Combat C. difficile with better hand hygiene

Stick with alcohol except in outbreak

As hospitals across the country struggle to combat a highly virulent strain of Clostridium difficile, compliance with hand hygiene takes center stage as a primary defense.

At least 16 states have detected this strain of C. diff, which has led to colectomies and deaths. The Centers for Disease Control and Prevention (CDC) is cautioning health care providers about the changing epidemiology of the disease.

"It's still predominantly a hospital-based disease and among people on antibiotics, but there may be more disease than we had previously recognized emerging in other persons [in the community]," says Clifford McDonald, MD, a CDC medical epidemiologist.

The CDC reports a 26% increase in the rate of hospital discharges with a diagnosis of C. diff from 2000 to 2001. Community cases among younger, otherwise healthy people also have raised concern.1

A worst-case scenario occurred in Montreal in 2003-2004, with an outbreak that had a mortality rate of 6.9%. A study of 12 hospitals revealed outbreaks that resulted in more than 80 deaths.2 One hospital, Hôpital du Sacre-Coeur de Montréal, closed its intensive care unit for a day and partly closed it for three weeks because it was inundated with C. diff patients. Based on the mortality rate associated with the C. diff strain, Quebec researchers estimated that 1,000 to 3,000 patients died as a result of the epidemic.3

The C. diff strain is more likely to be fluoroquinolone-resistant than other previous strains, and it produces more toxins that cause severe diarrhea. Victims of the virulent strain were more likely to have been taking fluoroquinolone antibiotics and were more likely to be elderly, researchers found.2

U.S. hospitals also have faced outbreaks that forced them into infection control vigilance. For example, in 1999-2000, the University of Pittsburgh reported 20 deaths and performed 40 colectomies related to an outbreak of C. diff.

Public health experts are concerned about the identification of cases of C. diff in people typically considered to be low risk. For example, researchers identified 10 cases in peripartum women (who were in the last trimester of pregnancy or within six weeks of delivery) in four states during May and June 2005. They detailed a C. diff case in an otherwise healthy woman in her second trimester of pregnancy who developed severe colitis, spontaneously aborted her twins, and died despite aggressive treatment.

Still, it remains predominantly a disease spread in hospitals and long-term care facilities.

"We think this organism is spread by a combination of a contaminated environment and contamination of the hands of the health care workers," says Dale Gerding, MD, associate chief of staff for research at the Hines VA Hospital in Chicago and a C. diff expert. "Those are the major areas of concern. It's a spore, and it's very difficult to get rid of these spores in the environment. They do resist pretty much all of the cleaning agents that we use.

"Clearly the best way to address it is to try to prevent it," he says.

Good hand hygiene is critical

Employee health professionals can play a role by educating employees about the potential for a C. diff outbreak and the importance of hand hygiene.

"I don't think you can emphasize enough the need for good hand hygiene between every patient care contact. It's just critical," says Gerding.

Alcohol-based gels have been effective in improving compliance with hand hygiene, public health experts say. But there has been some confusion about the role of alcohol gels in the prevention of C. diff.

Alcohol gels reduce the spore count on hands, though not as effectively as traditional hand washing, Gerding and colleagues found in a study.4 Because the alcohol-based gels are more readily used by health care workers, "we don't want to send a message not to use alcohol."

Even health care workers treating isolated cases of C. diff can continue to use alcohol gels. But the hand hygiene procedures should change if a C. diff outbreak occurs in the hospital, Gerding advises.

"When the C. diff patient is being cared for, you wear gloves. That is the very important infection control intervention," he says. "For isolated patients, follow the gloving and gowning recommendations for contact isolation. In an outbreak situation, when health care workers take their gloves off, we recommend they wash their hands rather than using alcohol."

McDonald agrees. "There have been many, many reports of hospitals instituting alcohol gel, using it widely among health care workers, and seeing no increase in C. diff," he says.

"There's no reason to believe that going to hand washing is going to change that low endemic rate [of C. diff in most hospitals]. If there are high rates in your facility or if there has been an increase, then it's wise to come in with this [hand washing] recommendation," he says.

References

1. Centers for Disease Control and Prevention. Severe Clostridium difficile-associated disease in populations previously at low risk — Four states, 2005. MMWR 2005; 54:1,201-1,205.

2. Loo VG, Poirier L, Miller MA, et al. A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med 2005; 353:2,442-2,449. Epub Dec. 1, 2005.

3. Pépin J, Valiquette L, Cossette B. Mortality attributable to nosocomial Clostridium difficile-associated disease during an epidemic caused by a hypervirulent strain in Quebec. CMAJ 2005; 173:1,037-1,042.

4. Leischner J, Johnson S, Sambol S, et al. Effect of alcohol hand gels and chlorhexidine hand wash in removing spores of Clostridium difficile from hands. Abstract LB-29. Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC). Washington, DC; Dec. 16-19, 2005.