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Preventing Transmission of C. difficile: Practice
Elise Tamplin, M(ASCP), MPH, CICBrigham & Women’s Hospital
Objectives
• Discuss practical challenges in implementing infection control measures
• Illustrate the value of periodic assessment of compliance
BWH healthcare-associated CDI rates
0.860.78
1.19
0.781
1.121.29
1.06
1.55
1.01
00.20.40.60.8
11.21.41.61.8
Jan-M
ar0
4
Apr-
Jun04
Jul-
Sep04
Oct
-Dec0
4
Jan-M
ar0
5
Apr-
Jun05
Jul-
Sep05
Oct
-Dec0
5
Jan-M
ar0
6
Apr-
Jun06
Jul-
Sep06
Oct
-Dec0
6
Jan-M
ar0
7
Apr-
Jun07
Jul-
Sep07
Oct
-Dec0
7
Jan-M
ar0
8
Apr-
Jun08
Jul-
Sep08
Num
ber
of CD
I c
ase
s per
1000 p
ati
ent
days
*Excludes NICU
CDI leading to colectomy and/or death:Nosocomial & non-nosocomial cases
0
1
2
3
4
5
6
7
8
Jan-
Mar
04
Apr-J
un04
Jul-S
ep04
Oct-Dec
04
Jan-
Mar
05
Apr-J
un05
Jul-S
ep05
Oct-Dec
05
Jan-
Mar
06
Apr-J
un06
Jul-S
ep06
Oct-Dec
06
Jan-
Mar
07
Apr-J
un07
Jul-S
ep07
Oct-Dec
07
Jan-
Mar
08
Apr-J
un08
Jul-S
ep08
Nu
mb
er o
f ca
ses
Death Colectomy Colectomy +/- Death
CDI Control Interventions
• Sentinel event and root cause analysis• Increase case finding & early identification
—quicker lab turn around time• Enhance Infection Control measures • Aggressive CDI management & surgical
evaluation (BWH CDI Treatment Guidelines)• Staff education• Minimize antibiotic utilization
Laboratory Testing
• Change in test methodology– Cytotoxicity assay to EIA
• From 3 day TAT to same day results– Lower sensitivity– Need for clinical judgment in
interpretation of negative result– Increased possibility of false negatives if
specimen taken while on antibiotics
Basic Infection Control Practices
• Hand hygiene• Contact precautions for infected patients• Ensure cleaning and disinfection of
equipment and the environment• Implement a laboratory-based alert
system• Conduct CDI surveillance• Educate patients and families about CDI
Special ApproachesSpecial Approaches to prevent transmission by healthcare personnel
• Perform hand hygiene with soap and water after contact with a patient with CDI– Pro:Pro: Alcohol is not sporicidal– Con:Con: Hand hygiene compliance is lower
for handwashing with soap and water vs. use of an alcohol-based hand disinfectant
Special ApproachesSpecial Approaches to prevent spread through the environment
• Use a hypochlorite-based room cleaning agent– Pro:Pro: Sporocidal and benefit has been
reported in outbreak settings– Con:Con: Can corrode equipment and can be
a chemical irritant for patients and staff
Special ApproachesSpecial Approaches to prevent transmission by healthcare personnel
• Prolong the duration of contact precautions after the patient becomes asymptomatic until hospital discharge– Patients may shed C. difficile in their
stool after diarrhea resolves
Bobulsky GS et al. Clin Infect Dis 2008; 46:447–50
New Infection Control Measures
• Enhancements to Contact Precautions• Contact Precautions Plus
– Soap & water hand hygiene– Hypochlorite based disinfectant-
detergent upon discharge/transfer– Precautions for duration of admission
Contact Precautions PlusPlus
• Discontinuation upon cessation of symptoms problematic
• Administration buy-in required for continuation during entire admission
• Automated “flag” developed by IS like those for MRSA & VRE but expiring upon discharge
• Education of Admitting staff re empiric precaution status
Soap & Water Hand Hygiene
• Major change from routine use of waterless hand sanitizer
• Visibility of sign key issue– Several design changes
• Sink availability challenging– Few in central areas of inpatient units– Reluctance to use patient room sink– Hand washing 101
Hypochlorite Disinfectant
• Infection 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 Disinfectant
• Compliance with use– Tracking mechanisms
Daily patient log from Infection Control to Environmental Service
Some rooms still missedDaily review/verification by ES &
return to Infection Control– Signs taken down before cleaning
CPP room status added to housekeeping page
Staff Education
• Physicians– Early severe patient outcomes helped– M&M conferences, Grand Rounds, etc.
• Nursing– Empiric precautions– Specimen collection prior to treatment
Staff Education
• Support (Environmental Services)– Balance between emphasis on need for
special measures vs. fostering undue personal safety concerns
– Regroup with supervisors• Administrative (Admitting)
– Achieving support for empiric precautions
CDI Management Guidelines
• Consensus document– Infection Control– Infectious Disease– Medical Intensive Care– General Surgery– Microbiology– Pharmacy– Nursing
CDI Management Guidelines
• Infection Control Precautions• Diagnostic testing• Clinical management of patients
CDI Management Guidelines
• Clinical categories based on specific clinical criteria– Appropriate management for each
Stop non-essential medications antimicrobials & antiperistaltics
Appropriate antibiotic therapyInfectious Disease & Surgical consultsRectal vancomycin (when & how)
BWH healthcare-associated CDI rates
0.860.78
1.19
0.781
1.121.29
1.06
1.55
1.01
0.740.50.60.50.60.60.50.50.6
0.70.7
0.55
0.790.69
0.63
00.20.40.60.8
11.21.41.61.8
Jan-M
ar0
4Apr-
Jun04
Jul-
Sep04
Oct
-Dec0
4Ja
n-M
ar0
5Apr-
Jun05
Jul-
Sep05
Oct
-Dec0
5Ja
n-M
ar0
6Apr-
Jun06
Jul-
Sep06
Oct
-Dec0
6Ja
n-M
ar0
7Apr-
Jun07
Jul-
Sep07
Oct
-Dec0
7Ja
n-M
ar0
8Apr-
Jun08
Jul-
Sep08
Oct
-Dec0
8Ja
n-M
ar0
9Apr-
Jun09
Jul-
Sep09
Oct
-Dec0
9Ja
n-M
ar1
0
Num
ber
of CD
AD
case
s per
1000
pati
ent
days
*Excludes NICU
Contact Precautions Plus
BWH Treatment Guidelines
Severe CDI leading to colectomy+/-deathNosocomial vs. non-nosocomial
0
1
2
3
4
5
6
7
8
Jan-
Mar
04
Apr-J
un04
Jul-S
ep04
Oct-Dec
04
Jan-
Mar
05
Apr-J
un05
Jul-S
ep05
Oct-Dec
05
Jan-
Mar
06
Apr-J
un06
Jul-S
ep06
Oct-Dec
06
Jan-
Mar
07
Apr-J
un07
Jul-S
ep07
Oct-Dec
07
Jan-
Mar
08
Apr-J
un08
Jul-S
ep08
Oct-Dec
08
Jan-
Mar
09
Apr-J
un09
Jul-S
ep09
Oct-Dec
09
Nu
mb
er o
f ca
ses
Nosocomial Other source
Contact Precautions Plus