Clostridium difficile Infections in Long Term Care Facilities
Emily Lutterloh, MD, MPH
Director, Bureau of Healthcare Associated Infections
New York State Department of Health
General Information
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Objectives
After watching the program participants will be
able to:
• Recall routine C. difficile prevention practices
• Describe how to control C. difficile outbreaks
• Discuss C. difficile testing methods and the indications and contraindications for C. difficile testing
Outline
• Background
• Environmental cleaning and disinfection
• Brief topics:
– Hand hygiene and PPE
– Patient placement
– Testing for CDI
– Antimicrobial stewardship
– National Healthcare Safety Network (NHSN)
– How NYSDOH can help you
• Summary
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Background
• CDC “Vital Signs”, March 2012*
– C. difficile infections (CDIs) at a historic high
– 14,000 deaths per year in U.S.
• 400% increase from 2000 to 2007
•Age‐adjusted Rate of C. difficile as the Primary (Underlying)
Cause of Death.
Source: CDC National Center for Health Statistics, 2012 *http://www.cdc.gov/vitalsigns/HAI/index.html
Background
• CDC “Vital Signs”, continued
– 25% of CDIs occur in hospitalized patients, and
75% of CDIs occur either in nursing home patients or in persons with recent outpatient treatment
– About 50% of infections occur in persons ≥65, but
>90% of deaths occur in persons ≥65
• It has been shown that prevention programs can reduce CDI rates
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Environmental Cleaning
and Disinfection
• “Cleaning” is the removal of visible soil (organic and inorganic material) from objects and surfaces
– Cleaning is critical for disinfection to be effective
– Detergents
• No antimicrobial claims
Environmental Cleaning
and Disinfection
• “Disinfection” is the thermal or chemical destruction of microorganisms
– Not equivalent to sterilization
– May not destroy all microbial forms, e.g. spores
– Disinfectant
• Substance applied to inanimate objects to destroy microorganisms
• “Hospital disinfectant” registered with EPA for use in medical facilities
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Disinfection when there is Elevated Concern about C. difficile
• CDI patient rooms, outbreak situations, and possibly throughout units with high endemicity or with ongoing transmission
– Clean
– Disinfect with 1:10 sodium hypochlorite solution (bleach and water) or an EPA‐registered disinfectant with a sporicidal claim
Disinfection when there is Elevated Concern about C. difficile
– Verify compatibility of equipment
with the bleach solution
– Training
• How to dilute and use
• Be aware that hypochlorite concentration decreases with time
• Don’t mix with other solutions
– Consider providing bleach wipes for use by healthcare workers
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Routine Disinfection
• Routine situations with no elevated concern about CDI
– Clean
– Disinfect with an EPA‐approved germicide
– Disinfectant wipes for use by healthcare workers
– Why not always use bleach‐based products?
• Can cause corrosion/pitting of some equipment and surfaces over time
• Concerns such as respiratory irritation
Environmental Services Staff
• Involve and engage Environmental Services staff, especially front‐line staff
– Infection prevention is a major part of their job!
– …and they need to know that
– and be trained with infection prevention in mind
– and routinely engaged in infection prevention activities related to environmental services
– and receive appropriate feedback in a
non‐punitive manner
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Environmental Services Staff
– Produced by the Illinois Department of
Public Health
– www.notjustamaidservice.com/
– www.youtube.com/notjustamaidservice
Monitoring of Environmental Cleaning and Disinfection
Carling PC, Bartley JM. Evaluating hygienic cleaning in health care settings: what you do not know can harm your patients.
Am J Infect Control. 2010;38:S41–50.
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Monitoring of Environmental Cleaning and Disinfection
• “…most near patient surfaces are not being cleaned in accordance with existing hospital policies…”
• “…patients admitted to rooms previously occupied by patients with hospital pathogens have a substantially greater risk of acquiring the same pathogen than patients not occupying such rooms.”
