Preventing Transmission of C. difficile: Practice

Elise Tamplin, M(ASCP), MPH, CICBrigham & Women’s Hospital

Objectives

• Discuss practical challenges in implementing infection control measures

• Illustrate the value of periodic assessment of compliance

BWH healthcare-associated CDI rates

0.860.78

1.19

0.781

1.121.29

1.06

1.55

1.01

00.20.40.60.8

11.21.41.61.8

Jan-M

ar0

4

Apr-

Jun04

Jul-

Sep04

Oct

-Dec0

4

Jan-M

ar0

5

Apr-

Jun05

Jul-

Sep05

Oct

-Dec0

5

Jan-M

ar0

6

Apr-

Jun06

Jul-

Sep06

Oct

-Dec0

6

Jan-M

ar0

7

Apr-

Jun07

Jul-

Sep07

Oct

-Dec0

7

Jan-M

ar0

8

Apr-

Jun08

Jul-

Sep08

Num

ber

of CD

I c

ase

s per

1000 p

ati

ent

days

*Excludes NICU

CDI leading to colectomy and/or death:Nosocomial & non-nosocomial cases

0

1

2

3

4

5

6

7

8

Jan-

Mar

04

Apr-J

un04

Jul-S

ep04

Oct-Dec

04

Jan-

Mar

05

Apr-J

un05

Jul-S

ep05

Oct-Dec

05

Jan-

Mar

06

Apr-J

un06

Jul-S

ep06

Oct-Dec

06

Jan-

Mar

07

Apr-J

un07

Jul-S

ep07

Oct-Dec

07

Jan-

Mar

08

Apr-J

un08

Jul-S

ep08

Nu

mb

er o

f ca

ses

Death Colectomy Colectomy +/- Death

Challenges

• Preventing acquisition/transmission• Improving outcomes for patients with

CDI

CDI Control Interventions

• Sentinel event and root cause analysis• Increase case finding & early identification

—quicker lab turn around time• Enhance Infection Control measures • Aggressive CDI management & surgical

evaluation (BWH CDI Treatment Guidelines)• Staff education• Minimize antibiotic utilization

Laboratory Testing

• Change in test methodology– Cytotoxicity assay to EIA

• From 3 day TAT to same day results– Lower sensitivity– Need for clinical judgment in

interpretation of negative result– Increased possibility of false negatives if

specimen taken while on antibiotics

Basic Infection Control Practices

• Hand hygiene• Contact precautions for infected patients• Ensure cleaning and disinfection of

equipment and the environment• Implement a laboratory-based alert

system• Conduct CDI surveillance• Educate patients and families about CDI

Special ApproachesSpecial Approaches to prevent transmission by healthcare personnel

• Perform hand hygiene with soap and water after contact with a patient with CDI– Pro:Pro: Alcohol is not sporicidal– Con:Con: Hand hygiene compliance is lower

for handwashing with soap and water vs. use of an alcohol-based hand disinfectant

Special ApproachesSpecial Approaches to prevent spread through the environment

• Use a hypochlorite-based room cleaning agent– Pro:Pro: Sporocidal and benefit has been

reported in outbreak settings– Con:Con: Can corrode equipment and can be

a chemical irritant for patients and staff

Special ApproachesSpecial Approaches to prevent transmission by healthcare personnel

• Prolong the duration of contact precautions after the patient becomes asymptomatic until hospital discharge– Patients may shed C. difficile in their

stool after diarrhea resolves

Bobulsky GS et al. Clin Infect Dis 2008; 46:447–50

New Infection Control Measures

• Enhancements to Contact Precautions• Contact Precautions Plus

– Soap & water hand hygiene– Hypochlorite based disinfectant-

detergent upon discharge/transfer– Precautions for duration of admission

Contact Precautions PlusPlus

• Discontinuation upon cessation of symptoms problematic

• Administration buy-in required for continuation during entire admission

• Automated “flag” developed by IS like those for MRSA & VRE but expiring upon discharge

