ECDC: Rigorous infection control measures may help fight C. difficile outbreaks

Issue: September 2008

In response to several recent outbreaks of hyper virulent strains of Clostridium difficile in Europe, European public health officials have been advised to implement rigorous infection control measures to fight further outbreaks.

Rigorous hygiene practices and appropriate antimicrobial stewardship practices to prevent outbreaks of C. difficile were recommended by researchers in a document published recently by the European Centre for Disease Prevention and Control (ECDC). Researchers from several institutions in Europe compiled data from literature published on incidences of C. difficile-associated diarrhea from around the world. The study appears in the Journal of Clinical Microbiology and Infection.

Although several guidelines for the treatment of the infection are available, the investigators believed that an outline with broader scope was necessary in light of the emergence of hyper virulent new strains, including PCR ribotype 027. “The increasing prevalence of PCR ribotype 027 was the catalyst for writing this article,” Carl Suetens, MD, senior expert in health care-associated infections at the European Centre for Disease Prevention and Control, told Infectious Disease News.

Recommendations

Suetens said certain hygiene procedures are most critical in controlling the infection. “Probably the most significant findings from our review are the need for additional hand hygiene measures after caring for known C. difficile patients,” he said. “We advise meticulous hand washing with soap and water in addition to the standard alcohol rubs and specific environmental cleaning of rooms of patients with C. difficile infections.”

Estimates for rates of nosocomial infection vary with strain and location, so the researchers stressed early diagnosis to identify carriers of pathogens and prevent cross-contamination within the hospital setting.

The researchers wrote that routine surveillance should be conducted during times when there is no outbreak to help detect increased incidence and to provide baseline data for comparison. Defining a threshold for frequency of infection may be helpful in faster implementation of infection control procedures during an outbreak.

A broad spectrum of precautionary isolation measures may include isolating individual patients or closing down entire wards or departments, depending on the severity of the outbreak. “If daily clinical practice does not allow the isolation of symptomatic patients in single rooms on a regular ward, cohorting several patients on a separate cohort/isolation ward may be considered,” the researchers wrote.

Routine education about the clinical features, transmission and epidemiology of C. difficile infection should be carried out. Everyone who comes into contact with patients with C. difficile, including health care workers, visitors and hospital cleaning staff, should be instructed in these areas.

The researchers recommended cessation of all antimicrobial treatment that does not specifically treat C. difficile infection in patients with C. difficile -associated diarrhea. Although many antibiotics may induce C. difficile-associated diarrhea, cephalosporins, broad-spectrum penicillins and clindamycin are most often implicated. Fluoroquinolones also may be a risk factor, especially for PCR ribotype 027.

During outbreaks, multiple containment strategies must be initiated immediately. Epidemiological information needs to be gathered and assessed to correctly identify the source of the infection. After that, hygiene measures and antibiotic stewardship policies should be instituted as needed. Isolates should be collected and identified from fecal samples. “Outbreaks may be very difficult to control and require a combination of rigorous infection control measures with appropriate use of antibiotics, including avoiding the use of high-risk agents,” said Suetens. – by Rob Volansky

For more information:

Vonberg RP, Kuijper EJ, Wilcox MH, et al. Infection control measures to limit the spread of Clostridium difficile. Clin Microbiol Infect. 2008;14:2-20.