecautionsyoumaydothefollowingtoreducethechanceofspreadtoothers:
• washhandswithsoapandwater,especiallyafterusingtherestroomandbeforeeating;• cleansurfacesinbathrooms,kitchensandotherareasonaregularbasiswithhouseholddetergent/disinfectants
Should special practices be done when I go home? HealthypeoplelikeyourfamilyandfriendswhoarenottakingantibioticsareatverylowriskofdevelopingClostridium difficile infection.However,itisprudentforeveryonetocleantheirhandsregularlyandmaintainahygienicenvironment,especially the bathroom area. Cleaning of the environment can be done using your regular germicide or you can use asolutionofchlorinebleachandwater.Ifyouusethissolution,mix1partchlorinebleach(unscented)with9partstapwater.Changethesolutiondailyandbesuretoprotectyourselffromsplashesorspraysofthesolutionintoyourfaceandeyes.Youmightwanttowearprotectiveglovessothebleachsolutiondoesnotcomeintocontactwithyourskin.
What else should I know about cleaning the house environment?Useacleanclothandsaturateitwiththegermicideorbleachsolution.Usefrictionwhencleaningsurfacesthenallowthesurfacetoairdry.Ifthereissoilonthesurface,removeitthenuseanewclothsaturatedwiththegermicideinordertodisinfectthesurface.Payspecialattentiontoareasthatmayhavesomeintocontactwithfecessuchasthecommodeandsink.Whenlaunderingitems,rinseclothingorfabricthathasbeensoiledwithstool,thenuseyourregularlaundryprocesses.Usethehotwatercycleanddetergent.Ifyouwanttoaddsomechlorinebleach,thatwillassistwithkillingofthegerms.Drytheitemsinthedryer.Thereisnoneedtoinitiatespecialprecautionswithdishesandeatingutensils.
What about cleaning of hands?Havingcleanhandsisthemostimportantthinganyofuscandotopreventillness.Whenperforminghandhygiene(anothertermforcleaninghands),itcanbedoneusingtraditionalsoapandwaterhandwashingorusinganalcohol-basedsolution.SinceClostridium difficileisanorganismfoundinfeces,useoftraditionalhandwashingispreferred.
Whenwashingyourhands,firstwetyourhandswithwaterthanapplysoapinthepalm.Rubhandstogethertakingcaretocoverallsurfacesofthehandsaswellasbetweenthefingers.Rubforatleast15seconds,thenrinsewithwater.Pathandsdryinsteadofrubbingasthismaypreventdamagetotheskinofthehandsandchapping.Ifalcohol-basedhandrubsareused,putasmallamountofthesolution(aboutthesizeofanickel)inthepalmofonehandthenrubthesolutionoverbothhandsandbetweenfingersuntilthesolutiondries.Thereisnoneedtorinsehandsafterward.
Performhandhygieneafterusingthetoilet,aftertouchingdirtysurfacesoritems,beforeeating,beforepreparingmeals,andanytimeyourhandsarevisiblysoiledor“feel”dirty.Teachthisimportantpracticetoothersincludingchildren.
What other information is important for me to know?Itisveryimportantthatyoutakeallyourmedicationasprescribedbyyourdoctor.Youshouldnotuseanydrugsfromthedrugstorethatwillstopyourdiarrhea(e.g.,Imodium)asthismayresultintheClostridium difficiletoxinsstayinginsideyourcolonandcausingmoresevereillness.If your diarrhea persists or comes back, contact your doctor.
FormoreinformationonClostridiumdifficileinfection,gototheCentersforDiseaseControlandPreventionwebsitewww.cdc.gov/ncidod/dhqp/id_CdiffFAQ_general.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�2 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Focusing on Prevention: Environmental Control
Theenvironmentmustberecognizedasacriticalsourceofcontamination,anditplaysasignificantroleinsupportingthespreadofinfection.BecauseC. difficileisshedinfeces,anysurface,item,ormedicaldevicethatbecomescontaminatedwithfecescanactasasourceforthesporesand,therefore,beinvolvedininfectiontransmission.50,51
C. difficilesporescanexistforfivemonthsonhardsurfaces.50,51Inonestudy,sporeswerefoundin49%oftheroomsoccupiedbypatientswithCDIand29%ofthetimeinroomsofasymptomaticcarriers.80Theheaviestcontaminationisonfloorsandinbathrooms.74
Othersitesthatcanbecontaminatedincludeelectronicthermometers,bloodpressurecuffs,bedrails,callbuttons,tubefeedings,flow-controldevicesforIVsandtubefeedings,bedsheets,commodes,toilets,scales,telephones,TVcontrols,lightcontrols,andwindowsillsinthepatientroom.Aslevelsofenvironmentalcontaminationincrease,thelevelofhandcontaminationofhealthcarepersonnelalsoincreases.ThegreatertheincidenceofCDI,thegreatertheopportunityfortransmission,sointerventionsshouldbetiedtosurveillanceresults.
Disinfectantscommonlyusedinhealthcaresettingsincludequaternaryammoniumsandphenolics,neitherofwhicharesporicidal81,82Somedisinfectantsmayactuallyencouragesporulation(thechangingoftheorganismfromthevegetativestatetotheprotectedsporestate).Thetermhypersporulationhasbeenusedtodenotethepropensityofthebacteriumtomovefromthevegetativeformtothesporeformwithincreasedrapidity.Thetermhasalsobeenusedtonotethatcontactwithsomegermicidesstressthebacterium,soitmorereadilytransitionstothesporeform.Therefore,thetermhypersporulationmaybeunderstoodasthepropensityoftheorganismtomorereadilymovefromthevegetativeformtothesporethanoccursunderusualconditions.AlthoughmanyEPA-registeredgermicideskillthevegetativeC. difficile,onlychlorine-baseddisinfectantsandhigh-concentration,vaporizedhydrogenperoxidekillspores.Currently,therearenoEPA-registeredsporicidalagentsacceptableforuseasageneralsurfacedisinfectant.83-85
ThisinformationmightleadonetobelievethattheenvironmentsofallpatientswithCDImustorshouldbecleanedwithahypochloritesolution.Butthereareanumberofproblemsassociatedwithuseofasodiumhypochloritesolution(hereafterreferredtoasbleach),includingcorrosionandpittingofequipmentandothersurfacesovertime,andemployee-relatedconcernssuchasthetriggeringofrespiratorydifficultiesinworkersusingthesolutions.Therefore,theuseofbleachshouldbelimitedtooutbreaksituationsasrecommendedbytheCDC.Cleaninganddisinfectionactivitiesusingthephysicalmotionsofcleaninganduseoftheroutinegermicideremovesanddilutessporeconcentrationandisacceptableintheabsenceofanoutbreak.
Ingeneral,surfacesshouldbekeptclean,andbodysubstancespillsshouldbemanagedpromptly,asoutlinedinCDC’s“GuidelinesforEnvironmentalInfectionControlinHealth-CareFacilities.”86Thisdocumentcanbeaccessedatthewebsitewww.cdc.gov/ncidod/hip/enviro/guide.htm.DisinfectantproductswithEPAregistrationcanbeusedforroutinecleaninginhealthcaresettings.Activecleaninginvolvestheremovalanddilutionofdirtandcontamination.Cleaningiscriticalforoptimaldisinfectiontooccur.
AstheCDCenvironmentalguidelineindicates,hypochlorite-baseddisinfectantshavebeenusedwithsomesuccessforenvironmentalsurfacedisinfectioninthosepatient-careareaswheresurveillanceandepidemiologyindicateongoingtransmissionofC. difficile.Theuseofa10%sodiumhypochloritesolutionmixedfreshdaily(oneparthouseholdchlorinebleachmixedwithninepartstapwater)hasbeenassociatedwithareductioninCDIin
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY ��
somesettings.81CommunicationfromtheEnvironmentalProtectionAgency(EPA)hassuggestedthatuseofapH-adjustedbleachsolutionmadebymixingoneparthouseholdbleach(5.25%-6%),ninepartswaterandonepartvinegar(5%aceticacid),mayprovideanevengreaterimpactonC. difficile(J.Kempter,EnvironmentalProtectionAgency,2008,personalcommunication).
Awordofcautiontotheinfection-preventionteamwhentheyevaluateadisinfectant’sclaimsofefficacy;besuretoclarifywhattheclaimsmean.Forexample,aproductmayclaimtokillC. difficileandbereferringtothevegetativecells,notthespores.Vegetativecellsarereadilykilledbymostdisinfectants.Cleaninganddisinfectingagentsshouldbereviewedandapprovedbyinfectionpreventionandcontrolcommitteestoassurethechemicalsmeetthestandardsandareeffectivefortheintendeduse.
Ifusinga10%sodiumhypochloritesolution,thereareseveralkeypointstoremember:• Commerciallyavailablesolutionscontainadetergentbase,whichishelpfulincleaningaswellas
disinfecting.• Evaluatetheuseofcommerciallyavailablesolutionswithinyourfacility.Somehypochloriteproductsare
availableinareadytousesolution.Thismaybeatime-savingprocessthatminimizesdilutionerror,butitmayalsobeachallengeforstorageandprovetobemorecostly.
• Makingamixtureofbleachandwaterwillprovideonlythedisinfectant,notthedetergentbase.Therefore,atwo-stepprocessmaybeneededifcleaningistobeperformedpriortodisinfection.
• Ifableachandwatermixtureismade,useonlychlorinebleachwithoutthescentadditive,asthisreducestheresultantpartspermillion(ppm)ofavailablechlorine.
• Ableachandwatersolutionshouldprovideatleast4,800ppmofavailablechlorine.• Thereisadifferencebetweenagermicidalbleach(6.15%hypochlorite),alaundrybleach(6.0%
hypochlorite),andadiscountedbleach(5.25%orlesshypochlorite).• Acontacttimeofoneminuteforthehypochlorite(bleachandwater)solutionshouldprovideadequate
disinfectionfornon-poroussurfaces.Thisisaccomplishedbyathoroughwettingofthesurfacewiththehypochloritesolution,thenallowingittoairdry.(Rutala,APIC2008).
Contact TimeContacttimereferstotheamountoftimenecessaryforthegermicidetocomeintocontactwiththeorganismandresultinasignificantreductioninthenumberofmicro-organisms.Thisusuallymeansa3logarithmic(3log)reductioninthenumberoforganisms.ItisthiskillclaimthatmustbesubmittedtotheEPAinorderforagermicidetoreceiveapprovalasacceptableforuseinhealthcaresettings.
Whenapplyingtheconceptofcontacttimeinthehealthcareenvironment,itisvitalfortheinfectionpreventionisttoknowthecontacttimeoftheselectedgermicideandhowtoapplythisknowledge.Germicidescommonlyusedinthehealthcaresettinghaveacontacttimeof10minutes,althoughsomehaveashortercontacttime.Thismeansthatthesurfacebeingdisinfectedshouldcomeintocontactwiththegermicide(staywetaftercleaning)for10minutes(orlessaccordingtothespecificsofthegermicide)inordertoreducetheamountoforganismsby3logs(99%).Thiscanbestbeaccomplishedbyusingthebucketmethodofcleaning,wherethegermicideismixedwiththeappropriateamountofwaterinaccordancewithmanufacturer’srecommendationsandplacedinacleanbucketorcontainer.Acleanclothisusedduringcleaning,andthecleaningprocessprohibitsthedirtyclothfromreturningtothebucketorcontainerofcleangermicide.Thegermicidesolutionmustbechangedperiodicallytoensureitseffectiveness,andbucketsorcontainersarewashedanddisinfectedregularly,inadditiontobeinginspectedforcracks.Thepracticesusedduringcleaninganddisinfectionshouldbeclearlyoutlinedinpolicyformatandobservationusedtoevaluateadherence.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�� ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Germicidalwipeshavebecomeanimportantadditiontoenvironmentalcleaning,buttheymustbeusedappropriatelytobeeffective.Wipesaremadeofamaterial,orsubstrate,thatletsthemabsorbthegermicideinwhichtheyarepackagedandallowsthatgermicidetobedistributedontothesurfaceduringthecleaninganddisinfectionprocess.
GermicidalwipesareregisteredwiththeEPAandthegermicidehasaspecificcontacttimeaspartofthatEPAapprovalprocess.Thismeansthatthewipemustenabletheusertowetthesurfacebeingdisinfectedforthecontacttimenotedonthelabelinordertodestroytheorganismsonthesurfacebeingcleaned.Therefore,itisimportanttousewipesfortherighttypeofjob.Forexample,onecurrentlyavailablegermicidalwipehasacontacttimeof30secondsforsomebacteria(includingC. difficile)andoneminuteforsomeviruses.Tomaintainawetsurfaceforthatcontacttime,thatwipeisappropriatefordisinfecting20squarefeet.Forinfectionpreventionists,itisimportanttoknowthecontacttimeforthegermicide,aswellastheabilityofthewipetomaintaincontacttimeforthetaskinwhichitwillbeused.Ifwipesareusedtocleanthehigh-touchsurfacesinapatientroom,multiplewipeswilllikelyneedtobeusedtoaccomplishthattask,duetothenumberofsurfacestobedisinfected.Healthcarepersonnel,includingenvironmentalservicesstaff,mustbetrainedtousethewipesappropriately.Theinfectionpreventionistmustbeinvolvedinselectionoftherighttypeofwipetoperformthedesiredjobs.
Monitoring Environmental CleaningConsistencywithrecommendedcleaninganddisinfectionproceduresshouldberoutinelymonitored.Allsurfacesanditemsnearthepatientshouldbeincludedinthisprocess.Achecklistwillhelptheworkertoconfirmthateachcriticalareahasbeencleanedanddisinfected—however,theworkermustfollowthelistandcheckoffeachitemasthecleaninganddisinfectionprocessiscompleted.
