Dramatic reduction of C. diff infections in the UK an ‘indictment’ of U.S. struggles
‘Reputation costs’ of CDI reporting may spur culture change
By Gary Evans, Executive Editor
The dramatic reduction of Clostridium difficile infections (CDI) in hospitals in the United Kingdom is putting considerable pressure on American infection preventionists and health care epidemiologists to follow suit with similar success. Yet despite increasing infection prevention efforts in many U.S. hospitals, CDI is giving ground grudgingly if at all, according to a new survey of infection preventionists by the Association for Professionals in Infection Control and Epidemiology (APIC). (See related story,below)
Though there are numerous caveats about comparing nationalized health care in the UK to the complex multi-payer system in the U.S., the striking success of the Brits in reducing CDI is nothing less than an “indictment” of infection control in the U.S, said Dale Gerding, MD, a long-time C. diff researcher and a leading international expert on the pathogen. An associate chief of staff for research at the Hines VA Hospital and professor of medicine at Loyola University of Chicago, Gerding made the damning observation recently in Baltimore at a C. diff meeting held by APIC.
“The incidence [of C. diff] is stable in the North American population, but the rates in UK and the EU have really declined,” he said. “I think it is an indictment of all of us in this room that we haven’t been able to do that.”
The rate of CDI in the UK has dropped over 30% a year for several years, with the epidemic 027 strain — called NAP1 in the U.S. — going from 55% to 21%, he said.
“The challenge to all of us is if they can do it why can’t we?” Gerding said. “Of course they have a national health service. And several health service trust managers — or hospital directors as we would call them here — have lost their jobs because they did not take care of their C. diff rates. If they start to see one or two cases in an institution they bring in a team to start an investigation. They are very aggressive and maybe if [U.S.] hospital directors’ jobs were on the line we might have better results.”
Tough talk indeed, but there was also an undercurrent of skepticism in the audience of some 250 IPs that a similar national effort could be successfully applied in the U.S. Though it is currently killing some 14,000 patients a year, CDI has not stirred the national outcry and sensational press coverage that spurred the national prevention campaign in the UK. Essentially, a sweeping culture change has been achieved across the pond that hospitals in the U.S. do not appear ready to emulate.
“I think every infection preventionist in this room is ready,” said Vickie Brown, RN, MPH, CIC, director of infection prevention and control at WakeMed in Raleigh, North Carolina. “Do I think our health care organizations are ready — I would say no.”
A U.S. system of ‘perverse incentives’
To understand the difference between countries and medical cultures, consider a surprisingly frank assessment of the “perverse incentives” in the U.S. health care system by L. Clifford McDonald, MD, FACP, a leading C. diff expert at the Centers for Disease Control and Prevention.
“We are a fragmented health care delivery care system with multiple payers,” he said. “At the heart of it are perverse incentives. We hear or read all kinds of literature about the cost of an HAI (health care associated infection) or the cost of an adverse patient event, but what you don’t read very much about – because there is very little data on it – is what are a hospital’s margins on an adverse event? Hospital margins are not at all clear. Most of their costs are what is known as ‘fixed costs’ — you have all of these costs that go on. It is not always clear that hospitals lose money on HAIs. It’s just a fact.”
Though essentially suggesting that some health care systems may factor in HAIs as a part of the overall cost of doing business, McDonald added that hospitals may also seek out diagnosis-related groups (DRGs) that reimburse at higher levels — typically for care delivered in intensive care units.
“Sometimes they do [lose money on HAIs] because they are in a market where they could get a much higher reimbursing DRG,” he added. “This is where you will find sometimes that CFOs and CEOs are much more interested in the capacity of your ICU than anything else because you can get another higher-reimbursing DRG into an ICU after a CABG or something like that. This all has to do with why we have surgeons who don’t wash their hands and do whatever else they want, and no one from the central office ever jumps on them. Why? Because they bring in all these highly reimbursed DRGs that have a high positive margin. This is the underbelly — what we really don’t want to talk about. But this is the reality of what is going on in health care. It is a volume driven system. It is not a quality driven system. It is not an outcomes driven system.”
The Affordable Care Act includes measures designed to bring more accountability into the process, but the main driver to reduce infections like C. diff may ultimately be the “reputation costs” that come with publicly reporting infection rates, McDonald said.
“This is an intangilble, but CEOs and CFOs know about this,” he told APIC attendees. “They know that a long period of multiple events — where you end up in the headlines of your local media with the highest rates — [affects] reputation.”
A reputation for having high infection rates may in turn lead to providers admitting patients elsewhere and insurers offering preferential care deals to facilities that have a better CDI report card. “I think it is going to take quite a while, but this [HAI reporting] gets the C suite and the hospital boards involved,” said McDonald, prevention and response branch chief in the CDC’s Division of Healthcare Quality Promotion.
