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Hand hygiene woes impact C. diff response
Hospitals, nursing homes will 'sink or swim'
An epidemic of Clostridium difficile (C. diff ) in the United States is killing some 12,000 patients annually, in part because neither alcohol hand rubs nor soap and water can effectively remove the spore-forming bacillus from hands, researchers are finding.
With the pathogen practically impervious to the hand hygiene approaches used by the vast majority of health care providers, the Centers for Disease Control and Prevention (CDC) is considering the radical step of recommending "universal gloving" for some situations. However, infection preventionists warn that such policies invariably lead to health care workers going from patient to patient and room to room without changing gloves, which is an ideal scenario for disease transmission.
In short, there are no simple solutions to an increasingly complex problem, an epidemic of C. diff driven by the highly virulent NAP1 strain, which is more deadly to patients and six-fold more prevalent than the next most common C. diff strain, epidemiologists and infection preventionists (IPs) reported recently in Atlanta at the Fifth Decennial International Conference on Healthcare-Associated Infections. One study particularly underscored the dramatic rise of C. diff , noting that it has surpassed dreaded methicillin-resistant Staphylococcus aureus (MRSA) as the leading nosocomial pathogen in community hospitals in the Southeast.
"Times are changing," said Becky Miller, MD, lead author of the study and an epidemiologist at Duke University Medical Center in Durham, NC. "What was once thought of as a nuisance infection has become an increasing problem, carrying increased morbidity, mortality, and health care costs for patients."
A personal loss
A leading cause of diarrhea in hospitalized patients, C. diff infection can lead to serious complications such as pseudomembranous colitis, toxic megacolon, perforations of the colon, and sepsis.
Though a national surveillance system for C. diff is under development at the CDC, the latest estimates outline the formidable extent of the problem. According to extrapolated data released by the CDC at the decennial conference, hospital-acquired C. diff , which includes both hospital-onset cases and post-discharge cases that occur up to 4 weeks later, causes some 215,000 infections annually, resulting in 12,000 deaths and costs of $1.6 billion. The thousands of C. diff deaths were reduced to one in a personal aside by former CDC director Julie Gerberding, MD, MPH, who lost her aunt to the infection last year.
"In my own personal experience of these pathogens, the reality check of sitting in the acute setting as well as the rehab environment and watching the absurd interpretation of what contact precautions were all about from a practical perspective, was really a very poignant and eye-opening experience of how ubiquitous these pathogens are and how easily they spread throughout the system, and unfortunately, how deadly, because my aunt died of C. difficile," said Gerberding, president of Merck Vaccines in Whitehouse Station, NJ.
Beyond the hospital setting, even more C. diff deaths are occurring in long term care. Nursing home-onset C. diff infections were estimated at a staggering 263,000 cases annually, with 16,500 deaths and costs of $2.2 billion. All told, that's in the ballpark of a half-million cases and 25,000 deaths in hospitals and nursing homes every year in the United States. The familiar refrain of "who gave what to whom" came up in discussions of transmission between hospitals and nursing homes, which must nevertheless work together and improve communication about patients and residents if the problem is going to be solved.
L. Clifford McDonald, MD, FACP, a leading C. diff expert in the CDC's Division of Healthcare Quality Promotion, said, "For a community or a region to drive down C. diff rates, it's going to really require coordination between a variety of facilities. Most of you are from acute care facilities, but it is clearly nursing homes that need our help. You are not going to get your rates really down until you start being concerned [about that]. You are your brother's keeper, here."
Extended isolation, universal glove use considered
Core and supplemental infection control strategies for Clostridium difficile (C. diff ) discussed recently in Atlanta at the Fifth Decennial International Conference on Healthcare-Associated Infections included the following:
Core prevention strategies:
Contact precautions for duration of diarrhea.
Hand hygiene in compliance with Centers for Disease Control and Prevention/World Health Organization.
Cleaning and disinfection of equipment and environment.
Laboratory-based alert system for immediate notification of positive test results.
C. diff education for health care workers, housekeeping, administration, patients, and families.
Supplemental prevention strategies:
Extend use of contact precautions beyond duration of diarrhea (e.g., 48 hours).*
Presumptive isolation for symptomatic patients pending confirmation of C. diff infection (CDI).
Evaluate and optimize testing for CDI.
Implement soap and water for hand hygiene before exiting room of a patient with CDI.
Implement universal glove use on units with high CDI rates.*
Use sodium hypochlorite (bleach)–containing agents for environmental cleaning.
Implement an antimicrobial stewardship program.
* Not included in the CDC/Healthcare Infection Control Practice Advisory Committee (HICPAC) 2007 Guideline for Isolation Precautions.