• Checkliststhatdelineaterecommendedpracticesforafacilityandroutineroundstoevaluatepracticeswillassistthecareteaminidentifyingopportunitiesforimprovement.Workingwithunitandspecialtyspecificgroupstodevelopchecklistsandmeasurestosupportadherencewithenvironmentalcleaningactivitieswillhelpimproveadherence.Table10.1showsachecklistusedamonghealthcarefacilitiesinNewYorktoassessenvironmentalcleaning.Table10.2showsachecklistusedwhenC. difficileisinvolvedandenvironmentalcleaningpracticeshavebeenaltered.Figure10.1depictsapatientroomthathasnotyethadhigh-touchsurfacesidentified.Figure10.2depictsapatientroomandidentifieshigh-touchsurfacesthatneedtobetargetedforspecificpatientenvironments.(Thesechecklistsandfiguresarealsoavailableathttp://www.apic.org/eliminationguides)
Notethatinsomesettings,somepatientcareequipmentsuchasinfusionpumpsandventilatorsarecleanedbynursesorspecialequipmenttechnicians.Adaptationoftheseexamplesshouldincludelocalpractices.
ThereisnoneedforroutineenvironmentalbiologicalsamplingforC. difficile. Itisimportantfortheteamtoselecttheappropriateenvironmentaldisinfectant.Non-compliancewithprotocolswillusuallybedetectedbyongoingtransmissionoftheorganism.Ifongoingtransmissionisnoted,thenathoroughcleaninganddisinfectionoftheenvironmentmustbedone.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY ��
ENVIRONMENTAL CHECKLIST -
Hospital:_____________________________________
Date:________________________________________
Unit:_________________________________________
Room:________________________________________
Time:________________________________________
Instruction Component Yes No N/A
At start, perform hand hygiene.
Put on PPE.
Disinfect high-touch surfaces: Door knobs/handles
Door surface
Bed rails
Call button
Phone
Overbed table & drawer
Countertop
Light switches
Furniture
Arms of patient chair
Seat of patient chair
All other miscellaneous horizontal surfaces
Window sills
Bedside commode
Medical equipment (e.g., IV controls)
Spot clean walls with disinfectant cloth
Disinfect: BATHROOM, including:
Bathroom door knob
Toilet horizontal surface/seat
Toilet lever/flush
Faucets (at sink)
Bathroom handrails
Sink
Tub/shower
Mirror
Damp dust: Overhead light (if the bed is empty)
TV & stand
Clean: Lights
Clean floor: Dust mop tile
Wet mop tile
Replace as needed: Hand sanitizer
Paper towels
Soiled curtains
For terminal cleaning, damp dust: Bed frame
Mattress
Remake bed with clean linen
Replace as needed: Pillows, mattresses, pillow
covers, mattress covers
Other: Empty trash & replace liner
Discard dust cloths.
Change mop heads after each isolation room.
Remove PPE before exit.
Perform hand hygiene.
Any significant areas not mentioned above (please describe):
This room looks clean and ready for use:
Sign-off by environmental services employee cleaning the room:______________________________________________
Sign-off by TBD, based on your hospital process for cleaning room:_______________________________________________
Table 10.1 - Environmental Checklist for Daily Cleaning
FOR DAILY CLEANING - ROOM OBSERVATIONS: Please review a sample of 5 patients per week (1 patient per day)
Table 10.1. Environmental checklist using sodium hypochlorite for daily cleaning.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�� ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Clostridium difficile ENVIRONMENTAL CHECKLIST USING SODIUM HYPOCHLORITE
Hospital: _____________________________________
Date:________________________________________
Unit:_________________________________________
Room:________________________________________
Time:________________________________________
Instruction Component Yes No N/A
At start, perform hand hygiene. N/A
Put on PPE. N/A
Disinfect w/ hypochlorite-based disinfectant, high-touch
surfaces. Door knobs/handles
Door surface
Bed rails
Call button
Phone
Overbed table & drawer
Countertop
Light switches
Furniture
Arms of patient chair
Seat of patient chair
All other miscellaneous horizontal surfaces
Window sills
Bedside commode
Medical equipment (e.g., IV controls)
Spot clean walls with disinfectant cloth
Disinfect w/ hypochlorite-based disinfectant: BATHROOM, including:
Bathroom door knob
Toilet horizontal surface/seat
Toilet lever/flush
Faucets (at sink)
Bathroom handrails
Sink
Tub/shower
Mirror
Damp dust: Overhead light (if the bed is empty)
TV & stand
Clean: Lights
Clean floor: Dust mop tile
Wet mop tile
Replace as needed: Hand sanitizer
Paper towels
Soiled curtains
For terminal cleaning, damp dust: Bed frame
Mattress
Remake bed with clean linen
Replace as needed: Pillows, mattresses, pillow
covers, mattress covers
Other: Empty trash & replace liner
Discard dust cloths. N/A
Change mop heads after each isolation room. N/A
Remove PPE before exit. N/A
Perform hand hygiene. N/A
Any significant areas not mentioned above (please describe):
This room looks clean and ready for use:
Sign-off by Environmental Services employee cleaning the room:______________________________________________
Sign-off by TBD, based on your hospital process for cleaning room:_______________________________________________
Table 10.2 - ENVIRONMENTAL CHECKLIST USING SODIUM HYPOCHLORITE FOR DAILY CLEANING
FOR DAILY CLEANING - ROOM OBSERVATIONS: Please review a sample of 5 patients per week (1 patient per day) with known or suspected C. difficile.
Table 10.2. Environmental checklist using sodium hypochlorite for daily cleaning when C. difficile is involved.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY ��
Figure 10.1. Picture of a patient’s room for use in training individuals regarding room cleaning.
Figure 10.2. Picture of room noting some high touch surfaces and items.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�8 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Tiered Approach to CDI Transmission Prevention
ThepriorsectionshavefocusedonexpandingknowledgeregardingCDIandthemanyquestionsastothemosteffectiveandefficientwaytoeliminatetransmissionwhilecontinuingtoprovidecareforallpatientsinacomplexhealthcareenvironment.Understandingthosechallengesandconstraints,theCDCfirstintroducedtheideaofatieredapproachtoaddresstheuniqueaspectsofmultidrug-resistantorganismsaspartofthe2006guidelinesforpreventingtransmissionofMDROs.
Followingthatlead,thisguideoutlinessomeofthetransmission-preventionactivitiesthatshouldbeundertakenaspartofroutineinfectionpreventionandcontrolresponsestoC. difficile.Inthepagesthatimmediatelyfollowtheseroutineactivities,thenexttierofheightenedactivitiesareprovided.Routineandheightenedactivitieshavebeenseparatedsotheyclearlydemonstratewhenandhowtoinitiateamoreintenseresponsetopatientoutcomesspecifictoasinglehealthcaresetting.Thesetieredactivitiesarerelevanttoavarietyofhealthcaresettingsandstresstheuseoflocaldatatoguidedecision-making.
Summary of C. difficile Transmission Prevention Activities During Routine Infection Prevention and Control Responses
Early Recognition of CDI Surveillance
• Performfacility-widesurveillanceforCDI.• Calculatehealthcare-onset/healthcare-associatedCDIratesforeachpatientcareareaaswellasan
aggregateorganization-widerate.• ProvideCDIdataandinterventionstokeyindividualsandgroupssuchastheinfectioncontrolcommittee,
administration,medicalstaff,nursingstaff,andpharmacyandtherapeuticscommittee.• Monitorforanincreasedrateofcolectomies.• NetworkwithotherareainfectionpreventionistsasameansofassessingtheimpactofCDIacrossthe
community.• CommunicateopenlywithlocalhealthdepartmentregardingCDIrates.
Microbiologic identification
• WorkwithmicrobiologylabtoensurerapidreportingoftestresultsforCDI,includingweekendsandholidays.• Ensurethereisaprocessforprovidingresultstothepatientcareareasoisolationprecautionscanbe
initiatedpromptly.
Implementation of Contact Precautions for Patients with CDI
• UseStandardPrecautionsforallpatients,regardlessofdiagnosis.• PlacepatientswithCDIonContactPrecautionsinprivateroomswhenavailable.Preferenceforprivate
roomsshouldbegiventopatientswhohavefecalincontinence.• Ifaprivateroomisnotavailable,cohortpatientswithCDI;however,patientsinfectedwithotherorganisms
ofsignificance(i.e.,MRSA,VRE,Acinetobacter)shouldnotbehousedwithpatientswhoarenot.• Usededicatedequipment(i.e.,bloodpressurecuff,thermometer,stethoscope).• Putongownandglovesuponentrytothepatient’sroom.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY ��
• Changeglovesimmediatelyifvisiblysoiled,andaftertouchingorhandlingsurfacesormaterialscontaminatedwithfeces.
• Removegownandglovesbeforeexitingtheroom.• Ifcohortingisused,changegownandglovesandperformhandhygienepriortotouchingthenextpatient.• RoutinelycheckavailablesuppliesforContactPrecautionstoensurethatadequateselectionandamounts
arereadilyavailable.Thismaybestoccurbyassigningspecificresponsibilityforthetaskofcheckingandrestockingsuppliesonaregularbasis.
• DiscontinueContactPrecautionswhendiarrhearesolves.ConsiderincreasingthedurationofIsolationPrecautionsinepidemicsituations,orwhenongoingtransmissionissuspected.RefertothesectionoutliningSummaryofAdditionalC. difficileTransmissionPreventionActivitiesDuringHeightenedInfectionPreventionandControlResponses.
• DonotisolateasymptomaticcarriersofC. difficile.
Environmental Controls
• UseEPA-approvedgermicideforroutinedisinfectionduringnon-outbreaksituations.• Ensurethatpersonnelallowappropriategermicidecontacttime.• Ensurethatpersonnelresponsibleforenvironmentalcleaninganddisinfectionhavebeenappropriatelytrained.• Forroutinedailycleaningofallpatientrooms,addressatleastthefollowingitems:
o Bed,includingbedrailsandpatientfurniture(i.e.,bedsideandover-the-bedtablesandchairs)o Bedsidecommodeso Bathrooms,includingsink,floor,tub/shower,toileto Frequentlytouchedorhigh-touchsurfacessuchaslightswitches,doorknobs,callbell,monitorcables,
computertouchpads,monitors,andmedicalequipment(e.g.,intravenousfluidpumps)• Disinfectallitemsthataresharedbetweenpatients(e.g.,glucosemeters,infusionpumps,feedingpumps).• Monitoradherencetocleaninganddisinfectionprocessesbypersonnelresponsibleforenvironmentalcleaning.
Hand Hygiene
• Performhandhygieneuponremovalofgownandglovesandexitingthepatient’sroom.• Usealcohol-basedhandrubsforhandhygieneduringroutineinfectionpreventionandcontrolresponsesto
C. difficile.• Handwashingisthepreferredmethodforhandhygienewhenhandsarevisiblysoiled.• Assesshandhygienecompliancetoaddressobstaclestoperformance.
Antimicrobial Stewardship
• Implementaprogramthatsupportsthejudicioususeofantimicrobialagents.• Theprogramshouldincorporateaprocessthatmonitorsandevaluatesantimicrobialuseandprovides
feedbacktomedicalstaffandfacilityleadership.
Patient Education
• ShareinformationregardingC. difficileanditstransmissionwithpatientsandtheirfamilies.• Instructpatientsandfamiliesonhandhygieneandpersonalhygiene.• Instructpatientsandfamiliesregardingtheimportanceofdailybathingandprovideassistanceasneeded.
Healthcare Workers Education
• Provideongoingeducationregardingmodesofinfectiontransmission,ratesofCDI,andinfectionpreventioninterventionswithpatientcarestaff.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�0 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
• Expandcapacitythroughdevelopmentofinfectioncontrolliaisonorlinkswithpatientcarestaffandutilizetheirassistanceinmonitoringadherencetopreventivepracticessuchasisolation,handhygiene,andenvironmentalcleanliness.
Administrative Support
• Shareratesandinfectionpreventioninterventionswithseniorleadership.• Includeseniorleadershipincommunicationsregardingadherencemonitoring.• Communicateexpectationofsupportandaccountabilityregardingpreventionactivitiestokeyleadership
andprovideconcreteexamplesofwaystheycansupportinfectionpreventionandcontrol.
Summary of Additional C. difficile Transmission Prevention Activities During Heightened Infection Prevention and Control Responses AheightenedlevelofinterventionsshouldbeimplementedwhenthereisevidenceofongoingtransmissionofC. difficile,anincreaseinCDIrates,and/orevidenceofchangeinthepathogenesisofCDI(e.g.,increasedmorbidity/mortalityamongpatientswithCDI),despiteroutinepreventiveactivities.
Early Recognition of CDI Surveillance
• PerformpatientcareroundstoidentifypatientswhohavediarrheathatmayberelatedtoCDI.• InitiateContactPrecautionsforallsymptomaticpatientsinwhomCDIissuspected(e.g.,patientswith
diarrheaofunknownorigin).IfinitialtestingisnegativeforC. difficile, discontinueisolation.• ConsiderexpandingsurveillancetoincludeothercategoriesofCDIpatients,suchascommunity-onset,
healthcare-associated.• Increaseactivecommunicationwiththelocalhealthdepartmentandotherinfectionpreventionistsinyour
community.
Microbiologic identification
• DiscussaCDIrateincreasewithmicrobiologystaff,andevaluatealterationsintestingmethodsthatmayhaveimpactedresults.
Implementation of Contact Precautions for Patients with CDI• ConsidertheutilityofanadditionalCDIsigninordertoensureawarenessofallstaff,includingpersonnel
responsibleforcleaningtheenvironment,astheywillneedtouseanalternativecleaningsolutionandprocess.Ifused,thesignmustprotecttheprivacyofthepatientandnotrevealthediagnosis.
• Evaluatethecurrentsystemforpatientplacement.• ConsiderplacingallpatientswithdiarrheainContactIsolationuntilCDIisruledout(asopposedto
waitingforpositivetestresultstoinitiateisolation).• Increasemonitoringofadherencetoisolationprecautionsandhandhygiene.• Holdanopenforumwithpatientcarestafftoidentifybarrierstoinfectionpreventionpractices(e.g.,
interruptioninisolationsupplies,lackofprivaterooms).• ContinueContactPrecautionsevenwhendiarrhearesolves.Considerextendingisolationuntilpatient
discharge.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY �1
Environmental Controls• Use10%sodiumhypochloritefordisinfectingthepatient’sroomandallequipmentusedinthatroom.