Though she originally questioned the value of public reporting of HAIs, Brown said a new reporting initiative for C. diff that began this January could actually be a key to reducing CDI rates. As of Jan. 1, the Centers for Medicare and Medicaid Services is calling for hospitals to report CDI “laboratory-identified events” to the CDC’s National Healthcare Surveillance System.
“I think it is a very good thing that organizations are being required to report C. diff lab events. We can start getting information on its impact and then that information is going to go out to the payers and the public,” said Brown, a former director on the APIC Board with 20 years’ experience in infection prevention. “That’s what our organizations and hospital boards respond to. They want to know how they are looking compared to everybody else — why they are looking worse than everybody else. I have seen over time that in a competitive health care environment if you have a public perception that your hospital is not performing as well [as others] that gets the attention of the organization on multiple levels – administrators, physicians, nurses and nurse leaders.”
Ultimately, C. diff reporting and the attendant reputation costs could provide IPs with more resources to reduce CDIs. While CDI rates have climbed to all-time highs in recent years, 77% of IPs polled in the aforementioned APIC survey said they have not been able to add staff to address the problem.
UK goes ‘bare below the elbows’
Additional resources may require a broader culture change and national recognition that C. diff is a major problem in the U.S. In the UK, they didn’t just roll up their sleeves — they got rid of them – going to a “bare below the elbows” campaign for health care workers. Stephen Parodi, MD, chief of infectious diseases for the Kaiser Permante Napa Solano Service Area in northern California, consulted with clinicians in the UK in trying to get a handle on C. diff problems at his health care system.
“There were a couple of things that really stood out to me. One is that they had an entire national campaign,” Parodi said. “It touched all facilities, not just the acute care facilities. They had an entire change in mindset. They chose to manifest this change in mindset with what they called the ‘bare below the elbows’ campaign. Essentially they got rid of white coats, ties, long sleeves – none of which, they freely say, was evidence based from the standpoint of reducing infections per se. But it had the purpose of changing culture, making people realize that when they walk into the hospital that this was a different setting. That this is a place that is clean and I am supposed to behave in a certain way.”
Moreover, all staff members in UK hospitals were empowered to remind their colleagues to follow infection control measures, including washing hands with soap and water and wearing gloves for C. diff patients.
“The other thing that stood out to me when they spoke to us was that they had a defined sort of escalation process for dealing with folks that missed opportunities to wear PPE or to degerm,” he said. “Generally it consisted of just someone actually coming up and reminding them, and everyone was empowered to do that. And [if that didn’t work] then it was escalated to the nurse ‘matron,’ as they call them, on the floor and if that didn’t work it got escalated further.”
That being said, C. diff is a complex multifaceted problem that goes beyond issues of individual compliance to system-wide programs like antibiotic stewardship. Again, the UK health care system may be more empowered to rein in antibiotics that trigger C. diff, but efforts are growing the U.S. Sixty percent of respondents to the APIC C. diff survey reported using antimicrobial stewardship programs at their facilities, up from 52% in 2010. As we reported in the last issue of HIC, the Agency for Healthcare Research and Quality has created a toolkit to guide implementation of antibiotic stewardship programs specifically aimed at reducing C. diff infections. (Available at http://ow.ly/jglNx)
“I think we are our own worst enemy when it comes to antimicrobial prescribing,” Gerding said, noting that UK hospitals have substantially reduced the cephalosporins and floquinolone drugs that are often linked to C. diff emergence. In contrast, antibiotic misuse and overuse has been a widely reported problem in the U.S. As a result, C. diff has moved beyond the hospital to a variety of other settings where antibiotics may be prescribed.
“It isn’t just nursing homes and hospitals but doctors and dentists offices, dialysis outpatient surgery,” Gerding said, citing CDC data.1 “Although half the infections are in people younger than 65 more than 90% of the deaths are in patients older than 65. The real zinger out of all this is that almost all — 94% — of the C. diff infections occurred in people who recently received medical care either in or out of a health care facility. In other words, outpatient exposures appear to be a big factor in terms of predisposing you to C. diff. There’s two ways that might occur. One is getting antibiotics from a health care exposure and [the other] is that health care facilities are probably contaminated with C. diff spores.”
The futility of Sisyphus
Indeed, C. diff spores are notoriously difficult to eradicate in the contaminated rooms of symptomatic patients, making housekeepers armed with bleach increasingly important members of medical teams. If that wasn’t challenge enough, Gerding’s research group recently published a study showing that soap and water hand washing fails to achieve significant log reductions in C. diff spore counts.2 “If you are looking for something to wash your hands with there are an awful lot of things that are no better than tap water,” he said.
