Hospitals increase efforts, but C. diff persists

IPs reaching point of being ‘maxed out’

Despite increased infection prevention efforts in many hospitals, Clostridium difficile infection (CDI) remains a persistent threat to patient safety, according to a new survey of infection preventionists by the Association for Professionals in Infection Control and Epidemiology (APIC).

Though 70% of responding IPs reported increasing C. diff interventions, 43% of the IPs surveyed said CDI rates have not declined.

“This is very concerning to me because it implies prevention activities are up, but we are not seeing an impact,” said Jennie Mayfield, BSN, MPH, CIC, APIC president-elect and a clinical epidemiologist at Barnes-Jewish Hospital in St Louis. “That makes me wonder if we need to know more about the basic science and epidemiology. Are we individually spinning our wheels and not really able to focus on the things that might be working? This [finding] is a concern because it tells me we still aren’t sure what to do and what really works.”

Released recently at a C. diff conference in Baltimore, the APIC survey also cited staffing woes in infection control departments. While CDI rates have climbed to all-time highs in recent years, 77% of IPs surveyed said they have not been able to add staff to address the problem, Mayfield said.

“Twenty-one percent were able to add staff and that’s encouraging, but we still have a ways to go,” she told conference attendees. “I know at my facility we are starting to reach the point where we are maxed out, and we are not going to be able to take on a lot more without giving something else up.”

APIC conducted the 2013 CDI Pace of Progress survey in January 2013 to assess activities that have been implemented in U.S. healthcare facilities in the last three years to prevent and control CDI. A total of 1,087 APIC members completed the survey, which is intended to provide a general overview of trends and indicate areas where more in-depth research might be beneficial. The majority of survey respondents work in acute care settings (78%). Respondents also work in long term care (9%), ambulatory care (4%), and other settings (9%) such as long-term acute care, rehabilitation, behavioral health, and hospice.

“Over half of the respondents that knew whether or not C. diff was declining in their institutions, said ‘No, it’s not,” said Stephen Parodi, MD, chief of infectious diseases for the Kaiser Permante Napa Solano Service Area in northern California. “Of those who don’t know [whether CDI is declining] I have to wonder whether they don’t know because they don’t have the ability to surveil it in an accurate fashion or they just don’t know at all.”

Approaches to CDI prevention appear to vary widely, both in diagnostic testing and duration of contact isolation for infected patients. Concerning the latter, 42% of respondents keep CDI patients in isolation for the duration of their stay. A quarter keep CDI patients in isolation until treatment has started and there has been no diarrhea for 48 hours. There is no national practice recommendation for discontinuation of contact precautions for CDI, APIC noted.

“We don’t have answers to some of the critical questions — testing methodologies are varied across institutions, duration of isolation is all over the map,” Parodi said.

IPs are battling back

While C. diff has clearly won the early rounds, infection preventionists are making some progress in the fight to prevent CDIs. Perhaps most importantly, antimicrobial stewardship programs are slowly increasing. Sixty percent of survey respondents are using antimicrobial stewardship programs at their facilities, compared with 52% in 2010. Because antimicrobial use is one of the most important risk factors for CDI, stewardship programs that promote judicious use of antimicrobials should be encouraged, APIC urged.

Other APIC survey findings include:

  • Health care facilities are making CDI a tracking and monitoring priority. Three-quarters of respondents were actually performing surveillance for CDI before the Centers for Medicare & Medicaid Services reporting requirements went into effect in January 2013.
  • A known killer of C. diff, bleach is widely used over many less effective cleaners. Two-thirds of respondents (67%) use bleach for all daily and discharge cleaning of rooms with CDI patients. Moreover, new tech weapons are being brought to bear on the persistent spores, as 9% of respondents report using at least one of the emerging disinfection technologies such as ultraviolet light or vaporized hydrogen peroxide.
  • More than three-quarters of facility policies (77%) promote soap and water hand wash for CDI patients, but also have alcohol-based hand rubs (ABHR) available on the units. Fifteen percent of facilities surveyed also promote soap and water hand washing for CDI patients but do not provide ABHR in patient care areas. Ten percent of respondents indicate that their policy requires the use of soap and water hand washing for CDI patients in outbreak situations, and 8% said their hand hygiene policy is the same for CDI and non-CDI patients. Current opinions regarding the use of hand washing with soap and water instead of ABHR are conflicting. Recommendations on the use of soap and water in outbreak settings are based on the theoretical benefit of physical removal and dilution of spores by friction and rinsing rather than definitive evidence, APIC noted.
  • Environmental cleaning programs have been enhanced, but monitoring the effectiveness of cleaning has not kept pace. More than nine in 10 respondents (92%) have increased the emphasis on environmental cleaning and equipment decontamination practices since March 2010, but 64% said they rely on observation, versus more accurate and reliable monitoring technologies to assess cleaning effectiveness. Fourteen percent said that nothing was being done to monitor room cleaning. Because C. diff spores can survive in the environment for many months and are highly resistant to cleaning and disinfection, environmental cleaning and disinfection are critical to prevent the transmission of CDI, APIC reminded.
  • Those who have not adopted more aggressive CDI prevention measures already have strong programs in place. Among those who have not adopted more aggressive measures to combat CDI in the last three years, the most common reasons cited were best practices were already in place (65%); CDI was not identified as a high-priority problem for their facility (37%); there is an infection control plan to increase interventions in the event of an outbreak (34%); and CDI rates are declining with current practices (18%).
  • Patient education lags behind provider education. Eighty-five percent of survey respondents say they or others at their facility have participated in educational offerings about CDI. Only 50% have initiated patient education programs about CDI.
  • Nearly a third of respondents (30% percent) have participated in CDI learning collaboratives. Learning collaboratives bring together hospitals and health facilities in a specific region to share best practices, provide training, and implement successful prevention approaches, APIC noted.