Verifycompatibilityoftheequipmentwiththebleachsolution.• Use10%sodiumhypochloritefordailydisinfectionaswellasdischargedisinfectionfortheroomofthe
patientwithCDI.• Ifthereisevidenceofongoingtransmission,considerexpandingtheuseof10%sodiumhypochloritefor
disinfectionofallpatientroomsandequipment.• Ensurethatstaffmembersunderstandhowtousethesodiumhypochlorite(bleach)solutionandallow
adequatecontacttime.• Ensurethatpersonnelresponsibleforenvironmentalcleaninganddisinfectionhavebeenappropriately
trainedandareusingthecorrectPPE.• Usebleachwipesasanadjuncttoenvironmentalcleaninganddisinfection;trainstaffontheiruse,
includinginstructiononhowlargeanareacanbedisinfectedwithasinglewipeandpotentialadverseeffectsoftheproduct,suchasstaining,corrosion,anddamagetoequipment.
• Monitorandenforceadherencetocleaninganddisinfectionprocessesbypersonnelresponsibleforenvironmentalcleaning.
Hand Hygiene• Ensurecompliancewithappropriatehandhygieneuponremovalofgownandglovesandexitingthe
patient’sroom.• Enforcehandwashingasthepreferredmethodforhandhygieneduringthisheightenedresponse.• Assesshandhygienecompliancetoaddressobstaclestoperformance.• Ensurethatalcohol-basedhandrubsareavailableforuseaspartofacomprehensivehandhygiene
program.
Antimicrobial Stewardship• Aprogramthatsupportsthejudicioususeofantimicrobialagentsshouldbeinplace.• EvaluatetheuseofantimicrobialsamongpatientsidentifiedwithCDIandprovidefeedbacktomedical
staffandfacilityleadership.
Patient Education• ShareinformationregardingC. difficileanditstransmissionwithpatientsandtheirfamilies.• Instructthemregardinghandhygiene,andmonitorforadherence.
Education of Healthcare Workers• Provideongoingeducationtoclinicians,healthcareprovidersandancillarypersonnel(e.g.,environmental
services)regardingCDIratesandtheirchangingresponsibilitiesinlightoftheincreasedrates.
Administrative Support• Shareratesandinterventionswithseniorleadershipandclearlyoutlinetheactivitiesneededtodemonstrate
administrativesupport.• SharecostsassociatedwithCDIandthefinancialimpactonthefacility.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�2 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Other Preventive Measures
DespitethemyriadofpublisheddataontheincreasingmorbidityandmortalityratesassociatedwithC. difficiletransmissioninU.S.healthcareinstitutions,andtheimportanceofhandwashingandbasicinfectioncontrolpracticesinpreventingthisadverseevent,nationaldatapublishedbytheCDCindicateincreasingseculartrendsofC. difficile infectionanddiseaseinU.S.healthcareinstitutionsoverthepastdecade.Thisrealityhasbroughttotheforefrontthequandaryofwhetherotherpreventiveeffortsarerequiredinadditiontoexistinginfectioncontrolpracticesandprocedures.Inthecurrenteraofmanagedcare,additionalpreventiveeffortsneedtobefocusedonareaswherethereisatleastamodicumofevidenceofpotentialeffectiveness.
Therearedataonthreeadditionalareasofprevention:
1. Antimicrobial Stewardship BecauseanyantimicrobialcanpotentiallyinduceC. difficiledisease,stewardshipprogramsthatpromotejudicioususeofantimicrobialsshouldbeencouragedandcomplementinfectioncontroleffortsandenvironmentalinterventions.87,88IntermsofCDIprevention,antimicrobialstewardshipcaninvolverestrictionofantibioticsassociatedwithCDIatthatinstitution(s)and/ordecreasingunnecessaryantimicrobialuseandisdiscussedelsewhereinthisguide.
2. ProbioticsThesearenaturallyoccurring,livebacteriathatarelargelynon-pathogenic.TherationalefortheiruseinpreventingC. difficilediseaseisbasedonthehypothesisthattheywouldrestoreequilibriumtothegastrointestinalflorathathavebeenalteredbypriorantimicrobialexposureandthusprotectagainstcolonizationorovergrowthwithC. difficile.ProbioticsthathavebeenconsideredforpreventionofC. difficilediseaseincludevariousbacteria(Bifidobacterium,agram-positiveanaerobethatiscommonlyfoundinthecolon;Lactobacillus spp., Enteroccus faecium),andyeasts(Saccharomyces boulardii, S. cerevisiae).Theyarecommonlyavailableaslyophilizedcapsulesorintheformofafermenteddrink.SullivanandNord89havesuggestedthatS. boulardiiwassomewhateffectiveinpreventingrecurrentC. difficileinfection.However,studiesoftheutilityofprobioticsinpreventingC. difficilediseaseinpatientsreceivingantimicrobialagentshaveshownnoreductionsintheincidenceofC. difficiledisease.Todate,thereisinsufficientevidence-baseddatatosupportroutineclinicaluseofprobioticstopreventortreatC. difficiledisease.
3. Decolonization Todate,therearenodatathatsupporttheuseofvancomycinormetronidazoleinasymptomaticindividualswhoarecolonizedwithC. difficile inanattempttoridthepatientoftheorganism;suchuseoftheseantimicrobialsdoesnotwork.Moreover,theeffectivenessofvancomycinandmetronidazoleinpreventingC. difficilediseaseinpatientswhoarereceivingotherantimicrobialshasnotbeenshown.
Inconclusion,untilthereisfurtherpublishedevidenceontheutilityofprobiotics,vaccines,anddecolonizationmodalities,thebasisofeffectivepreventionofC. difficileinfectionanddisease,forthetimebeing,willrestlargelyonanintegratedinfectioncontrolprogramthatincludesthefollowing:(a)enforcementofhandhygiene,(b)appropriateuseofstandardandcontactprecautions,(c)maintenanceofahighstandardofenvironmentalcleanliness,and(d)anantimicrobialstewardshipprogram.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY ��
Antimicrobial Stewardship and Clostridium difficile Infection: A Primer for the Infection Preventionist
Antimicrobialstewardshipisanaspectofinfectionpreventionandcontrolthatmaybeanewadditiontothejobresponsibilitiesoftheinfectionpreventionist.ThediscussionofantimicrobialuseanditsimpactonpatientsinallhealthcaresettingsandantimicrobialstewardshipprogramswillbesolelywithinthecontextofC. difficileinfection(CDI).Theterm“antimicrobialstewardship”isusedinplaceof“antibioticstewardship,”sincedevelopmentofastewardshipprogramideallyincludesantiviralandantifungalagentsinadditiontoantibiotics;henceuseofthebroaderterm.Theterm“antibiotics”isusedmostofteninthisdiscussion,whereasthosearetheagentsmostrelevantwhenaddressingC. difficileinfection.
Role of Antibiotic Use in the Occurrence of CDISinceCDIisseenalmostexclusivelyasacomplicationofantibioticuse,thedevelopmentofahealthcarefacilityprogramtoensureappropriateantibioticuseisconsideredanimportantinterventionforthecontrolofCDI24,90,91Figure13.1representsthedifferentphasesofC. difficileinfectionofthecolon,startingwithanormalcolonicenvironment(phaseA),throughthedevelopmentofpseudomembranouscolitis(phaseD).Tounderstandthecriticalrolethatantibioticuseplaysinthedevelopmentofpseudomembranouscolitis,thedifferentstepsinthepathogenesisofCDIwillbereviewed.
Normal Colonic Flora Thenormalgastrointestinalfloraisanimportantdefensemechanismagainstintestinalpathogens.Someofthenormalfloraisattachedtoreceptorsinthecolonicepithelialcells,whileotherbacteriaarepresentinthelumenof
Figure 1�.1. Phases of the pathogenesis of C. difficile colitis.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�� ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
thegut(Figure13.1,phaseA).InorderforC. difficiletocolonizethegut,thenormalfloraneedstobedisrupted.Duetothediversenumberofbacterialspeciesinthehumancolon,ithasbeendifficulttoidentifywhichparticularorganismsareresponsiblefortheprotectiveeffectagainstC. difficile.TheexactmannerbywhichanintactgutfloraprotectsagainstC. difficilecolonizationisnotcompletelyunderstood,butseveralmechanismshavebeenproposed.C. difficileneedstoattachtoreceptorsinthehumangutcells,butaslongasthereceptorsareoccupiedbynormalgutflora,C. difficilestrainsreachingthegutmucosawillhavenoplaceforattachment.
Besidespreventingcolonizationbycompetingforattachmentsites,thenormalfloramaypreventcolonizationbydeprivingC. difficilefromessentialnutrients.ThenormalfloramayalsoantagonizeC. difficilethroughproductionofsubstancesthatinhibitorkillC. difficile.AntibioticsmayfavorC. difficilenotonlybyalteringthecolonicflora,butalsobyalteringthecolonicmicroenvironmentbychangingthelocalproteincompositionoramountoflocalmucusproduction.
C. difficile ColonizationPatientsadmittedtoahealthcarefacilityarelikelytocomeincontactwithfacilitystrainsofC. difficile. EventhoughC. difficilemayreachthecolonicenvironment,itwillnotbeabletobecomeestablishedaspartoftheintestinalfloraandcolonizetheintestinesaslongasthepatienthasanormalflora.ThepatientwithanormalgutfloraisgenerallyresistanttoC. difficilecolonization.ItisconsideredthatC. difficiledoesnothaveanadvantageoversusceptibleorganismsinregardtosurvivalmechanismsinthepatient’scolonicmicrofloraenvironment.Oncethemicrofloraenvironmentisdisruptedbyantibioticuse,thepatientisplacedatriskforcolonization(Figure13.1,phaseB).
Thepropensityofaparticularantibiotictoalterthegutfloraisdefinedasantibioticcollateraldamage.Theextentofcollateraldamagedependsuponaseriesofantibioticfactorssuchasthespectrumofactivity,theamountoftheantibioticthatreachesthecolonicenvironment,andthebactericidalactivityoftheantibioticundertheanaerobicconditionsofthecolon.Otherconsiderationsthatwillaffecttheextentofcollateraldamageincludetheantibioticdose,therouteofadministration,eliminationbythebile,andthepresenceofantibioticmetabolitesinthegut.Antibioticcollateraldamageisforthemostpartduetothekillingofnormalcolonicflora,butantibioticsmaycausecollateraldamagebyalteringothercolonicfactorsbeyondbacteriathatmayplayanimportantroleinlocaldefensemechanismsagainstC. difficile.
C. difficile Toxin ProductionNotallstrainsofC. difficileproducetoxins.Thetoxigenicstrainsprimarilyproducetwotypesoftoxins:AandB.Thetoxinsneedtoattachtoreceptorsintheepithelialcellstobeabletopenetratethecells(Figure13.1,phaseC).TheabsenceofintestinalreceptorsfortoxinsAandBinneonatesmayexplainwhyneonatesareprotectedagainstCDI.
Bothtoxinspossesscytotoxicactivity.RecentoutbreaksofsevereCDIinU.S.hospitalshavebeencausedbyahighlytoxigenicstrainthatproducesabout15to20timestheamountoftoxinsAandBasusualstrains.ThestrainwascharacterizedbymoleculartechniquesastoxinotypeIII,NorthAmericanPFGEtype1(NAP1).
C. difficile Colitis Aftercolonizationanddevelopmentoftoxins,thetoxinsattachtocellreceptorsandpenetratethecellsinthecolon.C. difficiletoxinsinducecelldeathbypromotingcellapoptosis.Apoptosisisanaturalprocessofself-destructionincertaincellsthataregeneticallyprogrammedtohavealimitedlifespanoraredamaged.Epithelialcellsareshedfromthebasementmembraneintothelumen,leavingashallowcoloniculcer.Whitebloodcellsandotherinflammatorycells,aswellasserumproteinsandmucus,flowoutwardfromtheulcer,creatingthetypicalC. difficile-associatedcolonicpseudomembrane(Figure13.1,phaseD).
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY ��
Antimicrobial Stewardship as a Component of C. difficile Prevention ActivitiesTheworstpossibleclinicalscenarioforhealthcare-associated,healthcare-onsetCDIwouldberepresentedbyapatientwhoisadmittedtothehospitalwithoutaninfection,withnormalgastrointestinalflora,whoafterseveraldaysofhospitalizationdiesduetointra-abdominalsepsisasaconsequenceofC. difficilefulminantcolitis.Figure13.2depictsthedifferentstepsintheclinicalcourseofthistypeofpatientfromthetimeofhospitalizationuntilthepatientdeath.Thefigurealsodepictsanorganizedandsystematicapproachtothestrategiesthatcanbeappliedfortheprevention,control,andtreatmentofhealthcare-associated,healthcare-onsetCDI.ImprovingtheuseofantibioticsinthehealthcaresettingbydevelopingandimplementingalocalantimicrobialstewardshipprogramisacriticalcomponentinseveralstepsintheprocessesinvolvingC. difficilepreventionactivities.
Role of Antimicrobial Stewardship in Prevention of ColonizationAllantibioticsproducedisruptionofthecolonicflora,butantibioticsarenotequalintheircapabilityofcausingcollateraldamageofthepatient’sgastrointestinalflora.TwoelementsneedtobeconsideredwhenevaluatingtheriskforCDIproducedbyaparticularantibiotic(Figure13.3).Oneisthelevelofriskproducedbyaparticularantibiotic.Inthisregard,someantibioticswillplacethepatientatlow,intermediate,orhighriskfordevelopmentofCDI.TheotheristhenumberofdaysthatthepatientwillbeatriskfordevelopmentofCDI.Daysatriskforcolonizationoccurduringthetimethatthepatientisreceivingantibiotictherapy,anduptofiveto10daysafterdiscontinuationofantibiotics.
Forexample,apatientwhoreceivesanarrowspectrumantibioticforlessthanoneday,suchasonedoseofafirst-generationcephalosporinforsurgicalprophylaxis,willbeconsideredtohavealowlevelofriskandashortdurationofrisk(Figure13.3,pointA).Ifthesamepatientisgivensurgicalprophylaxiswithanunnecessarybroadspectrumantibiotic,thelevelofriskcanmovefromlowtohighwithoutanyadditionalclinicalbenefitfromthatunnecessaryantibiotic(Figure13.3,pointB).Extensionofsurgicalprophylaxiswithafirstgenerationcephalosporinfor
Figure 1�.2. Activities to prevent and manage C. difficile infection in healthcare settings.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�� ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
multipledosesthatcontinuebeyondthedayofsurgerywillalsoincreasetheriskofCDIbyextendingthenumberofdaysthatthepatientwillbeatrisk(Figure13.3,pointC).
