Preventing Clostridium difficile Infection (CDI)—An Infection Preventionist’s Perspective

Jennie L. Mayfield, BSN, MPH, CIC
—Jennie L. Mayfield, BSN, MPH, CIC

Preventing Clostridium difficile Infection (CDI)—An Infection Preventionist’s Perspective
June 4th, 2010 5:34 pm ET -

One of the most challenging things I have been asked to do in my infection prevention career is a presentation on “Preventing C. difficile: What Works and What Doesn’t.” The list of what is research-proven to be effective is a short one—wearing gloves for contact with all body substances, changing from electronic rectal thermometers to disposable ones, and antibiotic stewardship. Beyond that, the data are tantalizing but not definitive, and the truth is, we don’t really know what will consistently work and what won’t really help. During outbreaks, I suspect many of us use what I call the ‘kitchen sink’ approach, i.e., several simultaneous interventions in the hopes that some combination of them will be effective. Unfortunately, when rates decrease, we’re not quite sure which intervention(s) actually worked. Some of this uncertainty is reflected in the recent poll of its members done by the Association for Professionals in Infection Control and Epidemiology (APIC).

The 2010 C. difficile infection (CDI) Pace of Progress survey was a follow-up to the 2008 APIC CDI prevalence study, which found rates to be much higher than previously thought. The 2010 poll was conducted to determine if facilities have increased interventions to prevent CDI in the interim.

The good news is that institutions are using multiple prevention strategies, as recommended in guidelines from the CDC and the Society for Healthcare Epidemiology of America (SHEA). These include hospital-wide hand hygiene initiatives, surveillance to promptly identify CDI cases, Contact Precautions to isolate patients with symptoms, and enhanced environmental cleaning practices. In addition, 78% of respondents have used the “APIC Guide to the Elimination of Clostridium difficile in Healthcare Settings” to identify and guide improvements.

The down side is that 34% of respondents felt their facilities should be doing more to prevent and control CDI, and only 23% have been able to add staff in the past 18 months. One of the most sobering findings is that 42% of respondents do not have an antimicrobial stewardship program, a research-proven effective intervention, due to lack of resources and/or knowledge.

The poll also showed wide differences in common day-to-day practices. Forty-six percent of participants do not know if their facility’s colectomy rate has increased; 38% isolate CDI patients until diarrhea has stopped while another 33% isolate for the entire hospital admission; and environmental cleaning protocols include the gamut from nothing special to only bleach all the time. We’re also unsure of the best way to monitor environmental cleaning, and we have a variety of hand hygiene policies and practices.

One thing we in healthcare know for certain is that Clostridium difficile is not going away any time soon. The results of the APIC CDI Pace of Progress report send two clear messages: the first is that more research is needed to identify the specific practices that prevent transmission of CDI and, second, Infection Preventionsts in the trenches need more resources to battle this insidious organism. More with less is not an intervention that will work.
http://blogs.cdc.gov/safehealthcare/?p=384