Study: C. Difficile is very common in U.S. hospitals

Earlier research underestimated number of infections

A study initiated by the Association for Professionals in Infection Control and Epidemiology (APIC), has shown that 13 of every 1,000 inpatients surveyed were either infected or colonized with Clostridium difficile (C. difficile), an infection associated with severe diarrhea, colitis, toxic megacolon, sepsis, and death. According to APIC, this rate is 6.5-20 times higher than previous incidence estimates, which had looked at only one hospital or hospitals in one state, and it used different methodologies.

The APIC study was led by William Jarvis, MD, president of the epidemiology and infectious disease firm Jason and Jarvis Associates. Jarvis, formerly with the Centers for Disease Control and Prevention (CDC), oversaw a project that asked infection preventionists (primarily APIC's 12,000+ U.S. members) to collect data about all patients in their facilities who were identified with C. difficile on one day in May-August 2008. In all, 648 facilities of varying sizes were involved, located in 47 states.

"Most previous studies, including one I did at the CDC, did not even have hospital-wide data available," notes Jarvis. "It showed the infection rate increasing, but it was very slanted. Since that time, there have been two other analyses, but usually with very shallow data. With those little slices of all U.S. hospitals, they extrapolated to national numbers."

The advantage of this survey, he says, is that it represents "a slice of bread, not the whole loaf," which allowed for the collection of much more detailed information, including what kind of hospital was involved; how big it was; surveillance practices; antibiotic protocols; and so forth. "There was a lot of information generated including patient age, outcomes, what they were exposed to, if they required surgery, and so on," Jarvis adds.

"This gave us a snapshot in time, and indicates the prevalence was much higher than the other studies showed," he adds.

A wake-up call

Jarvis says he hopes these findings will be a wake-up call to QI personnel that we need to put the necessary resources in place to help reduce the rate of infection. "The way to control it is to identify who the high-risk patients are," he says. For example, the study found that people at highest risk were the elderly (over 60 years age). In fact, he says, "69.2% were over 60, and the rate of infection increased as they went up in age." The high-risk patients also had a history of repeat hospital admissions, and more than 80% had received antibiotics within eight days.

"That population is increasing, so we think the prevalence we detected is a minimum," Jarvis adds. (Since the immunoassay test used is 73% reliable, he points out, 25% of the cases could have been missed.)

Jarvis recommends that hospitals put in place a surveillance program that detects any patient who comes in with or develops diarrhea, and puts them in isolation preemptively. "If they are not in isolation, others are at risk," he explains. He further recommends that all health care workers wear gowns and gloves when they treat these patients, and that they use good hand hygiene.

There are two different forms of C. difficile, Jarvis says: vegetative and spore. "The spore form is very hard to kill," he warns. "The alcohol gel doesn't kill it. Neither will soap and water, but it will get it off your hands." Only bleach actually kills the spores, he adds, so rooms, equipment, and so forth must be cleaned with bleach.

A major driver of C. difficile, he adds, is antibiotic resistance. In particular, drugs like cephalosporin, fluoquinolone, clindamycin, and macromycins have been connected to the disease, and all are used widely in hospitals.

All of these factors must be taken into account, Jarvis advises. "Make sure your people understand how important their role is as part of the infection control team," he says. "Your next patient may be at risk."

[For more information, contact:

Association for Professionals in Infection Control and Epidemiology, 1275 K St., NW, Suite 1000, Washington, DC 20005-4006. Phone: (202) 789-1890. Fax: (202) 789-1899. E-mail: apicinfo@apic.org.

William Jarvis, MD, President, Jason Jarvis and Associates. Phone: (404) 512-4777. E-mail: WRJMJ@aol.com.]