Eventhoughallantibiotictherapy,appropriateorinappropriate,willproducecollateraldamageandplacethepatientatriskforCDI,theprolongedinappropriateuseofbroad-spectrumantibioticsisacriticaldeterminantofcollateraldamagethatshouldbeprevented.Thistypeofcollateraldamagewillplacethepatientathighriskforalongdurationoftime(Figure13,3,pointD).
Themostcommoninappropriateantibioticusethatwillplaceapatientatahighlevelandprolongeddurationofriskisthecontinuationofbroad-spectrumantibioticsaftertheetiologyofinfectionhasbeenidentifiedandthepathogenissusceptibletoanarrowerspectrumantibiotic.Forexample,inapatientwithaprolongedICUstaywhodevelopedaventilator-associatedpneumonia(VAP),itwouldbeappropriatetostartempirictherapywithabroad-spectrumregimentocoverthepossibilityofresistantgram-positiveaswellasgram-negativebacteria.
IfrespiratoryorbloodculturesidentifyaMethicillin-susceptibleStaphylococcus aureus(MSSA)astheetiologyofVAP,thecontinuationoftheinitialbroad-spectrumcoverageshouldbeconsideredinappropriate.Inthisclinicalscenario,antibiotictherapyshouldbede-escalatedtoaregimenthattargetsMSSA,suchasnafcillinorcefazolin.Initialempiricbroad-spectrumtherapyinhospitalizedpatientsatriskofinfectionsduetoresistantorganismsshouldalwaysbefollowedbyde-escalationoftherapyifresistantorganismsarenotidentifiedastheetiologyofinfection.Sincelackofde-escalationisacommonreasonforinappropriateantibioticuse,theantibioticstewardshipprogramshoulddevelopstrategiestopreventthecollateraldamageassociatedwithlackofappropriatede-escalationofantibiotictherapy.
Theantibioticprogramshouldintervenetocorrectotherpoorantibioticpracticesthatareassociatedwithcollateraldamage,suchastheuseofantibioticsdirectedtotreatbacterialcolonizationorcontamination,aswellastheuseofantibioticsinpatientswithoutdocumentedinfections.
Role of Antimicrobial Stewardship in Prevention of InfectionOnceapatientiscolonizedwithC. difficile,thepatientmayprogresstodevelopC. difficilecolitis,ormayremaincolonizedwithoutdevelopingdisease.LackofdiseasemaybeduetocolonizationwithaC. difficilestrainthatdoesnotproducetoxins.Inthisclinicalscenario,oncethepatientiscolonizedwithanon-toxigenicstrain,the
Figure 1�.�. Patient’s level of risk and duration of risk for CDI, according to antibiotic use.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY ��
patientwillbeprotectedfromcolonizationwithatoxigenicstrain.Itisconsideredthattheinitialstrainmayoccupyreceptorsthatbecomeunavailabletothenewstrain.Theuseofmetronidazoleinapatientcolonizedwithanon-toxigenicC. difficilestrainmayfavordevelopmentofC. difficilecolitisbykillingthenon-toxigenicstrainandallowingcolonizationandinfectionduetoatoxigenicstrain.
IthasbeensuggestedthatC. difficilemaychangeitsabilitytoproducetoxinswhenitisincontactwithcertainantibiotics.InvitroexperimentsindicatethatC. difficileincontactwithantibioticsmaybeabletoexpressmoretoxins.Intheory,apatientalreadycolonizedwithC. difficilewhoisstartedonantibioticsmaybeatincreasedriskofdiseasebythedirecteffectoftheantibioticonC. difficile.Thishasimplicationsfortheantibioticstewardshipprogram,sinceavoidanceofunnecessaryantibioticusemaybeanimportantstrategytopreventC. difficileinfectiononceapatientisalreadycolonized.
NotallstrainsofC. difficilehavethesamecapabilitiestoproducetoxinsandcolitis.FulminantcolitisismorefrequentwhenapatientisinfectedwiththehypervirulentNAP1strain.SincethisparticularC. difficilestrainisresistanttofluoroquinolones,theuseoffluoroquinolonesmayaltergutfloraandproduceselectivepressureinfavoroftheNAP1strain.AntimicrobialstewardshipregardingfluoroquinolonesisimportantinareaswheretheNAP1strainispresent.
ApositivetestforC. difficiletoxininthestoolisnotbyitselfindicationforantibiotictherapy.ApatientwhoisasymptomaticbuthasapositiveC. difficiletestshouldbeconsideredacarrier,andantibiotictherapyisnotindicated.Theinappropriateuseofmetronidazoleorvancomycinmayfavordevelopmentofdiseaseinapatientwhoisonlyacarrier.SincethepresenceofnormalgutfloramayinhibittoxinproductionbyC. difficile,theinappropriateuseofbroad-spectrumantibioticsmayfavortoxinproductionanddevelopmentofdiseaseinapatientwhoisonlycolonizedwithC. difficile.
Role of Antimicrobial Stewardship in Treatment of InfectionOnceapatientisdiagnosedashavingCDI,antimicrobialstewardshipisimportanttoachieveoptimalmedicaltherapy.ThisisrepresentedintheC. difficilePreventionActivities(Figure13.2)asthefourthlevelofintervention.TherearethreestrategiesthatcanbeconsideredforthemanagementofapatientwithC. difficilecolitis:1)killingofC. difficile,2)blockingtoxin,and3)restoringnormalflora.
KillingofC. difficileinthecoloncanbeachievedwiththeuseoforalmetronidazoleorvancomycin.Inpatientstreatedwithoralmetronidazole,thestoolmetronidazolelevelsdecreaseascolonicinflammationimproves,whenthepatientmovesfromliquidstoolstomoreformedstools.Oralvancomycinmaintainssimilarconcentrationsthroughouttherapy.Inpatientswithanileus,asignificantdelayinthepassageofantibioticsfromthestomachtothecolonmayoccur.Whenintravenoustherapyisnecessary,metronidazolecanbeusedsinceitisexcretedbythebileandbytheinflamedcolonicmucosa,achievingfecallevelssufficienttotreatCDI.Ontheotherhand,intravenousvancomycinisnotexcretedintothecolonandcannotbeusetotreatCDI.Iforalvancomycincannotbeused,vancomycinenemasareanalternativetokillC. difficileinthecolon.Evenwhenappropriatemetronidazoleorvancomycintherapyisused,relapseofCDIisexpectedtooccurin10%to25%ofpatients.
BlockingC. difficiletoxininthecolonwiththeanion-bindingresinscolestipolandcholestyraminehasbeeninvestigated,butthisstrategyisnoteffectiveasprimarytherapyforCDI.Thetoxinsmaybeblockedbyadministrationofintravenousimmunoglobulin,sincecommerciallyavailableintravenousformulationcontainsantibodiestotoxinAandB.Thisapproachisconsideredforpatientswithseveredisease.
RestorationofthenormalcolonicmicroenvironmentisofparamountimportanceinthemanagementofCDI.Acriticalstepintherestorationofnormalcolonicfloraisanevaluationofthepatienttodetermineifcurrentantibiotic
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�8 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
therapycouldbediscontinued.Insomepatients,continuationofantibiotictherapywillbenecessarytocompletetreatmentofadefinedinfection.Inthesecases,theantimicrobialteam,consideringthetypeofinfection,cansuggestcontinuationoftherapywithanantibioticthatproducesminimalcollateraldamageofthegastrointestinalflora.
Inanattempttorestorecolonicmicroenvironment,theoraladministrationofmicroorganismswithbeneficialproperties,orprobiotics,hasbeeninvestigatedinpatientswithCDI.ThetheoreticalbenefitsofprobioticsinpatientswithCDImayincludethesuppressionofC. difficilegrowth,thebindingofprobioticstoepithelialcellswithnoreceptorsavailableforC. difficilebinding,improvementofintestinalbarrierfunction,andfavorablemodulationofthelocalimmunesystem.SincethedatafromclinicalstudiesofprobioticsinpatientswithCDIisinconclusive,probioticsarenotconsideredcurrentstandardofcareinthemanagementofpatientswithCDI.
Inanefforttorestorenormalcolonicflora,theadministrationoftheentirefecalflorafromahealthyindividual,anapproachreferredtoasfecaltransplant,hasbeeninvestigated.Althoughthedataarelimitedtocaseseries,fecaltransplanthasbeenusedsuccessfullytotreatrelapsingCDI.
Elements of an Antimicrobial Stewardship Program Thegoalofanantimicrobialstewardshipprogramistooptimizetheuseoftherightdrug,fortherightpurpose,andfortherightdurationinanefforttopromotejudicioususeoftheantimicrobialagent.Discussionofwhatconstitutesaneffectivestewardshipprogramisbeyondthescopeofthisdocument,butthebasicsincludeelementssuchas:
1. writtenguidelinesforuseofspecificantimicrobialsthathavebeendevelopedusingevidenceasabasisandinvolveinputfromclinicians
2. accuratemicrobiologicresultsandpromptreportingofthoseresults3. antibiogramscompiledanddisseminatedinamannerthatenablesclinicianstoselecttheappropriate
agent(s)forempirictherapy4. systemsthatminimizeopportunitiesforinappropriatedurationoftherapy5. processesthatactivelysupportde-escalationoftherapytoamorenarrowspectrumagent6. feedbackonadherencetoguidelines,and7. monitoringofsystemsthatsupportthetotalprogram
Theseexamplesarebutafewoftheimportantelementsforaneffectiveantimicrobialstewardshipprogramandservetodemonstratethescopeofactivitiesanddepthofadministrativesupportnecessaryforsuccess.
ConclusionsCDIisincreasinginincidenceandseverityinhealthcaresettings.InfectionsduetoC. difficileareassociatedwithincreasedpatientmorbidityandmortality.Itisdeeplydisturbingthatpatientsadmittedtoahealthcarefacilityforanon-infectiousdiseasecandieduringhospitalizationduetoaninfectionproducedbyC. difficile.ConsideringthecriticalrolethatantibioticuseplaysinthepathogenesisofCDI,itisimportantforhospitalstoimplementanantimicrobialstewardshipprogramwithafocusonCDIprevention,control,andtreatment.AcombinationofoptimalinfectionpreventionandcontrolactivitiesandantibioticcontrolisnecessarytopreventthetransmissionofC. difficileanddevelopmentofCDI.
Tomaintainacomprehensiveapproachtooptimizinguseofantimicrobialagents,itisimportantthattheinfectionpreventionistunderstandsthecomponentsofanantimicrobialstewardshipprogramandtheorganizationalsupportnecessaryforitssuccess.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY ��
Using a Systems Approach to Eliminate Clostridium difficile Infection
Ashealthcareknowledgeincreasedexponentiallyoverthepast50years,healthcaredeliveryintheU.S.evolvedintosilosofcare,withgroupsofspecializedworkersprovidinghighlyspecializedservicesandinformationsystems.Manyofthesesystemscouldnotcommunicateorsharedatawithoneanother,increasingthepaperworkburdenandaddingmoretasksforalreadyover-burdenedhealthcareworkers(HCW).Healthcarehastraditionallylackedstandardizedperformancemeasures,andactivitiestoimprovequalityandefficiencyarefrequentlyisolatedwithinalargersystem.Insituationswhereperformancegoalsareestablished,agoalof80%complianceisoftenconsideredacceptable.Comparedtonon-healthcareindustries,however,healthcaregoalsappearwoefullyinadequate—aperformancelevelof80%inotherindustrieswouldmeanthat36millioncheckswouldbedrawnonthewrongaccounteveryday;9millioncreditcardtransactionswouldcontainerrors,andtherewouldbea1,000-foldincreaseinaviationdeaths.
OnefactorcomplicatingthehealthcaresystemintheU.S.isthatitisevent-based.Inotherwords,theoccurrenceofanevent(e.g.,apositivestooltoxinassayforC. difficile)triggersotherworkactions(e.g.,theinitiationofContactPrecautions).Theseeventsarefrequentlydisconnectedfromthetriggeringeventandfromoneanother.
TheInstituteofMedicine(IOM)identifiedseriousandwidespreadproblemsthroughouttheU.S.healthcaresystemalmost10yearsago.Initslandmarkreport,To Err is Human: Building a Safer Health System,theIOMnotedthatasmanyas98,000patientsdieeveryyearasaresultofmedicalerrors.92Themajorityoftheseerrorsdonotresultfromindividualorevenagroup’scarelessness,butratherfromfaultysystems,processes,andconditionsthateitherfailtopreventmistakesorleadpeopletomakethem.
TheIOMrecognizedthatbuildingasaferhealthcaresystemmeantdesigningprocessesofcaresothatpatientsaresafefromaccidentalinjury.Italsorecognizedthattheworkofotherhigh-riskindustrieshasprovidedexperienceandtoolswhichcanbeusedtoimprovehealthcaresystems.
In2005,theIOMpublishedanotherseminalreport,Building a Better Delivery System: A New Engineering/Health Care Partnership.93Thisreportnotedthatsystemsengineeringtoolshavebeenusedtorevolutionizethequalityandperformanceoflarge-scaleindustriesliketelecommunications,transportation,andmanufacturingcompanies,andsuggestedthatthesetoolscanalsobeusedtoimprovethehealthcaresystem.
A Review of Systems Engineering Systemsengineeringisthedesign,implementation,andcontrolofinteractingcomponentsorsubsystemstoproduceasystemthatmeetstheneedsofusersandparticipants.Allsystemsconsistofinterrelated,interdependentparts,orsubsystems.Thesesubsystemsareasetofinteractingobjectsorpeoplethatbehaveinwaysindividualswouldnot,andtheinteractionofthesesubsystemsisresponsibleforthesystem’scharacteristics.
