Preventing Transmission of C. difficile: Practice Elise Tamplin, M(ASCP), MPH, CIC Brigham & Women’s Hospital

Preventing Transmission of C. difficile: PracticeElise Tamplin, M(ASCP), MPH, CICBrigham & Womens Hospital

ObjectivesDiscuss practical challenges in implementing infection control measuresIllustrate the value of periodic assessment of compliance

BWH healthcare-associated CDI rates*Excludes NICU

CDI leading to colectomy and/or death:Nosocomial & non-nosocomial cases

ChallengesPreventing acquisition/transmissionImproving outcomes for patients with CDI

CDI Control InterventionsSentinel event and root cause analysisIncrease case finding & early identificationquicker lab turn around timeEnhance Infection Control measures Aggressive CDI management & surgical evaluation (BWH CDI Treatment Guidelines)Staff educationMinimize antibiotic utilization

Laboratory TestingChange in test methodologyCytotoxicity assay to EIAFrom 3 day TAT to same day resultsLower sensitivityNeed for clinical judgment in interpretation of negative resultIncreased possibility of false negatives if specimen taken while on antibiotics

Basic Infection Control PracticesHand hygieneContact precautions for infected patientsEnsure cleaning and disinfection of equipment and the environmentImplement a laboratory-based alert systemConduct CDI surveillanceEducate patients and families about CDI

Special Approaches to prevent transmission by healthcare personnelPerform hand hygiene with soap and water after contact with a patient with CDIPro: Alcohol is not sporicidalCon: Hand hygiene compliance is lower for handwashing with soap and water vs. use of an alcohol-based hand disinfectant

Special Approaches to prevent spread through the environmentUse a hypochlorite-based room cleaning agentPro: Sporocidal and benefit has been reported in outbreak settingsCon: Can corrode equipment and can be a chemical irritant for patients and staff

Special Approaches to prevent transmission by healthcare personnelProlong the duration of contact precautions after the patient becomes asymptomatic until hospital dischargePatients may shed C. difficile in their stool after diarrhea resolvesBobulsky GS et al. Clin Infect Dis 2008; 46:44750

New Infection Control MeasuresEnhancements to Contact PrecautionsContact Precautions PlusSoap & water hand hygieneHypochlorite based disinfectant-detergent upon discharge/transferPrecautions for duration of admission

Contact Precautions PlusDiscontinuation upon cessation of symptoms problematicAdministration buy-in required for continuation during entire admissionAutomated flag developed by IS like those for MRSA & VRE but expiring upon dischargeEducation of Admitting staff re empiric precaution status

Soap & Water Hand HygieneMajor change from routine use of waterless hand sanitizerVisibility of sign key issueSeveral design changesSink availability challengingFew in central areas of inpatient unitsReluctance to use patient room sinkHand washing 101

Do not remove sign until after room has been cleaned*Bleach-based

Hypochlorite DisinfectantInfection Control & Safety approvals

Odor/symptom complaints from staff- OHS evaluation/tracking- MNA discussion re safety concerns- Evaluation of new products- Change from liquid to impregnated wipes- Adequacy of surface wetting evaluated

Hypochlorite DisinfectantCompliance with useTracking mechanismsDaily patient log from Infection Control to Environmental ServiceSome rooms still missedDaily review/verification by ES & return to Infection ControlSigns taken down before cleaningCPP room status added to housekeeping page

Staff EducationPhysiciansEarly severe patient outcomes helpedM&M conferences, Grand Rounds, etc.NursingEmpiric precautionsSpecimen collection prior to treatment

Staff EducationSupport (Environmental Services)Balance between emphasis on need for special measures vs. fostering undue personal safety concernsRegroup with supervisorsAdministrative (Admitting)Achieving support for empiric precautions

CDI Management Guidelines Consensus documentInfection ControlInfectious DiseaseMedical Intensive CareGeneral SurgeryMicrobiologyPharmacyNursing

CDI Management GuidelinesInfection Control PrecautionsDiagnostic testingClinical management of patients

CDI Management GuidelinesClinical categories based on specific clinical criteriaAppropriate management for eachStop non-essential medicationsantimicrobials & antiperistalticsAppropriate antibiotic therapyInfectious Disease & Surgical consultsRectal vancomycin (when & how)

BWH healthcare-associated CDI rates*Excludes NICUContact Precautions PlusBWH Treatment Guidelines

Severe CDI leading to colectomy+/-deathNosocomial vs. non-nosocomialContact Precautions Plus

ObjectivesDiscuss practical challenges in implementing infection control measuresIllustrate value of periodic assessment of compliance

*These are cases classified as nosocomial per our surveillance definitions. These dont include community-acquired cases or cases attributed to other healthcare facilities. The denominator is 1,000 inpatient days, since risk for these cases is associated with time in the hospital.*This included cases leading to death or colectomy ascertained by ICD-9 procedure and diagnosis codes. These include hospital-associated and community-associated cases. *These are cases classified as nosocomial per our surveillance definitions. These dont include community-acquired cases or cases attributed to other healthcare facilities. The denominator is 1,000 inpatient days, since risk for these cases is associated with time in the hospital.*This included cases leading to death or colectomy ascertained by ICD-9 procedure and diagnosis codes. The cases are categorized as nosocomial (per surveillance definitions) vs. any other source, including other healthcare facilities and community cases.