• Disinfection and cleaning “can be improved on average more than 100% over baseline” and “such improvement has been associated with a decrease in environmental contamination…”
Approaches to Environmental Monitoring
• “Conventional”
–
–
–
–
Subjective, visual
Deficiency‐oriented
Episodic
Feedback about problems
• “Enhanced”
–
–
–
–
Objective, quantitative
Performance‐oriented
Ongoing, cyclic
Feedback about performance
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Monitoring Methods
•
•
•
•
•
Direct covert practice evaluation
Swab cultures
Agar slide cultures
Fluorescent markers
ATP bioluminescence
Direct Covert Practice Evaluation
• Observer monitors cleaning and disinfection using a checklist
– Observation and recognition issues
• Conceptually easy but logistically might
be challenging
• Resource needs
– Staff time to observe cleaning and disinfection
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Fluorescent Markers
• Fluorescent gel, powder, or lotion used to mark surfaces before room cleaning;
UV light used to look for fluorescent marks
after cleaning
– Gels might be preferred – invisible when dry
– Physical removal of the marker used as a proxy to indicate that the item or surface was cleaned
– Same person should place markers and look for markers after cleaning, using checklist both times
• Resource needs
– Staff time
– UV light, fluorescent markers
Items and Surfaces of Concern
• Daily cleaning
– Bed, bedrails, furniture
– Commodes
– Bathrooms (sink, floor, tub/shower, toilet)
• High‐touch surfaces and items
– Light switches, door knobs, call bell, monitor cables, computer touchpads, monitors, medical equipment (e.g. IV fluid pumps)
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Monitoring Checklist
• http://www.cdc.gov/HAI/prevent/prevention_tools.html
• Checklists can be used regardless of
monitoring method chosen
• Excel spreadsheet with pre‐set
calculations available for use when
monitoring multiple rooms
• Use CDC checklist, or modify as
needed for your facility
For more information…
• http://www.cdc.gov/HAI/toolkits/Evaluating‐
Environmental‐Cleaning.html
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Hand Hygiene and PPE
• Alcohol‐based hand rub does not kill
C. difficile spores
– But do not remove dispensers in the face of
C. difficile
• Soap and water mechanically removes spores
– Imperfect
Hand Hygiene and PPE
• Non‐outbreak settings
– Alcohol‐based hand rub probably okay after caring for patients with CDI (recommendations vary)
• Consider pros and cons for your facility
• No studies have found increased CDI transmission when alcohol‐based hand rub is used
• Decreased transmission of MDROs (MRSA, VRE)
• Better adherence
• Outbreaks/high endemic rates
– Soap and water after caring for patients with CDI
• Transmission presumed, so want to use best method of hand hygiene
• Requires careful communication of recommendations
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Hand Hygiene and PPE
• Contact precautions – gown and gloves
• Gloves
– Because it’s difficult to remove spores with hand hygiene, glove use is critically important
to prevent contamination of hands
– Consider implementation of universal glove use (for all patients) on units with outbreaks or high endemic rates
• Imperfect efficacy of and adherence to hand hygiene
• Potential transmission from asymptomatic carriers
Asymptomatic Carriers
– Rationale for universal glove use when CDI rates are high
Riggs MM, Sethi AK, Zabarsky TF, et al. Asymptomatic carriers are a potential source for transmission of epidemic and
nonepidemic Clostridium difficile strains among long‐term care facility residents. Clin Infect Dis. 2007;45:992–8.
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Patient Placement
• Private room preferred
– Prioritize for patients needing isolation
• If not possible, cohort with others with the same organism
• If no private room and can’t cohort
– ≥ 3 feet of separation
– Draw privacy curtain
– Consider roommate risk factors (immunosuppression, recent antibiotic use, etc.)
Patient Placement
• Make appropriate plans for bathroom vs. commode use for CDI patients
– Private bathroom preferred
– Avoid sharing with non‐CDI patients unless thoroughly cleaned and disinfected between uses
– Consider commode use
• For non‐CDI roommate or resident sharing bathroom?
• For CDI patient?
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Testing for CDI
• Difficult to grow on conventional culture media (hence the name “difficile”)
• Infection caused by strains that produce toxins
• Need non‐culture‐based testing methods that detect toxigenic strains
Testing for CDI
• Test for C. difficile toxins
– Enzyme immunoassay (EIA) for toxin A, B, or both
• Test for C. difficile antigen
– EIA for glutamate dehydrogenase (GDH)
• Test for C. difficile DNA (nucleic acid amplification test – NAAT)
– Polymerase chain reaction (PCR)
• Test for the C. difficile organism
– Culture
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Testing for CDI
• EIA for toxins
– Most common test
– Not as sensitive as some other tests
• EIA for GDH
– Very good at ruling out CDI – negative result
is reliable
– Often used in a 2‐ or 3‐step algorithm
Testing for CDI
• PCR
– Very sensitive and specific
– More expensive
– Many hospitals switching to this method despite the increased cost because of the importance of diagnosing CDI quickly and correctly
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Testing for CDI
• Know which type of test your facility uses
• Know who NOT to test
– Asymptomatic
– Recovered as a “test of cure”
– For the purpose of deciding whether to remove Contact Precautions
• What about repeat testing after a negative?