Asystem’sgoalistomeetspecificperformanceobjectives.Thetwobroadcategoriesofperformanceobjectivesareservice(availability,reliability,quality,etc.)andcost(thedegreetowhichcostscanbecontrolledorreduced).Mathematicalandanalyticalmethodsallowmeasurementofsystemperformanceandcanalsoimprovetheoperationofexistingsystemsandtheirsub-systems.The2005IOMreportreviewsanddiscussessystemsdesign
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�0 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
andanalysistoolswhichmaybeusefulinmeasuringhealthcaresystemperformance,includingconcurrentengineeringandqualityfunctiondeployment,queuingmethods,discrete-eventsimulation,supply-chainmanagement,andothers.93
Onefrequentlyusedmethodfordevelopingstreamlinedandefficientsubsystemsistheprocessflowmodel.Processflowidentifiesallthestepsandtasksintheidealstate;thesearethencomparedtotheexistingprocess.Agapanalysisenablesidentificationofpotentialbottlenecksandencouragestheconsiderationofeveryimprovementopportunity.Theworkteam,composedofrepresentativesfromalldisciplinesinvolvedintheprocess,visualizestheidealprocessandworkstoturnthatvisionintoareality.Oneofthemostimportantquestionstoaskwhenperformingprocessevaluationis“why?”Inotherwords,whydowedothisthewaywedo?Thisquestionhelpsidentifystepsnecessarytothetask,versusthosethataredonebecausethey’vealwaysbeendonethatway.
ThefollowingsectionsreviewkeyprocessesineliminatingC. difficile fromasystemsperspective,andidentifyissuestoconsiderwhenmappingtheidealprocessflow.
Using a Process Flow Model to Eliminate Clostridium difficile Infection TransmissionThesysteminthiscaseiscomprisedofalloftheworktasksandresourcesrequiredtoprevent,control,andeliminatethetransmissionofC. difficile.Thedesiredperformancethresholdisthatnocasesofhospital-acquiredCDIwilloccur.However,preventingC. difficilerequiresseveralsubsystems,orprocesses,includingsurveillance,promptdiagnosisandtreatment,initiationandmaintenanceofContactPrecautions,andenvironmentalcleaninganddisinfection.
SurveillanceIfthemedicalrecordiselectronic,itmaybepossibletoworkwithIT/IStodevelopanautomatedC. difficilequeryusingrecentlypublishedsurveillancedefinitions.30Thesurveillancedefinitionsprovidetheprogrammingrulesforthequery.Ifroomorwarddatafrompreviousadmissionsisinthehospitaldatabase,anautomatedquerywouldenablesurveillanceforcommunity-onset,healthcarefacility-associated(CO-HCFA)casesaswellashealthcarefacilityonset,healthcarefacility-associated(HCFO-HCFA)cases.Developinganautomatedquerywouldallowmoretimetobeallocatedtopreventioneffortsandlesstimespentreviewingandcollectingdata.
Prompt Diagnosis and Treatment of High-risk Patients
What triggers C. difficile testing? HavingahighindexofsuspicioninpatientswithriskfactorsforCDI(prioruseofantimicrobialsorantineoplasticagentswhichimpactgutflora;increasingage;previoushospitalizationwithin30days;residentofalong-termcarefacility)isessentialforearlydetection.
1. Ifantibioticsareordered,givethoughttoactivitiesthatenhancetheindexofsuspicion.Oncesuchmethodmightbetoplaceastickeratthefrontofthechartwiththemessage:“AntibioticsareariskfactorforthedevelopmentofClostridium difficileinfection(CDI).ConsiderevaluatingforCDIifpatientdevelopsdiarrheawhilereceivingantibioticsorhasreceivedantibioticswithinthepast60days.”a. Ifthemedicalrecordiselectronic,theabovemessagecouldbeautomaticallygeneratedatthetimethe
antibioticisenteredintothecomputerizedorderentrysystem(COE)andsenttotheattendingortreatingphysician’se-mailorcomputerizedtasklist.EntryintotheCOEcouldalsotriggeraflagonthenursingcareplantoremindstafftoevaluatethepatientfordiarrhea.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY �1
b. Anorderforantibioticscouldtriggerasearchofthemicrobiologydatabase;ifthepatienthasapreviouspositivetoxinassay,anelectronicmessagenotifyingoftheCDIhistoryandrecommendingrepeattestingifthepatienthasnewonsetofdiarrheaisautomaticallysenttophysiciansandthenursingcareplan.
2. AfieldinthecomputerizedI&Osheetcouldbededicatedtoliquidstooloutput.Ifthepatientisreceivingantibioticsandanumberotherthan0isenteredintothediarrheafield,amessageisautomaticallytriggeredtoencouragethephysiciantoconsiderC. difficiletesting.
How often does the microbiology or reference laboratory perform C. difficile toxin assays?Manylaboratoriesbatchtestsandrunthemonceortwiceaweek.Dependingonthevolumeofassays,itmaybefeasibletoincreasethefrequencyoftoxinassaytesting.
If the toxin assay is positive, are appropriate staff members notified immediately (infection prevention, treating physician, nursing staff)? Is the microbiology laboratory able to call in the results if positive? Who should be called? Can that person be reached 24/7/365?
1. Iftherecordiselectronic,anautomatedmessagecouldbesenttotheattending/treatingphysician,infectionpreventionist,andnursingstaffatthetimethemicrobiologylaboratoryentersapositiveresultintothecomputer.
2. Haveadesignatedfieldintherecordforisolationcategoryandflagallisolationpatients.Maketheflagvisibletootherpatientcaredepartmentssothattheisolationcategoryisknownatthetimeofschedulingproceduresandtests.
How much time elapses from when the result of the toxin assay is available to when the physician writes an order for metronidazole? How much time elapses from when the order is written to when the patient receives the first dose of metronidazole?
1. Ifthenotificationsystemisautomated,theautomatedmessagecouldcontainafieldforthemedicationorder,e.g.,“PatienthavingdiarrheaandstoolispositiveforC. difficile.Doyouwanttoordermetronidazolenow?”
2. Ifthephysicianclicksyes,theorderwouldbeautomaticallyenteredintotheCOE,triggeringothermessages.
Initiation and Maintenance of Contact Precautions
Who initiates Contact Precautions, and why? Requiringaphysicianorderwasnecessarywhenpay-for-performancewasthestandardforreimbursement.Today,healthcarefacilitiesnegotiatereimbursementschedulesbasedonDRG,andaphysician’sordermaynotbenecessary.AuthorizingstaffcaringforpatientswithCDItoinitiateisolationshouldshortenthetimerequiredtoisolatethatpatient.
How much times elapses from when the test result is available to when the isolation sign is placed on the door?IfCDIisstronglysuspected(priorantibioticuse,liquidstools,etc.)oriftheunithasmorethanoneHCFO/HCFAcaseatatime,nursingstaffmaywanttoinitiateContactPrecautionswhenthestoolissentfortoxinassay,ratherthanwaitfortheresult.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�2 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
How are isolation supplies obtained?1. Ifanisolationcartsystemisused,necessarysupplies(gowns,disposablestethoscope,disposableBPcuff,
thermometer,disinfectantwipes)aredeliveredwiththecart.2. Ifelectronic,anautomatedorderforisolationsuppliesissenttoCentralSupply(CS)whenapositivetest
resultisenteredbymicrobiology.
Are isolation supplies (gowns, gloves, etc.) readily available? Who is responsible for re-filling isolation carts or wall-mounted racks with necessary supplies? If isolation supplies are needed, can they be obtained in a timely manner?
1. Verifythatre-stockingsuppliesonaregularscheduleisincludedinthetasklistoftheindividualassignedtodoit.
2. Useavisualcue,e.g.,aredarrowatadesignatedlevelonthewall-mountedisolationrack,tohelpstaffeasilyrecognizewhensuppliesaregettinglow.Whenthelevelofgownsfallsbelowtheredarrow,therackshouldbere-stocked.
3. Ifaparticularitem,suchasgowns,forexample,isfrequentlyinshortsupply,thenursingunitandCSshouldevaluateunitparlevelsforthatitem.
4. Ifshortagesoccuronmorethanoneunit,CSmayneedtoevaluateparlevelshouse-wide.5. Determineanaveragenumberofisolationgownsusedperpatient,perday.NotifyCSdailyofthenumber
ofisolationpatientsontheunit.Anautomatedreportwithnumbersofisolationpatientsperunit,perdayshouldbepossibleifisolationstatuscanbeflaggedinthepatient’srecord.Sendtheautomatedreportdaily,sothatCScanrestockbasedontheactualnumberofisolationpatientsratherthanafixedparlevel.
6. Keepextra“isolationpacks”containingisolationsign,gowns,stethoscope,etc.,inthecleansupplyroom.7. Keepextragownsinthecleansupplyroom.
If the facility requires hand hygiene with soap and water following contact with a CDI patient, how is staff from other units or departments notified of the patient’s CDI status?
1. Apictureofableachbottleonthedoorcouldbeusedtoindicatethatsoapandwatermustbeusedforhandhygiene.
2. Awordofcaution:Bleachshouldnotbeusedonthehands,sorecognizethepotentialforaccesstobleachandmisinterpretationofthebleachbottlesign,andbuildinappropriatetrainingandmonitoring.
Environmental Cleaning and Disinfection
If bleach is used to clean the rooms of C. difficile patients, how is housekeeping notified?a. Havethehousekeeperscheckdailywiththechargenurseforthelistofroomsneedingbleachorplacea
pictureofableachbottleonthedoor.
Toensureefficientandeffectivecleaninganddisinfection,thereareotherquestionsthatneededtobeaddressedaswell.
• Arecleaningsupplies(prepackagedwipes,spraybottlesandcloths,impregnatedcloths,etc.)readilyavailabletostaffforcleaningequipmentthatcannotbededicated?
• Whoisresponsibleformaintainingthesupply?• Whoisresponsibleformonitoringandreplacingdatedsupplies,e.g.,pre-mixedquaternaryammonium?
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY ��
• Arecleaningsupplieskeptwithportableequipment(bedscales,EKGmachines,x-ray,ultrasound,etc.)sothatstaffcaneasilycleananddisinfectbetweenpatients?
• Whoisresponsibleformaintainingthesupply?• Whoisresponsibleformonitoringandreplacingdatedorpre-mixedsupplies?
EliminatingthespreadofCDIrequirestheeffortsofawiderangeofhealthcaredepartmentsandpersonnel.Systemsengineeringprovidestoolswhichwillallowthedevelopmentofefficientprocessesandcommunicationofinformationforitscontrol.Systemsengineeringwillalsoenableongoingevaluationofthoseprocesses,whilecontinuallylookingforwaystoimprovethem.Havingefficientcaremodelsandautomatingprocessesthatintegrateisolationtaskswheneverpossiblewilleliminatesomeoftheadded-onstepsthatisolatingpatientsrequires.Thisinturnwilldecreasethelikelihoodthataparticularstepintheprocessisover-lookedorforgotten.Ultimately,healthcareworkerswillhavemoretimetodowhattheywantanddobest—spendtimewiththeirpatients.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�� ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Glossary of Terms
BI/NAP1/027 Strain:AhypervirulentepidemicstrainofC.difficilefoundtobeassociatedwiththeoutbreaksinQuebec,theU.S.,andEurope.TheBI/NAP1/027strainhasbeenfoundtoproduce16-foldhigherconcentrationsoftoxinAand23-foldhigherconcentrationsoftoxinBinvitro.Anotherfeatureofthisstrainistheproductionofatoxincalledbinarytoxin,theroleofwhichisnotyetdefined;however,strainsthatproducebinarytoxinmaybeassociatedwithmoreseverediarrhea.ThecauseoftheextremevirulenceoftheBI/NAP1/027strainmaybeacombinationofincreasedtoxinAandBproduction,binarytoxin,orotherunknownfactors.
CDAD:Clostridium difficile-associateddisease.ThistermisbeingreplacedbythetermClostridium difficileInfection(CDI).
CDI:Clostridium difficileInfection.
Clostridium difficile: Ananaerobic,gram-positive,spore-formingbacillus.
Community-associated CDI:CDIsymptomonsetinthecommunity,or48hoursorlessafteradmissiontoahealthcarefacility,providedthatsymptomonsetwasmorethan12weeksafterthelastdischargefromahealthcarefacility.
Community-onset, healthcare facility-associated CDI:CDIsymptomonsetinthecommunity,or48hoursorlessafteradmissiontoahealthcarefacility,providedthatsymptomonsetwaslessthanfourweeksafterthelastdischargefromahealthcarefacility.
Exotoxin:Aproteinproducedbyabacteriumandreleasedintoitsenvironment,causingdamagetothehostbydestroyingothercellsordisruptingcellularmetabolism.
Fecal transplantation/fecal slurry:AsomewhatcontroversialprocedureusingaslurryofhumanfecesandsalinesolutiontoregrowhealthybacteriaintheintestinaltractofanindividualexperiencingCDIthathasbeenrefractorytotraditionaltherapy.Theprocessinvolvesobtainingdonorfecesfromanotherfamilymember,usuallyaspouse,andtransplantingitintotheillindividualvianasogastrictube.
Healthcare facility-onset, healthcare facility-associated CDI:DevelopmentofdiarrheaorCDIsymptomsmorethan48hoursafteradmissiontoahealthcarefacilityandfulfillscriterionforthecasedefinitionofCDI.
Hypersporulation:Thepropensityofthebacteriumtomovemorereadilyfromthevegetativeformtothesporethanoccursundernormalcircumstances.Hypersporulationcanbeinducedbycontactwithsomegermicides.
Hypochlorite solution:AsolutioncapableofkillingthebacterialsporesofC. difficileinconcentrationslargerthan4,800partspermillion(ppm)availablechlorine.Thisistypicallyasolutionofonepartunscentedchlorinebleachandninepartswater,yieldinga10%hypochloritesolution.Thesesolutionsarecommerciallyavailableandcontainadetergent,inadditiontothehypochloritesolution.
Probiotics:Naturally-occurring,livemicroorganismsthatareadministeredtoconferahealthbenefittoahost.TherationalefortheiruseinpreventingC. difficilediseaseisbasedonthehypothesisthattheywouldrestoreequilibriumtothegastrointestinalflorathathasbeenalteredbypriorantimicrobialexposureandthusprotect
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY ��
againstcolonizationorovergrowthwithC. difficile.Todate,thereisinsufficientevidence-baseddatatosupportroutineclinicaluseofprobioticstopreventortreatC. difficiledisease.
Pseudomembranous colitis:Aninflammatoryconditionofthecolonconsistingofacharacteristicmembranewithadherentplaquesassociatedwithseveresymptoms,includingprofusewaterydiarrheaandabdominalpain.TheconditionisconsideredpathognomonicforClostridium difficile infection.
