C. diff can be eradicated with aggressive effort

More sensitive test spurs hospitalwide effort

Clostridium difficile infections (C. diff) can be reduced sharply by aggressive, targeted infection control efforts that include interventions across various hospital departments.

"We had an increase, and we aggressively attacked it with the implementation of infection control programs specifically for C. diff," says Deoine Reed, PhD, infection control coordinator at Ochsner Clinic Foundation in New Orleans.

Interestedly, the increase in C. diff infections coincided with the introduction of a more sensitive test for the pathogen at the hospital.

"We began using a more sensitive assay; and as a result of that, we saw an increase in March of 2003," she explains. "It continued to increase into the early fall, and we decided to [take action]. C. diff had never really been much of an issue prior to this transition to this new assay. Before we were detecting only [C. diff] toxin A, and we switched to an assay that detects both A and B toxins. I think with the inclusion of the B, perhaps we began seeing more strains. They were real [infections] because the patients had the symptomatology that went along with it — the diarrhea and such."

From January 2002 to February 2003, the median number of nosocomial C. diff infections was 8.7. After March 2003, with the introduction and continued use of the more sensitive test, C. diff cases increased nearly fourfold. A multidisciplinary team was assembled that included members from infection control, performance improvement, microbiology, hospital nurses and physicians, pharmacy, informatics systems, environmental services, hospitality services, and ancillary clinical services.

Policies were written for patients with C. diff infections regarding isolation placement, barrier precautions, hand hygiene, and environmental cleaning. In particular, environmental services established the use of a hypochlorite rather than detergent cleaning.

"We had continued to clean as usual, but C. diff is not killed by regular detergent," Reed says. "You need a bleach solution to kill it; so even when we were wiping down surfaces, we weren’t killing the organism in the environment. So we put into place a policy of cleaning, and since we know that C. diff is spread by contact, we increased our hand-hygiene awareness."

Indeed, an emphasis was placed on traditional soap and water hand washing because alcohol hand rubs do not remove the spore-forming bacillus. With workers’ hands accounted for, a focus on fomites was added that included use of disposable meal trays and eating utensils for C. diff patients. "We also use dedicated [medical] equipment in taking care of these patients," she adds.

Within a month after the measures were put in practice, the troublesome pathogen began dropping off the radar screen. The number of C. diff cases dropped from 33 in September 2003 to seven, nine, and eight cases in October, November, and December, respectively. Fully aware that C. diff will recur in some patients, program planners developed a home care handout for discharged patients and their family members. (See handout.)

Take-home points

The following is a summary of some of the key features of the C. diff prevention program established by Reed and colleagues:

  • Barrier precautions

Contact precautions in addition to standard precautions are followed when caring for patients with C. diff infection. The door sign for the C. diff patients was changed. New signage clearly states the important engineering and work-practice controls for staff and visitors to follow. Hand washing and wearing of gloves and gowns for contact with patients with diarrhea were emphasized.

  • Hand hygiene

A hand-washing education campaign was launched to train medical staff on the use of soap and water vs. alcohol sanitizer for C. diff patients. Signs illustrating contact spread organisms were posted throughout the institution.

Additionally, signs demonstrating correct hand washing techniques (according to CDC hand hygiene recommendations) were posted in all restrooms throughout the institution.

  • Environmental cleaning

Environmental services established the use of hypochlorite rather than detergent cleaning alone. Careful, standard cleaning routines with the hospital-approved agents are adequate in most instances. However, upon discharge, the room requires terminal cleaning with a 1:10 bleach solution. All trash is treated as regulated waste and placed in red bags.

  • Departmental interactions

Infection control staff began active surveillance of C. diff infections in coordination with nursing, environmental services, and dietary departments. Once infection control receives confirmed positive results from the microbiology laboratory, nursing, environmental services, and dietary care are notified. Computerized notifications were established to provide real-time information to staff members involved with direct care of patients with C. diff.