• Education of Admitting staff re empiric precaution status

Soap & Water Hand Hygiene

• Major change from routine use of waterless hand sanitizer

• Visibility of sign key issue– Several design changes

• Sink availability challenging– Few in central areas of inpatient units– Reluctance to use patient room sink– Hand washing 101

Do not remove sign until after room has been cleaned

*Bleach-based

Hypochlorite Disinfectant

• Infection Control & Safety approvals

• Odor/symptom complaints from staff- OHS evaluation/tracking- MNA discussion re safety concerns- Evaluation of new products- Change from liquid to impregnated wipes

- Adequacy of surface wetting evaluated

Hypochlorite Disinfectant

• Compliance with use– Tracking mechanisms

Daily patient log from Infection Control to Environmental Service

Some rooms still missedDaily review/verification by ES &

return to Infection Control– Signs taken down before cleaning

CPP room status added to housekeeping page

Staff Education

• Physicians– Early severe patient outcomes helped– M&M conferences, Grand Rounds, etc.

• Nursing– Empiric precautions– Specimen collection prior to treatment

Staff Education

• Support (Environmental Services)– Balance between emphasis on need for

special measures vs. fostering undue personal safety concerns

– Regroup with supervisors• Administrative (Admitting)

– Achieving support for empiric precautions

CDI Management Guidelines

• Consensus document– Infection Control– Infectious Disease– Medical Intensive Care– General Surgery– Microbiology– Pharmacy– Nursing

CDI Management Guidelines

• Infection Control Precautions• Diagnostic testing• Clinical management of patients

CDI Management Guidelines

• Clinical categories based on specific clinical criteria– Appropriate management for each

Stop non-essential medications antimicrobials & antiperistaltics

Appropriate antibiotic therapyInfectious Disease & Surgical consultsRectal vancomycin (when & how)

BWH healthcare-associated CDI rates

0.860.78

1.19

0.781

1.121.29

1.06

1.55

1.01

0.740.50.60.50.60.60.50.50.6

0.70.7

0.55

0.790.69

0.63

00.20.40.60.8

11.21.41.61.8

Jan-M

ar0

4Apr-

Jun04

Jul-

Sep04

Oct

-Dec0

4Ja

n-M

ar0

5Apr-

Jun05

Jul-

Sep05

Oct

-Dec0

5Ja

n-M

ar0

6Apr-

Jun06

Jul-

Sep06

Oct

-Dec0

6Ja

n-M

ar0

7Apr-

Jun07

Jul-

Sep07

Oct

-Dec0

7Ja

n-M

ar0

8Apr-

Jun08

Jul-

Sep08

Oct

-Dec0

8Ja

n-M

ar0

9Apr-

Jun09

Jul-

Sep09

Oct

-Dec0

9Ja

n-M

ar1

0

Num

ber

of CD

AD

case

s per

1000

pati

ent

days

*Excludes NICU

Contact Precautions Plus

BWH Treatment Guidelines

Severe CDI leading to colectomy+/-deathNosocomial vs. non-nosocomial

0

1

2

3

4

5

6

7

8

Jan-

Mar

04

Apr-J

un04

Jul-S

ep04

Oct-Dec

04

Jan-

Mar

05

Apr-J

un05

Jul-S

ep05

Oct-Dec

05

Jan-

Mar

06

Apr-J

un06

Jul-S

ep06

Oct-Dec

06

Jan-

Mar

07

Apr-J

un07

Jul-S

ep07

Oct-Dec

07

Jan-

Mar

08

Apr-J

un08

Jul-S

ep08

Oct-Dec

08

Jan-

Mar

09

Apr-J

un09

Jul-S

ep09

Oct-Dec

09

Nu

mb

er o

f ca

ses

Nosocomial Other source

Contact Precautions Plus

Objectives

• Discuss practical challenges in implementing infection control measures

• Illustrate value of periodic assessment of compliance