Recurrent CDI:AnepisodeofCDIthatoccurseightweeksorlessaftertheonsetofapreviousepisodethatresolvedwithorwithouttherapy.
Spore:Thedormantstagesomebacteriawillenterwhenenvironmentalconditionscausestresstotheorganismornolongersupportitscontinuedgrowth.C. difficilesporesarehighlyresistanttocleaninganddisinfectionmeasures,andthesporesalsomakeitpossiblefortheorganismtosurvivepassagethroughthestomach,resistingthekillingeffectofgastricacid.
Systems engineering:Thedesign,implementation,andcontrolofinteractingcomponentsorsubsystems,withthegoalbeingtoproduceasystemthatmeetstheneedsofusersandparticipants.
Toxic megacolon:Alife-threateningcomplicationofintestinalconditions,characterizedbyadilatedcolonwithseverecolitisandsystemicsymptomssuchasfever,tachycardia,orshock.
Vegetative C. difficile:Theactivelygrowingandmetabolizingstateofthebacteria.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�� ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Frequently Asked Questions
1. What is the incubation period for C. difficile?TheincubationperiodforC. difficilefollowingacquisitionhasnotbeenclearlydefined.Althoughonestudysuggestedashortincubationperiodoflessthansevendays,theintervalbetweenexposureandonsetofsymptomsmaybelonger.Thus,manycasesofhealthcare-associatedCDImayhavetheironsetinthecommunityafterhospitalization.
2. If the patient is on antibiotics, is there a way to prevent them from developing C. difficile colitis?Atpresent,thereisnoprophylaxisforC. difficile.Themosteffectivepreventionactivityisthroughantimicrobialstewardshipprogramstargetedtothespecificorganism(s),andtoquicklyde-escalatetherapy(narrowthespectrum)andpromotetheshortestdurationoftherapywhileadequatelytreatingtheinfection.
3. When should a patient with C. difficile be removed from contact isolation?Underroutinecircumstances,apatientwithCDIcanberemovedfromisolationwhenthediarrhearesolves.IfthereisanoutbreakorevidenceofongoingC. difficiletransmission,theinfectionpreventionistrecognizesthatevenafterthediarrhearesolves,thepatientmaycontinuetoshedC. difficile,sothepreventionistmayconsiderextendingcontactisolationuntilthepatientisdischarged.Aheightenedresponsemightalsoincludeanothermethodforextendingisolation,suchascontinuingContactPrecautions,untilthepatientiswithoutdiarrheafortwodays,followedbyshoweringorbathingofthepatient,provisionofcleanlinen,thenthoroughcleaningoftheroom.
4. We are currently using a germicide that kills C. difficile in the vegetative state. Is that good enough?C. difficileisaspore-former,andeventhoughitmayinitiallybeinthevegetativestateinthestool,soonafteritencountersstressfulenvironmentalconditions,itwilltrytoprotectitselfandtransformintoasporewhichremainsintheenvironmentuntilitisremovedordies,andmayormaynotreturntoavegetativestateatanytime.ManygermicideskillthevegetativeformofC. difficile,andaresuitableforuseduringnon-outbreaktimes.Somegermicidesinducehypersporulation,resultinginanincreasedsporeburdenintheenvironment,soifanoutbreakoccursand/orthereisevidenceofongoingpatient-to-patienttransmission,heightenedresponsesarenecessary.Theyshouldincludechangingthegermicidetoa10%sodiumhypochloritesolutionuntiltheoutbreakortransmissionisundercontrol.
5. Can bleach wipes be used to effectively clean frequently touched surfaces in rooms of patients suspected of having, or diagnosed with, C. difficile Infection? If so, what criteria should be used to select the product?
Germicidalwipesprovidinga10%sodiumhypochloritesolutionprovidingatleast5000partspermillionofchlorinearegoodadjunctstocleaningwhenithasbeendeterminedthattheroutinegermicideisnolongeradequateforthecircumstances.Effectiveness,cost,andeaseofuseareusuallythebiggestissueswhendecidingtouseagermicidalwipe.Lookathowthewipesarepackaged(individuallyorinapop-upcontainer).Aretheybigenoughforthejob?Readthedirectionsandlookatthesizeandwetnessofthewipe,anddoatesttocheckcontacttimeandthenumberofsurfacesthatneedtobewiped.Thiscanhelpyoudecideifawipewillmeetyourneeds,andifso,howmanyareneededforeachtask.Onceyouhaveanideaofuse,youcancalculatecosts.Checkotheraspectsofthewipesthatmayimpacthowtheyareused.Forexample,iftheusercannottolerateordoesnotlikethesmell,heorshemaybelessinclinedtouseit.Whenyouaretestingyourgermicidalwipe,leavetheroom,returningshortlyaftertodeterminewhetheraresidualodormaynegativelyimpactuse.Involvethosewhowillbeusingthewipesinthesetestsaswell.
6. How do we determine if diarrhea is due to C. difficile or from another cause?ThebestwaytoruleoutC. difficileasacausefordiarrheaistoperformanappropriatetest.IfdiarrheacontinuesandthereisstillconcernthatC. difficilemaybethecause,itisuptotheorderingcliniciantousehisorherbestjudgmentastowhetherornotthepatientshouldbeassumedtohaveCDI,andtoimplementisolationandtreatment.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY ��
7. Can bleach be used in the pediatric setting?Yes,ahypochloritesolutioncanbeusedinthepediatricsettingbut,asinallsettings,bleachhasacharacteristicodor,butthisodorisgenerallyinnocuousandbleachvaporsalonegenerallydonotcauseirritation.(Directexposuretospraysormistsofbleachproductsisadifferentissueandpotentiallycancauseirritation.)However,duringuse,bleachcaninteractwithsoilstoformmalodorousvaporsthatpeoplemightfindobjectionableorpossiblyirritating.Peoplewithpreexistingcompromisedlungfunctionmaybeparticularlysensitivetosuchvapors(e.g.asthma,obstructivelungdisease,heartconditions).Bleachshouldnotbemixedwithothercleaningproductssincemixingwithcertaintypesofproductscanformirritatingorharmfulvapors.Exposuretofumesfromimpropermixingisinfrequentandrarelyproducesserioushealtheffects,inpartbecausethefumescompelpeopletoleavetheareapreventingsignificantexposure.Exposuremightbemoreseriousifapersonisunabletoleavetheareaifimpropermixingoccurs.Careshouldbetakentoallowforadequateventilation,regardlessofthesetting.Commercialformulationsmayeasesomeoftheodorissues,butthoseusingtheproductsshouldbeinvolvedindeterminingtheeffectoftheodoranditsimpactonbothuserandpatient.Aswithallchemicals,hypochloritesolutionsmustbestoredinasecuremannersochildrenorotherunauthorizedpersonnelcannotaccesstheproduct.
8. Can bleach be used to clean the OR setting?Yes,butcaremustbetakentoavoidcontactwithitemssuchassurgicalinstruments,whereascorrosionanddamagemayoccurfollowinglong-termuse.Somecommerciallyavailablepreparationshavebeenformulatedtominimizethiscorrosiveeffect.
9. Is there a benefit to mixing a bleach solution over purchasing one pre-mixed?OnlyEPAregisteredproductsarereviewedforefficacy,purityandshelflife.EPAreviewestablishesstandardsforproductmanufacturinganddistributingtobetterensureproductquality,concentrationandefficacy.
Whenyouwanttocleanwithagermicide,itisimportantthatthegermicidehaveadetergentbasethatpromotestheremovaloforganicandinorganicmatter.Mixingsodiumhypochloritewithwaterdoesnotprovidethatdetergent.Ifitisdesiredtocombineadditionalcleaningagentsordetergentswiththegermicide,apre-mixedproductshouldbeused.Detergentshouldnotbeaddedtosodiumhypochloritedilutedinwatertoavoidthepotentialreleaseofhazardousfumes(seequestion7).Inaddition,somedetergentswilldestroyallorpartofthehypochloritesothatthedesiredantimicrobialbenefitwillnotbeachieved.InsteadoneshouldpurchaseaproperlyformulatedproductthathasbeenapprovedbytheEPAforproductsafetyandefficacy.Theseproductscanreducethetimerequiredforcleaninganddisinfectingbycombiningbothactivitiesintoonestepandreducetheoverallcostbyreducingtheamountoflaborrequired.
10. We do not restrict use of alcohol-based hand rubs for healthcare workers providing care for patients with CDI. Is this incorrect?
ThisisasatisfactorystrategytouseunlessyouhavebeenunabletocontrolyourcasesofCDI.Weknowthatalcohol-basedhandrubsdonotkilltheC. difficilesporesandthathandwashingservestophysicallyremovethenwashawayspores.WhenapatienthasCDI,theyhavediarrheaforsometimeuntiltreatmenthelpsresolvetheinfection.Therefore,itcanbereasonablyanticipatedthatfeceswillhavecontaminatedtheenvironment,anditislikelythatthehealthcareworkerwillcomeintocontactwithfeceswhilecaringforthepatient.Consequently,handwashingmakessense,butuseofalcohol-basedhandrubsshouldalsobeavailableduringroutinecareofpatientswithCDI.Wealsoknowthathandhygienecompliancegoesdownifalcohol-basedhandrubsareremoved,makingitcounterproductivetowhatwewishtoaccomplish.Tothatend,thefewsimplerulesforthiscomplexsituationinclude:
• performhandhygienebetweenallpatientcontactandimmediatelyafterremovalofPPE• washwithsoapandwaterasthepreferredhandhygienemethodifhandsarevisiblysoiled• providealcohol-basedhandrubsasanadditionalmethodtoperformhandhygieneforhealthcarepersonnel
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�8 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
11.What are the potential benefits and risks of the use of loperamide and opiates in the control of diarrhea in patients?
IntermsofdiarrheacausedbyC. difficile, itisimportanttorememberthatthereisatoxininvolvedanduseofanti-motilityagentsmaybeharmfultothepatient.Themostappropriateuseforloperamide,opiates,orothertherapiesthatservetominimizediarrheacomesafterthecausehasbeenidentified,andthedesireistonowminimizedehydration.AlthoughdehydrationmaycertainlyoccurwithCDI,themostimportantthingforthesepatientsistostartonappropriatetreatmentandcorrecttheinfection.Wheninfectioniscorrected,thediarrheawillresolve.
12. Is there a benefit to the use of disposable bedpans?Thisquestionimpliesthatuseofdisposablebedpansmaybeofgreaterbenefitinpreventingtransmissionthanistheuseofbedpansthataredisinfectedbetweenpatientsorbetweenuses.BedpansorcommodesmustbedesignatedforsoleusebythepatientwithCDI.Oncethatpatientnolongerneedsthisitem,itshouldbedisposedof(ifdisposable)orcleaned,thendisinfectedifitismadeofmaterialdesignedtobereused.Thesimpleuseofadisposablebedpandoesnotimplyincreasedpatientsafety.Thesystemsandprocessesofcarethatmakeitdifficultforcontaminatedequipmenttobesharedbetweenpatientsrepresentthegreateropportunityforpatientsafety.Handlingthebedpanpresentsthelikelihoodofhandcontaminationbythehealthcarepersonnelandthepatient,sohandhygieneremainsacriticalintervention.
13. Is there value in tracing previous locations of patients with CDI in the facility and then terminally cleaning the area?
Althoughtracingapatient’smovementmaybeanelementusedduringanepidemiologicstudy,whenconsideringthisquestioninthecontextofCDI,themoreusefulapproachistoensurethattherearesystemsinplaceforconsistentenvironmentalcleaningthroughoutthefacility.Theterm“terminalcleaning”seemstohavemanydefinitions,butwhenwehearthatterm,itisgenerallyusedtodescribethemorein-depthcleaningthatisdonefollowingpatientdischargeifitinvolvesapatientroom,orcleaningdoneattheendofthedayorendofaprocedureinareassuchastheoperatingsuite.Terminalcleaningshouldinvolvethecleaninganddisinfectionofallitemsandsurfacesintheroomandmayalsoincludethechangingofitemsthatmayremainintheroom(e.g.,cubiclecurtains)iftheyaresoiled.Therefore,thereshouldalreadybeasysteminplacethatsupportsconsistentterminalcleaningbypersonnelwhohavebeentrainedintheprocessandhavebeendeemedcompetenttoperformthatprocess.Theideathatterminalcleaningwouldbepartofapatienttracingsystemiscounterintuitivetothesystemsapproach.RoutinecleaningmethodsshouldimpacttheburdenofC. difficile,andterminalcleaningshouldmoveclosertowarderadicationoftheorganismintheenvironment.
14. What is the environmental transmission risk of CDI in long-term care facilities?Theriskoftransmissionwithinaspecificenvironmentsuchasalong-termcarefacilityhasnotbeenquantified,buttheriskfactorsinvolvedinCDIdevelopmentandtransmissionarelargelythesame,regardlessofthesetting.Inthelong-termcaresetting,emphasiswouldcertainlybeplacedonantimicrobialstewardship,handhygiene,andstandardandcontactprecautions.Thesearethesameelementsemphasizedinmostsettings.Althoughthereisno“onesizefitsall”foraCDIpreventionprogram,theelementsinallsuchprogramsshouldbefairlyconsistent.
15. What is the impact of ventilation and air pressure gradients on control of CDI?ThereisnoevidencethatC. difficilesporesareairborne,thereforeventilationandairpressuregradientsarenotelementsrequiringspecificactions.InhalationofC. difficilesporesisunlikelytocauseinfection.However,aerosolizationofsporesorvegetativebacteriumthatcomesintocontactwiththemouthorcontaminateshandsthattouchthemouthmayactasamodeoftransmission.ThisfurthersupportstheconceptsofStandardPrecautionsanduseofpersonalprotectiveequipmentandpracticesthatpreventcontactwithpatientbodyfluids.Airborneordropletprecautionsarenotindicated.Contactprecautionsandstandardprecautionsaretheappropriateactivitiestopreventtransmission.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY ��
16. What is the infectious potential of patients who have had interventions such as colectomy?Followingcolectomy,theareaofpseudomembranouscolitishasbeenremovedbuttheorganismscontinuetobepresentintheremainingareasofthecolon.Therefore,precautionsshouldcontinueasforallpatientswithCDI.Ifthepatienthasacolostomy,thestooldrainingintothecolostomybagshouldbeconsideredasourceofcontamination.ContactPrecautionsshouldcontinueuntilthediarrhearesolvesoruntilstoolconsistencythatcanbeexpectedviaacolostomyhasresumed.Inaddition,ifthepatienthasrectaldrainageviaamucousfistula,precautionsshouldcontinueuntilthatdrainagehasstopped.
