Measures to control and prevent Clostridium difficile infection.

Abstract

Clostridium difficile infection (CDI) rates in the United States have tripled from 2000 to 2005, and disease morbidity and mortality have increased, particularly among elderly persons. Clearly, there is a need for more-effective infection control and prevention measures to reduce CDI incidence and disease severity. Infection control measures for C. difficile involve 2 major approaches: preventing ingestion of the organism and its spores by patients and reducing the chance of developing CDI in the event of such ingestion.Measures to control and prevent Clostridium difficile infection.Strategies to achieve the former approach consist of traditional infection control strategies that target the environment, personnel hygiene, and barrier methods, whereas strategies for reducing disease are mainly focused on minimizing or eliminating antimicrobial exposure, particularly when use of these agents is unnecessary. The latter approach is often termed “good antimicrobial stewardship.”Measures to control and prevent Clostridium difficile infection.

Environmental Control, Personnel Hygiene, and Barrier Methods

All hospitals should actively monitor the severity and rate of hospital-acquired CDI as part of their infection control programs, so they can determine whether the rate is acceptable and quickly detect any increases in the CDI incidence, CDI-associated mortality rate, and colectomy rate. Comparison of rates within a hospital to rates at other hospitals for benchmarking is complicated by the variety of measures used to monitor CDI “rates,” including laboratory findings (i.e., positive results of C. difficile toxin tests), International Classification of Diseases, Ninth Revision codes for CDI, and laboratory findings combined with clinical symptoms (i.e., positive results of a C. difficile toxin test in conjunction with defined clinical symptoms), which is the most accurate method. Even when prospective surveillance is done, different case definitions and denominators are often used, making the creation of case comparators impossible. Measures to control and prevent Clostridium difficile infection.Two interventions have been shown to be effective at interrupting disease transmission during CDI outbreaks: disinfection with hypochlorite to minimize environmental contamination, and use of effective barrier precautions (particularly gloves) during patient contact to prevent transmission.Measures to control and prevent Clostridium difficile infection.

Although the efficacy of gown use during routine care of patients with CDI has not been adequately studied, intuition suggests that it is a viable precaution, because it prevents contamination of clothing. The CDC recommends that gowns be used during the care of patients with CDI.Measures to control and prevent Clostridium difficile infection.

Because patients are often discharged during the course of therapy for CDI, the principles discussed to this point should apply to the home and other venues to which patients are discharged, especially long-term care or rehabilitation facilities where other susceptible patients may reside. Fortunately, the risk of environmental contamination is markedly reduced once diarrhea has stopped. Additionally, the likelihood that other household inhabitants are taking antimicrobials—a major risk factor for CDI—is low. Although it may be more difficult to implement in the home, cleaning bathroom surfaces with diluted hypochlorite and washing hands with soap and water may help reduce the likelihood of recurrent disease as a result of reinfection of the patient.Measures to control and prevent Clostridium difficile infection.

Other Management Issues

Feeding tube use. A prospective cohort study of 76 consecutive hospitalized patients who were and 76 who were not using a feeding tube found that tube feeding was an independent risk factor for the acquisition of CDI (OR, 3.1; 95% CI, 1.1–8.7; P=.03) [50]. The investigators suggested that tube-fed patients may have acquired C. difficile from the hands of health care workers during routine handling of the feeding tube system; that formulas and delivery systems might have been contaminated with C. difficile; that formulas might have lacked dietary fiber, resulting an intestinal environment favorable to the growth of C. difficile; and that delivery of formulas below the gastric acid barrier might have promoted the introduction and survival of C. difficile [50]. Although the composition of formula is not readily modifiable, glove use by health care workers during handling of feeding tube systems may reduce the CDI risk; however, no studies are available to confirm the efficacy of such a precaution.Measures to control and prevent Clostridium difficile infection.

Conclusion

Control of CDI outbreaks presents substantial challenges to hospital infectious diseases specialists, epidemiologists, infection control practitioners, frontline clinicians, environmental services departments, and hospital administrators, as well as to patients and their families. Effective measures are available to reduce environmental contamination with C. difficile and to prevent the spread of this pathogen by workers and equipment. However, compliance with enhanced environmental cleaning and contact precautions must be closely monitored if these measures are to have an impact during outbreaks of CDI. Programmatic approaches to enhance antimicrobial stewardship are part of the multifaceted interventions to prevent CDI. Close collaboration among the aforementioned individuals and departments is necessary to combat the escalating challenges provided by C. difficile. Education of all personnel involved in the care of patients with CDI is essential.Measures to control and prevent Clostridium difficile infection.