Multifaceted approach needed to better control C. difficile in hospitals

Issue: May 2011

DALLAS — Contact isolation is no longer enough to control Clostridium difficile infections during an outbreak, and the best practice guidelines include multiple interventions, according to researchers at Wake Forest Baptist Medical Center.

“The overall message is the bundling of your interventions,” researcher Ryan Blanton, MS, MT, CIC, said. “One intervention is not effective anymore; it has to be the combination of contact isolation, proper cleaning with a bleach solution, and education of health care workers with early notification.”

Researchers evaluated the effect of more intensive interventions on the overall incidence of C. difficile infections during an outbreak from February to April 2010. Infections were classified as health care-associated or community-associated, using a positive toxin A/B result by enzyme immunoassay.

Interventions initiated after the outbreak included:

Immediate notification of C. difficile positivity to responsible health care providers.
Education for all internal nursing and housekeeping staff.
Daily bleach cleaning of rooms for patients with C. difficile infection.
Thorough bleach cleaning of all rooms where patients with C. difficile resided during the outbreak period.

A notification mechanism was then developed in which health care providers were immediately informed when a positive test was inputted. Blanton said the testing methodology changed from immunoassay to a polymerase chain reaction (PCR) test for toxins A/B, allowing a shorter turnaround time.

Compared with a rate of 5.7 per 10,000 patient-days for health care-associated C. difficile infections before the outbreak, the rate increased to eight per 10,000 patient-days during the outbreak (45/56,382; P<.000002). Five months after initiation of multiple interventions, the rate decreased to five per 10,000 patient-days (49/97,684; P=.03).

Moreover, PCR testing was associated with increased sensitivity. Compared with the previous 5-month infection rate of five per 10,000 patient-days, the PCR indicated a 12.2 infection rate per 10,000 patient-days.

Researchers observed an increased rate for infection (7.7) after implementation of the interventions during August. “We determined this to be due to lack of compliance of the housekeeping staff, who decided not to use bleach during cleaning as a result of patient and nurse complaints of smell. Once the bleach cleanings were re-initiated, the rate decreased to 3.1,” Blanton said.

“Daily bleach cleaning might be most effective, as shown by the increase of infections during a time of low compliance by housekeeping staff due to complaints. The ability to immediately notify health care personnel with a newly implemented automated notification system may have also contributed to the improvement,” he said. “This bundling approach should not only be used during times when increased rates are noticed by ongoing surveillance activities, but rather as standard practice when dealing with patients with C. difficile infections.” – by Ashley DeNyse

Disclosure: Blanton reports no relevant financial disclosures.

For more information:

Blanton R. #160. Presented at: SHEA 2011 Annual Scientific Meeting; April 1-4, 2011; Dallas.

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