17. What is the risk of transmission by asymptomatic carriers?Surveillancetesting,ora“testofcure,”shouldnotbedoneonasymptomaticpatients.NotallC. difficileisalikeinthatsomearenon-toxinproducers,andsomeproducethehypervirulenttoxin.Ifasymptomaticindividualsaretested,notonlyaretheysubjecttothesensitivityandspecificityconstraintsofthetesting,weareleftnotknowingwhattheresultsmean.Anindividualwithoutsymptoms(i.e.,diarrhea)isnotthoughttobealikelytransmitterofC. difficile.
18. What are the benefits of single rooms with their own toilets for the prevention and control of C. difficile?AprivateroomandtoiletaretwoofthemostcriticalactionsthatshouldbetakenaspartoftheCDItransmissionpreventionprogram.SeparatingdiarrheapatientsfromothersandprovidingthemwiththesoleuseofatoiletaretwovitalinterventionsthatdisablethechainofCDItransmission.
19. Do hyper-spreaders exist, and if so, who are they?Thereiscurrentlynoevidenceregardinghyper-spreaders.However,ifwelookattheconceptwithinthepresentationsandtransmissionofotherinfections,suchasSARS,theideaisthatthereareindividualswhoareseriouslyillandpresentwithpronouncedclinicalsymptoms.Thismakesitconceivablethatindividualswithprofounddiarrheamaycontaminatetheenvironmentatagreaterdegreethanothers.ItisalsoimportanttorecognizethatthehypervirulentstrainsofC. difficilearenotmoretransmissible;therefore,animportantelementintransmissionpreventioninvolvesearlyrecognitionofindividualswithCDI,followedbyrapidandearlyimplementationofContactPrecautions.
20. Is there a relationship between CDI rates and nurse-patient ratios?ThereisnospecificevidenceofarelationshipbetweenCDIratesandnurse-patientratios,althoughwecanlearnfrompriorresearchthatdemonstratestheeffectofstaffingandtheresultantdeclineinadherencewithbasicinfectionpreventionmeasures,suchashandhygieneandenvironmentalcleanliness.BecausethedevelopmentofCDIismultifacetedandinvolvesanumberofdifferentcomponents,includingantimicrobialusage,handhygiene,environmentalcleanliness,andContactPrecautions,itiseasytoseethatnurse-patientratioisnottheonlyconcern.PreventingthedevelopmentandtransmissionofCDIisanexcellentrepresentationoftheneedforasystemsapproach.Notonesingleprocessisresponsibleforthetransmission,andthereforenosingleprocessorinteractioncanbeentirelyresponsibleforprevention.
21. How many stool specimens should be sent for C. difficile diagnosis?Determiningtheapproachfortestingideallyoccursasacollaborativediscussionbetweenclinicians,microbiologistsandinfectionpreventionists.Therearecurrentlynodatatoguidetheestablishmentofasetnumberofstoolsamplesthatshouldbesentfortestingonanygivenpatient.Therefore,establishmentoflocalpolicyshouldbemadeusingthebestavailableinformationandwithinthesupportingsystemsandcapabilitiesofthefacility.Despitethelackofdatatoguidedecision-makingsurroundingthisissue,somefacilitieshaveimplementedthefollowingstepsasameansofdevelopingpolicydevelopment:
• WhentestingapatientforC. difficile, onlyloose,waterystoolspecimenswillbeevaluatedbymicrobiology.Formedstoolsampleswillbediscardedandnotevaluated.
• OnlyonestoolsampleforC. difficilewillbeevaluatedbymicrobiologyduringa24-hourperiod.Additionalsampleswillbediscardedandnotevaluated.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�0 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
• TestingforC. difficileconsistsofonesamplesenteachdayfortwoconsecutivedays.Ifbothspecimensarenegative,nofurthertestingwillbeconductedunlesstheclinicalcourseofthepatientchanges.IfthefirsttestispositiveforC. difficile,nofurthertestingwillbedone.
• Testsofcurewillnotbeperformed.
Thesearenothardandfastrules,butaresimplyacombinationofactivitiesusedatsomefacilities.Theinfectionpreventionistisencouragedtodiscussthisissuewiththeinfectionpreventionandcontrolcommitteetodeterminelocalstrategy.
22. Should I handle endoscopes differently after being used on a patient with CDI?Thereisnoneedtoalteryourmethodsforreprocessingofendoscopesifyourprocessesareconsistentwithcurrentrecommendations.TheMulti-societyGuidelineforReprocessingFlexibleGastrointestinalEndoscopes,publishedin2003,aswellasinformationprovidedintheHICPACSterilizationandDisinfectionguideline,canserveasresources.Certainlyerrorsinreprocessingofsemi-criticalitemsplacepatientsatrisk,soyourprocessshouldincludestepstomonitorandevaluateadherencetotheprocess.
23. I have seen a number of skin care items and fecal management systems. Do they have a role in the prevention of C. difficile transmission?
Maintainingtheintegrityofthepatient’sskinisalwaysapatientcaregoal.PatientswithCDIwillhaveliquidstools,soskincaremaybeaprimarynursingcaregoal.UseofasystemthatservestominimizeenvironmentalandhandcontaminationmayalsohavearoleinpreventingtransmissionofC. difficileinhealthcaresettings.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY �1
References
1DubberkeER,ReskeKA,OlsenMA,McDonaldLC,FraserVJ.Short- and long-term attributable costs ofShort-andlong-termattributablecostsofClostridium difficile-associateddiseaseinnonsurgicalinpatients.Clin Infect Dis.2008;46(4):497-504.
2RedelingsMD,SorvilloF,MascolaL.IncreaseinClostridium difficile-relatedmortalityrates,UnitedStates,1999-2004.Emerg Infect Dis.2007;13(9):1417-1419.
3KenneallyC,RosiniJM,SkrupkyLP,etal.Analysisof30-daymortalityforClostridium difficile-associateddiseaseintheICUsetting.Chest.2007;132(2):418-424.
4McDonaldLC,OwingsM,JerniganDB. Clostridium difficileinfectioninpatientsdischargedfromU.S.short-stayhospitals,1996-2003.Emerg Infect Dis.2006;12(3):409-415.
5O’BrienJA,LahueBJ,CaroJJ,DavidsonDM.TheemerginginfectiouschallengeofClostridium difficile-associateddiseaseinMassachusettshospitals:Clinicalandeconomicconsequences.Infect Control Hosp Epidemiol.2007;28(11):1219-1227.
6KyneL,HamelMB,PolavaramR,KellyCP.HealthcarecostsandmortalityassociatedwithnosocomialdiarrheaduetoClostridium difficile.Clin Infect Dis.2002;34(3):346-353.
7SiegelJD,RhinehartE,JacksonM,ChiarelloLandtheHealthcareInfectionControlPracticesAdvisoryCommittee2007.Guidelineforisolationprecautions:Preventingtransmissionofinfectiousagentsinhealthcaresettings.Am J Infect Control2007;35(10Suppl2):S65–164.
8MutoCA,BlankMK,MarshJW,etal.Control of an outbreak of infection with hypervirulentControlofanoutbreakofinfectionwithhypervirulentClostridium difficileBIstraininauniversityhospitalusingacomprehensivebundleapproach.Clin Infect Disease.2007;45(10):1266-1273.
9McDonaldLC.ConfrontingClostridium difficile ininpatienthealthcarefacilities.Clin Infect Dis.2007;45(10):1274–1276.
10BartlettJG.Antibiotic-associatedpseudomembranouscolitisduetotoxin-producingclostridia.N Engl J Med.1978;298:531-534.
11LarsonHE,PriceAB,HonourP,BorrielloSP.Clostridium difficileandtheaetiologyofpseudomembranouscolitis.Lancet.1978;1(8073):1063-1066.
12JohnsonS,GerdingDN.Clostridium difficile-associateddiarrhea.Clin Infect Dis.1998;26(5):1027-1034.
13LimayeAP,TurgeonDK,CooksonBT,FritscheTR.PseudomembranouscolitiscausedbyaToxinA-B+strainofClostridium difficile.J Clin Microbiol2000;38(4):1696-1697.
14BartlettJG.Narrativereview:ThenewepidemicofClostridium difficile-associatedentericdisease.Ann Intern Med2006;145(10):758-764.
15MutoCA,PokrywkaM,ShuttK,etal.A large outbreak ofAlargeoutbreakofClostridium difficile-associateddiseasewithanunexpectedproportionofdeathsandcolectomiesatateachinghospitalfollowingincreasedfluoroquinoloneuse.Infect Control Hosp Epidemiol.2005;26(3):273-280.
16GaynesR,RimlandD,KillumE,etal.Outbreak ofOutbreakofClostridium difficileinfectioninalong-termcarefacility:Associationwithgatifloxacinuse.Clin Infect Dis.2004;38(5):640-645.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�2 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
17PepinJ,SahebN,CoulombeMA,etal.Emergence of fluoroquinolones as the predominant risk factor forEmergenceoffluoroquinolonesasthepredominantriskfactorforClostridium difficile-associateddiarrhea:AcohortstudyduringanepidemicinQuebec.Clin Infect Dis.2005;41(9):1254-1260.
18McDonaldLC,KillgoreGE,ThompsonA,etal.Anepidemic,toxingene-variantstrainofClostridium difficile.N Engl J Med.2005;353(23):2433-2441.
19PriviteraG,ScarpelliniP,OrtisiG,NicastroG,NicolinR,deLallaF.ProspectivestudyofClostridium difficileintestinalcolonizationanddiseasefollowingsingle-doseantibioticprophylaxisinsurgery.Antimicrob Agents Chemother.1991;35(1):208-210.
20YeeJ,DixonCM,McLeanAP,MeakinsJL.Clostridium difficilediseaseinadepartmentofsurgery.Thesignificanceofprophylacticantibiotics.Arch Surg.1991;126(2):241-246.
21CarignanA,AllardC,PepinJ,CossetteB,NaultV,ValiquetteL.RiskofClostridium difficile infectionafterperioperativeantibacterialprophylaxisbeforeandduringanoutbreakofinfectionduetoahypervirulentstrain.Clin Infect Dis.2008;46(12):1838-1843.
22FowlerS,WebberA,CooperBS,etal.SuccessfuluseoffeedbacktoimproveantibioticprescribingandreduceClostridium difficileinfection:Acontrolledinterruptedtimeseries.J Antimicrob Chemother2007;59(5):990-995.
23HoM,YangD,WyleFA,MulliganME.IncreasedincidenceofClostridium difficile-associateddiarrheafollowingdecreasedrestrictionofantibioticuse.Clin Infect Dis.1996;23Suppl1:S102-S106.
24McNultyC,LoganM,DonaldIP,etal.SuccessfulcontrolofClostridium difficileinfectioninanelderlycareunitthroughuseofarestrictiveantibioticpolicy. J Antimicrob Chemother.1997;40(5):707-711.
25ClimoMW,IsraelDS,WongES,WilliamsD,CoudronP,MarkowitzSM.Hospital-widerestrictionofclindamycin:EffectontheincidenceofClostridium difficile-associateddiarrheaandcost.Ann Intern Med.1998;128(12Pt1):989-995.
26ThomasC,RileyTV.Restrictionofthird-generationcephalosporinusereducestheincidenceof Clostridium difficile-associateddiarrhoeainhospitalisedpatients.Commun Dis Intell.2003;27Suppl:S28-S31.
27LooVG,PoirierL,MillerMA,etal.A predominantly clonal multi-institutional outbreak ofApredominantlyclonalmulti-institutionaloutbreakofClostridium difficile-associateddiarrheawithhighmorbidityandmortality.N Engl J Med2005;353:2442-2449.
28JohnsonS,ClabotsCR,LinnFV,OlsonMM,PetersonLR,GerdingDN.NosocomialClostridium difficilecolonisationanddisease.Lancet.1990;336(8707):97-100.
29PalmoreTN,SohnS,MalakSF,EaganJ,SepkowitzKA.RiskfactorsforacquisitionofClostridium difficile-associateddiarrheaamongoutpatientsatacancerhospital.Infect Control Hosp Epidemiol2005;26(8):680-684.
30McDonaldLC,CoignardB,DubberkeE,etal.RecommendationsforsurveillanceofClostridium difficile-associateddisease.RecommendationsforsurveillanceofClostridium difficile-associateddisease.Infect Control Hosp Epidemiol.2007;28(2):140-145.
31ElixhauserA,JhungMA.Clostridium difficile-associateddiseaseinU.S.hospitals,1993-2005.HCUPStatisticalBrief#50.April2008.Agency for Healthcare Research and Quality,Rockville,MD.http://www.hcup-us.ahrq.gov/reports/statbriefs/sb50.pdf.
32SevereClostridium difficile-associateddiseaseinpopulationspreviouslyatlowrisk—fourstates,2005.MMWR Morb Mortal Wkly Rep.2005;54:1201-1205.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY ��
33MillerMA,HylandM,Ofner-AgostiniM,GourdeauM,IshakM.Morbidity,mortality,andhealthcareburdenofnosocomialClostridium difficile-associateddiarrheainCanadianhospitals.Infect Control Hosp Epidemiol.2002;23(3):137-140.
34WarnyM,PepinJ,FangA,etal.Toxin production by an emerging strain ofToxinproductionbyanemergingstrainofClostridium difficileassociatedwithoutbreaksofseverediseaseinNorthAmericaandEurope.Lancet.2005;366(9491):1079-1084.
35KuijperEJ,CoignardB,TullP.EmergenceofClostridium difficile-associateddiseaseinNorthAmericaandEurope.Clin Microbiol Infect.2006;12Suppl6:2-18.
36GericB,RupnikM,GerdingDN,GrabnarM,JohnsonS.DistributionofClostridium difficilevarianttoxinotypesandstrainswithbinarytoxingenesamongclinicalisolatesinanAmericanhospital.J Med Microbiol.2004;53(Pt9):887-894.