Given the litany of obstacles to C. diff eradication, Parodi invoked the Greek myth of Sisyphus, a man condemned to roll a rock up a hill only to watch it roll back down again. “Is this a Sisyphean task – are we being called to do something that is impossible?” he asked. That from a physician who spearheaded an effort that reduced CDI by 57% in Kaiser Permanente hospitals.
“We felt pretty good about that, but we are not sure if that’s enough,” he said, showing a comparative slide of his best-performing hospitals with CDI rates still two or three times higher than UK facilities.
“This is not just a hospital problem — this is a community problem,” he said. “Certainly what we have seen at Kaiser Permanente are patients from LTACs (long term acute care) and skilled nursing facilities that are contributing to the C. difficle burden. It’s occurring in the hospitals and also in the outpatient settings.”
At its peak in 2008, C. diff was accounting for 2% of all patient mortality in the northern California hospital group, he said. Though achieving substantial success in reducing CDIs, Parodi said the desired culture change remains a work in progress. Anecdotes shared at a recent infection control meeting included people still not washing their hands and a worker leaving gloves on and washing them between patients, he said. The latter cardinal sin drew an understandable reaction from the IPs in attendence, who know they face similar situations when they return to their facilities and rejoin the battle against C. diff. It is a formidable challenge that requires commitment and action on multiple fronts.
‘We are not promising any silver bullets,” said APIC president Patti Grant, RN, BSN, MS, CIC. “I think all of you in this room know there is not one [single] answer in the fight against CDIs. But for lack of a better term, we’ve got superbug C. diff out there and people do die from this – we know that to be true.”
- Centers for Disease Control and Prevention. Vital Signs: Preventing Clostridium difficile Infections. MMWR 2012;61(09):157-162.
- Edmunds SI, Zapka C, Kaspar D, et al. Effectiveness of hand hygiene for removal of Clostridum difficle spores from hands. Infect Control Hosp Epi 2013;34:302-305.
APIC issues new C. diff guidance
The Association for Professionals in Infection Control and Epidemiology (APIC) has published new revised and expanded guidance on the difficult task of preventing Clostridium difficile infections (CDIs). (See editor’s note below.) Compiled by a team of infection prevention experts, the APIC guide has a section on frequently asked questions that includes the following:
Is antibiotic therapy the only risk factor for CDI?
Patients who receive any medical care in any medical setting, patients with nasogastric tubes, prolonged hospital stays, gastric suppression with PPIs and hydrogen pump blockers, steroids, other immunosuppressors, and antibiotic therapies have increased risk of developing CDI. Advanced age is also a risk factor.
Which antibiotics are most frequently implicated in causing CDI?
Antibiotic therapy alters the normal gut flora. Although ampicillin, amoxicillin, cephalosporins, clindamycin, and fluoroquinolones are most frequently linked to CDI, most antibiotics predispose patients to CDI.
When should a patient with C. difficile be removed from contact isolation?
In normal situations, a patient with CDI can be removed from contact isolation when diarrhea resolves; however, some organizations recommend continuing contact precautions for at least 48 hours after diarrhea resolves. If there is an outbreak or evidence of ongoing C. difficile transmission, consider extending contact isiolation until the patient is discharged, or extending isolation until the patient is without diarrhea for 2 days.
How do we determine if diarrhea is due to C. difficile or from some other cause of diarrhea?
The best way to rule out C. difficile as a cause for diarrhea is to perform appropriate testing on nonformed stool. Several tests are available to identify C. difficile. These include tissue culture cytotoxicity assay, enzyme-linked immuno-absorbant assay (ELIZA), polymerase chain reaction (PCR), and glutamate dehydrogenase (GDH) testing. Each method varies based on cost, sensitivity, specificity, and technical expertise. It is important to understand the type of test being used and the risk of false-positive and false-negative results as this information may influence a clinician’s diagnosis.
What is the risk of transmission by asymptomatic carriers?
An individual without symptoms (i.e., diarrhea) is not thought to be a likely transmitter of C. difficile. At this time there is no support for testing of patients because not all carriers develop CDI and there are no recommended prophylaxis or decolonization methods. Remember that not all C. difficile is alike in that some are not toxin producers and some produce the hypervirulent toxin. If asymptomatic individuals are tested, not only are they subject to the sensitivity and specificity constrains of the testing, we are left not knowing what the results mean. This is a basis for the recommendation that a “test of cure” not be done.
How do we prevent the spread of C. difficile from ambulating patients and their families?
Engage your patients and their families in education about the transmission and prevention of C. difficile through hand hygiene, environmental cleaning, PPE, and containing or minimizing diarrhea and loose stools. Encourage them to comply with contact precautions by limiting their movement until their diarrhea has subsided.
Editor’s note: The complete “Implementation Guide to Preventing Clostridium difficile Infections” is available on the APIC website at http://www.apic.org/