– Decide based on whether patient still has diarrhea
– Use a more sensitive testing method if possible
Antimicrobial Stewardship
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Antimicrobial Stewardship
• The future?
“SHEA, IDSA, and PIDS recommend that the Centers for
Medicare and Medicaid Services (CMS) require participating
healthcare institutions to develop and implement antimicrobial
stewardship programs. This can be achieved by incorporating
the requirement into existing regulations via expansion of
interpretive guidelines of the relevant regulation(s). All
healthcare facilities, including hospitals, long‐term care
facilities, long‐term acute care facilities, ambulatory surgical
centers, and dialysis centers should develop and implement
an antimicrobial stewardship plan that is modeled after the
IDSA and SHEA “Guidelines for Developing an Institutional
Program to Enhance Antimicrobial Stewardship.”*
* Policy Statement on Antimicrobial Stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hospital Epidemiol. 2012;33:322‐7.
Antimicrobial Stewardship
• May be difficult to set up a full program in the long‐term care setting
• Has been shown to reduce CDIs*
• General precepts
– Narrow spectrum agents whenever possible
– Treat infections, not contaminants
– Appropriate duration
– Broad spectrum agents usually only for serious infections before the pathogen is known
* http://www.cdc.gov/getsmart/healthcare/support‐efforts/asp‐int‐cdiff.html
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Antimicrobial Stewardship
• Challenges in long‐term care
– Asymptomatic bacteriuria
– Respiratory illnesses
Antimicrobial Stewardship
• Guidelines for long‐term care
– http://www.cdc.gov/getsmart/healthcare/learn‐from‐
others/factsheets/longterm‐care.html
– http://www.shea‐online.org/
GuidelinesResources/
FeaturedTopicsinHAIPrevention/
AntimicrobialStewardship/
ImplementationToolsResources.aspx
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Antimicrobial Stewardship
• What can you do?
– Work with your medical director
– Start small
• Symptom or syndrome for which antibiotics are frequently prescribed not in accordance with
clinical guidelines?
– Chose an outcome(s) to measure,
likely “process” measures
– Consider using an antibiotic order form
Antimicrobial Stewardship
• Check your facility’s or community’s susceptibility data and share with clinicians
• Evaluate, summarize, and disseminate information about antibiotic use in your facility to staff
– Prescriptions with no documented indication?
– Treatment for asymptomatic bacteriuria?
• Clarify length of treatment upon admission, request stop orders or date of follow‐up evaluation
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National Healthcare Safety Network (NHSN)
National Healthcare Safety Network (NHSN)
• Secure, web‐based system for reporting healthcare‐associated infections
– Basic surveillance activities
– Analysis tools
• Used by New York State hospitals for mandatory reporting to NYSDOH and CMS
• New long‐term care module now available
– C. difficile infections
– Certain MDROs
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How NYSDOH Can Help You
• Advice about prevention measure to decrease high endemic rates
• Advice about how to control an outbreak
– Should be reported via NORA
• Specialized laboratory testing at Wadsworth
– Pulsed field gel electrophoresis (PFGE)
• Determines whether isolates are the same strain or not
• Can help determine whether transmission is occurring or whether a cluster consists of sporadic unrelated cases
– Save isolates if you’re concerned about a cluster!
Summary
• You can intervene to decrease your facility’s
C. difficile infection rates
• Working with Environmental Services and monitoring cleaning and disinfection is key
• Hand hygiene and PPE, especially glove use, are critically important
• Know and understand your facility’s
testing protocol
• Think about what antimicrobial stewardship initiatives might be appropriate for your facility
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For More Information
http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html
References
1. Carling PC, Bartley JM. Evaluating hygienic cleaning in health care settings: what you do not know can harm your patients.
Am J Infect Control. 2010;38:S41–50.
2. Carrico RM , Archibald LK , et al, Guide to the Elimination of Clostridium difficile in Healthcare Settings, APIC: 2008.
3. Johnson S, Gerding DN, Olson MM, et al. Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile
nosocomial transmission. Am J Med. 1990;88:137–40.
4. Riggs MM, Sethi AK, Zabarsky TF, et al. Asymptomatic carriers are a potential source for transmission of epidemic and
nonepidemic Clostridium difficile strains among long‐term care facility residents. Clin Infect Dis. 2007;45:992–8.
5. Rutala WA, Weber DJ, and the Healthcare Infection Control Practices Advisory Committee (HICPAC), Guideline for Disinfection
and Sterilization in Healthcare Facilities, 2008.
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