37BarbutF,DecreD,LalandeV,etal.ClinicalfeaturesofClostridium difficile-associateddiarrhoeaduetobinarytoxin(actin-specificADP-ribosyltransferase)-producingstrains.J Med Microbiol.2005;54(Pt2):181-185.
38EggertsonL.QuebecstrainofC. difficileinsevenprovinces.CMAJ.2006;174(5):607-608.
39HealthProtectionA.OutbreakofClostridium difficileinfectioninahospitalinsoutheastEngland.CDR Weekly2005;15(24).
40LarsonHE,BarclayFE,HonourP,HillID.EpidemiologyofClostridium difficileininfants.J Infect Dis.1982;146(6):727-733.
41Al-JumailiIJ,ShibleyM,LishmanAH,RecordCO.IncidenceandoriginofClostridium difficileinneonates.J Clin Microbiol1984;19(1):77-78.
42BoltonRP,TaitSK,DearPRP,LosowskyMS.AsymptomaticneonatalcolonizationbyClostridium difficile.Arch Dis Child.1984;59(5):466-472.
43ZeddAJ,SellTL,SchabergDR,FeketyFR,Coopstock,MS.NosocomialClostridiumdifficilereservoirinaneonatalintensivecareunit.Pediatr Infect Dis.1984;3(5):429-432.
44SvedhemÅ,KaijserB,MacDowallI.IntestinaloccurrenceofCampylobacter fetussubspeciesjejuniandClostridium difficileinchildreninSweden.Eur J Clin Microbiol1982;1(1):29-32.
45BoenningDA,FleisherGR,CamposJM,HolkowerCW,QuinlanRW.Clostridium difficileinapediatricoutpatientpopulation.Pediatr Infect Dis J. 1982;1(5):336-338.
46CerquettiM,LuzziI,CaprioliA,SebastianelliA,MastrantonioP.RoleofClostridiumdifficile inchildhooddiarrhea.Pediatr Infect Dis J.1995;14(7);598-603.
47DontaST,MyersMG.Clostridium difficiletoxininasymptomaticneonates. J Pediatr.1982;100(3):431-434.
48HeckerMT,RiggsMM,HoyenCK,LancioniC,DonskeyCJ.RecurrentinfectionwithepidemicClostridium difficileinaperipartumwomanwhoseinfantwasasymptomaticallycolonizedwiththesamestrain.Clin Infect Dis.2008;46(6):956-957.
49BensonL,SongX,CamposJ,SinghN.ChangingepidemiologyofClostridium difficile-associateddiseaseinchildren.Infect Control Hosp Epidemiol.2007;28(11):1233-1235.
50KimKH,FeketyR,BattsDH,BrownD,CudmoreM,SilvaJJr,WatersD.IsolationofClostridium difficilefromtheenvironmentandcontactsofpatientswithantibiotic-associatedcolitis.J Infect Dis.1981;143(1):42-50.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�� ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
51FeketyR,KimKH,BrownD,BattsDH,CudmoreM,SilvaJJr.Epidemiologyofantibiotic-associatedcolitis;isolationofClostridium difficilefromthehospitalenvironment.Am J Med.1981;70(4):906-8.
52GerdingDN,JohnsonS,PetersonLR,MulliganME,SilvaJJr.Clostridium difficile-associateddiarrheaandcolitis.Infect Control Hosp Epidemiol.1995;16(8):459-477.
53BrooksSE,VealRO,KramerM,DoreL,SchupfN,AdachiM.ReductionintheincidenceofClostridium difficile-associateddiarrheainanacutecarehospitalandaskillednursingfacilityfollowingreplacementofelectronicthermometerswithsingle-usedisposables.Infect Control Hosp Epidemiol.1992,13(2):98-103.
54JohnsonS,GerdingDN,OlsonMM,etal.Prospective,controlledstudyofvinylgloveusetointerruptClostridium difficilenosocomialtransmission.Am J Med.1990;88(2):137-140.
55SunenshineRH,McDonaldLC.Clostridium difficile-associateddisease:Newchallengesfromanestablishedpathogen.Cleve Clin J Med.2006;73(2):187-197.
56RiggsMM,SethiAK,ZabarskyTF,EcksteinEC,JumpRL,DonskeyCJ.AsymptomaticcarriersareapotentialsourcefortransmissionofepidemicandnonepidemicClostridium difficilestrainsamonglong-termcarefacilityresidents.Clin Infect Dis.2007;45(8):992-998.Epub2007Sep4.
57SimorAE,BradleySF,StrausbaughLJ,CrossleyK,NicolleLE.Clostridium difficileinlong-termcarefacilitiesfortheelderly.Infect Control Hosp Epidemiol.2002;23(11):696-703.
58JohnsonS,HomannSR,BettinKM,etal.TreatmentofasymptomaticClostridium difficilecarriers(fecalexcretors)withvancomycinormetronidazole.Arandomized,placebo-controlledtrial.Ann Intern Med.1992;117(4):297-302.
59MayerJ,SouthB,MooneyB,DerykeC,AlexanderD,RubinMetal.SurveillanceofClostridium difficile-associatedDiseaseBasedibToxinEnzymeImmunoassayResults:DidaProblemwithTestingLeadtoaPseudo-Epidemic?SocietyforHealthcareEpidemiologyofAmericaAnnualMeeting.2008;RefType:Abstract.
60FreemanJ,WilcoxMH.Theeffectsofstorageconditionsonviabilityof Clostridium difficilevegetativecellsandsporesandtoxinactivityinhumanfaeces.J Clin Pathol.2003;56(2):126-128.
61MasseyV,GregsonDB,ChaglaAH,StoreyM,JohnMA,HussainZ.ClinicalusefulnessofcomponentsoftheTriageimmunoassay,enzymeimmunoassayfortoxinsAandB,andcytotoxinBtissuecultureassayforthediagnosisofClostridium difficilediarrhea.Am J Clin Pathol.2003;119(1):45-49.
62SnellH,RamosM,LongoS,JohnM,HussainZ.PerformanceoftheTechLabC.DIFFCHEK-60enzymeimmunoassay(EIA)incombinationwiththeC. difficileToxA/BIIEIAkit,theTriageC.difficilepanelimmunoassay,andacytotoxinassayfordiagnosisofClostridium difficile-associateddiarrhea.J Clin Microbiol.2004;42(10):4863-4865.
63TicehurstJR,AirdDZ,DamLM,BorekAP,HargroveJT,CarrollKC.EffectivedetectionoftoxigenicClostridium difficilebyatwo-stepalgorithmincludingtestsforantigenandcytotoxin.J Clin Microbiol.2006;44(3):1145-1149.
64GerdingDN,OlsonMM,PetersonLR,etal.Clostridium difficile-associateddiarrheaandcolitisinadults.Aprospectivecase-controlledepidemiologicstudy.Arch Intern Med.1986;146(1):95-100.
65AshL,BakerME,O’MalleyCM,Jr.,GordonSM,DelaneyCP,ObuchowskiNA.ColonicabnormalitiesonCTinadulthospitalizedpatientswithClostridium difficilecolitis:prevalenceandsignificanceoffindings.AJR Am J Roentgenol.2006;186(5):1393-1400.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY ��
66BolandGW,LeeMJ,CatsAM,FerraroMJ,MatthiaAR,MuellerPR.Clostridium difficile colitis:CorrelationofCTfindingswithseverityofclinicaldisease.Clin Radiol.1995;50(3):153-156.
67BenneyanJC.Statisticalqualitycontrolmethodsininfectioncontrolandhospitalepidemiology,partI:Introductionandbasictheory.Infect Control Hosp Epidemiol.1998;19(3):194-214.
68BenneyanJC.Statisticalquality-controlmethodsininfectioncontrolandhospitalepidemiology,partII:Chartuse,statisticalproperties,andresearchissues.Infect Control Hosp Epidemiol.1998;19(4):265-283.
69AminSG.Controlcharts101:aguidetohealthcareapplications.Qual Manag Health Care.2001Spring;9(3):1-27.
70Blossom,DBandMcDonaldLC.ThechallengesposedbyreemergingClostridium difficileinfection.Clin Infect Dis.2007;45(2):222-227.
71BobulskyGS,Al-NassirWN,RiggsMM,SethiAK,DonskeyCJ.Clostridium difficileskincontaminationinpatientswithC. difficile-associateddisease.Clin Infect Dis.2008;46(3):447-450.
72LawrenceSJ,PuzniakLA,ShadelBN,GillespieKN,KollefMH,MundyLM.Clostridium difficileintheintensivecareunit:Epidemiology,costs,andcolonizationpressure.Infect Control Hosp Epidemiol.2007;28(2):123-130.
73PerryC,MarshallR,JonesE.Bacterialcontaminationofuniforms.J Hosp Infect.2001;48(3):238-241.
74GerdingDN,MutoCA,OwensRC.MeasurestocontrolandpreventClostridium difficileInfection.Clin Infect Dis.2008;46Suppl1:S43-49.
75BoyceJM,PittetD.Guidelineforhandhygieneinhealth-caresettings:recommendationsoftheHealthcareInfectionControlPracticesAdvisoryCommitteeandtheHICPAC/SHEA/APIC/IDSAHandHygieneTaskForce.Infect Control Hosp Epidemiol. 2002;23(12Suppl):S3-40.76BoyceJM,LigiC,KohanC,DumiganD,HavillNL.Lack of association between the increased incidence ofLackofassociationbetweentheincreasedincidenceofClostridium difficile-associateddiseaseandtheincreasinguseofalcohol-basedhandrubs.Infect Control Hosp Epidemiol. 2006,27(5): 479-483.
77DedrickRE,Sinkowitz-CochranR,CunninghamC,MuderRR,PerreiahP,CardoDM,andJerniganJA.HandHygienePracticesafterBriefEncounterswithPatients:AnImportantOpportunityforPrevention.Infect Control Hosp Epidemiol2007;28:341-345.
78WorldHealthOrganization.WorldAllianceforPatientSafety.Availableathttp://www.who.int/patientsafety/en.
79CroganNL,EvansBC.Clostridium difficile:Anemergingepidemicinnursinghomes.Geriatr Nurs.2007;28(3):161-164.
80SamoreMH,VenkataramanL,DeGirolamiPC,ArbeitRD,KarchmerAW.ClinicalandmolecularepidemiologyofsporadicandclusteredcasesofnosocomialClostridium difficilediarrhea.Am J Med.1996;100(1):32-40.
81MayfieldJL,LeetT,MillerJ,MundayLM.EnvironmentalcontroltoreducetransmissionofClostridium difficile.Clin Infect Dis.2000;31(4):995-1000.
82WilcoxMH,FawleyWN.HospitaldisinfectantsandsporeformationbyClostridium difficile.Lancet.2000;356(9238):1324.
83RutalaWA,WeberDJ.Usesofinorganichypochlorite(bleach)inhealth-carefacilities.Clin Microbiol.Rev1997;10:597-610.
Guide to the Elimination of Clostridium difficile in Healthcare Settings
�� ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
84OtterJA,FrenchGL,AdamsNM,WatlingD,ParksMJ.Hydrogenperoxidevapourdecontaminationinanovercrowdedtertiarycarereferralcentre:Somepracticalanswers.J Hosp Infect2006;62:384-5.
85BoyceJM,HavillNL,OtterJA,etal.ImpactofhydrogenperoxidevaporroomdecontaminationonClostridium difficile environmentalcontaminationandtransmissioninahealthcaresetting.Infect Control Hosp Epidemiol.2008;29(8):723-729.
86SehulsterLM,ChinnRYW,ArduinoMJ,CarpenterJ,DonlanR,AshfordD,BesserR,FieldsB,McNeilMM,WhitneyC,WongS,JuranekD,ClevelandJ.Guidelinesforenvironmentalinfectioncontrolinhealth-carefacilities.RecommendationsfromCDCandtheHealthcareInfectionControlPracticesAdvisoryCommittee(HICPAC).ChicagoIL;AmericanSocietyforHealthcareEngineering/AmericanHospitalAssociation.2004.
87OwensRCJr,DonskyCJ,GaynesRP,LooVG,MutoCA.Antimicrobial-associatedriskfactorsforClostridium difficileinfection.Clin Infect Dis. 2008;46Suppl1:S19-31.
88GerdingDN,MutoCA,OwensRCJr.TreatmentofClostridium difficile infection.CID. 2008Jan15;46Suppl1:S32-42.
89SullivanA,NordCE.Probioticsandgasronintestinaldiseases.J Intern Med. 2005Jan;257(1):78-92.
90CarlingP,etal.Favorableimpactofamultidisciplinaryantibioticmanagementprogramconductedduringsevenyears.Infect Control Hosp Epidemiol.2003;24(9):699-706.
91ValiquetteL,etal.Impactofareductionintheuseofhigh-riskantibioticsonthecourseofanepidemicofClostridium difficile-associateddiseasecausedbythehypervirulentNAP1/027strain.Clin Infect Dis.2007;45Suppl2:S112-21.
92CommitteeonQualityofHealthCareinAmerica,Institute of Medicine,1999.ToErrisHuman:BuildingaSaferHealthSystem.Availableathttp://www.nap.edu/catalog.php?record_id=9728#toc.
93CommitteeonEngineeringandtheHealthCareSystem,Institute of Medicine and National Academy of Engineering,2005.BuildingaBetterDeliverySystem:ANewEngineering/HealthCarePartnership.Availableathttp://www.nap.edu/catalog.php?record_id=11378#toc.
Additional ResourcesBogner,MarilynS,Editor.Human Error in Medicine.LawrenceErlbaumAssociates,Hillsdale,NJ,1994.
CommitteeonQualityofHealthCareinAmerica,InstituteofMedicine,2001.Crossing the Quality Chasm: A New Health System for the 21st Century. Availableathttp://www.nap.edu/catalog.php?record_id=10027#toc.
WangMC,HyunJK,HarrisonMI,ShortellSM,FraserI.RedesigningHealthSystemsforQuality:LessonsfromEmergingPractices.Journ Qual Patient Safety 2006;32:599-611.
Kopah-KonradR,et.al.Applying Systems Engineering Principles in Improving Health Care Delivery.ApplyingSystemsEngineeringPrinciplesinImprovingHealthCareDelivery.J Gen Intern Med2007;22(Suppl3):431-437.
For links to references and resources, please visit www.apic.org/EliminationGuides.