The Clostridium difficile Dilemma: Working Toward Prevention

According to an Institute of Medicine (IOM) report, there are 2 million healthcare-associated infections (HAIs) per year in the United States. We also know that 100,000 of these infected patients die. The problem with this picture is that HAIs are preventable and with proper attention, these lives could be saved. Hence, our focus as infection preventionists needs to be on infection prevention rather than infection control.

By Irena L. Kenneley, PhD, APHRN-BC, CIC

According to an Institute of Medicine (IOM) report, there are 2 million healthcare-associated infections (HAIs) per year in the United States.  We also know that 100,000 of these infected patients die. The problem with this picture is that HAIs are preventable and with proper attention, these lives could be saved. Hence, our focus as infection preventionists needs to be on infection prevention rather than infection control.

During the past few years, Clostridium difficile, a bacterium that can cause symptoms from diarrhea to life-threatening inflammation of the colon, has become more frequent, more severe, more resistant to standard treatment and more likely to cause patient relapse. In fact, according to the Centers for Disease Control and Prevention (CDC)'s recent Vital Signs Report, Clostridium difficile infection (CDI)-related deaths have increased by 400 percent between 2000 and 2007.  Current treatment with antibiotics is suboptimal and has limited efficacy, leading to recurrences in up to 50 percent of CDI patients.
To understand the full scope of this problem, its helpful to review a typical CDI case scenario that commonly occurs in U.S. healthcare facilities.

CDI Case Study
An 87-year-old female arrives at the emergency department with fever, abdominal distention and diarrhea, after being discharged from the hospital the previous week following surgery for a hip fracture. Her surgical course was uneventful, and she was transferred to a rehabilitation center four days after surgery. While hospitalized for her surgery, she was treated with perioperative cefazolin according to the hospital protocol. She also received a course of ciprofloxacin three weeks prior for a urinary tract infection.
Documentation from the rehabilitation center indicates that the patient has had diarrhea for the preceding 24 hours and developed a distended abdomen approximately 12 hours before that. The patient is evaluated by a physician in the emergency department who believes she is suffering from a severe case of CDI.

Three hours after admission to the intensive care unit, the patients condition worsens. Her blood pressure remains very low despite pressers, and the mottling noticed on her extremities earlier is now moving upward and involving her trunk as well. She is completely unresponsive, even to deep palpation of her abdomen.

Two hours later, the patient goes into full cardiac arrest with pulseless electrical activity. Advanced Cardiac Life Support (ACLS) protocol is carried out, a rhythm is restored and the patient is intubated. Further discussion with her daughter at this point indicates that due to the poor likelihood of survival, she wishes no further measures to be carried out. The patient expires peacefully 30 minutes later. The following day, an initial stool sample sent to the laboratory tests positive for CDI.

This example and accompanying discussion highlight the need for efforts to prevent CDI through the judicious use of antibiotics and early adoption of infection prevention and control measures. The early recognition of CDI, as well as the understanding of more severe disease, is very important in managing a patient such as the one presented above.
Fortunately, there are a number of reports, strategies and best practices that can help infection control practitioners prevent CDI occurrences in their facilities.

New Reports and Strategies
The CDC recently reported on the work of three collaborative states, New York, Massachusetts and Illinois that have been successful in reducing Clostridium difficile infections.  The commonalities of certain shared variables among the three were striking. All of them mentioned that demonstrated support from executive leadership was imperative. Multidisciplinary teamwork and ongoing communication were also important exemplified by the inclusion of not only clinicians but environmental and transport services professionals as well. Other recommendations for reducing CDI included:
Patient placement and isolation
Monitoring personal protective equipment use and handwashing practices
A CDI prevention bundle
 - The measures that are commonly bundled to prevent CDI include: hand hygiene, environmental cleaning, barrier precautions and antibiotic stewardship.  The specific interventions should be deployed after an infection prevention risk assessment.
 - To learn more about bundle elements and for additional resources, visit Clean Spaces Healthy Patients,, a collaborative project between Association for Professionals in Infection Control (APIC) and the Association for the Healthcare Environment (AHE).
A prevention toolkit
Statewide educational campaigns

CDI Evidence-Based Prevention Strategies
CDI is transmitted in healthcare settings on the hands of healthcare workers by failing to wash hands or change gloves or gowns between patients or by touching soiled rooms surfaces and shared devices and then touching patients. According to the APIC Elimination Guide for Clostridium difficile (2008), many patient-care activities provide an opportunity for the transmission of CDI. Some examples of these activities are: sharing electronic thermometers used for obtaining rectal temperatures (even though probes are changed and probe covers are used, handles may be contaminated); poor hand hygiene practices; ineffective or inconsistent disinfection of patient care equipment; and ineffective environmental cleaning.

According to the CDC Toolkit for Evaluation of Environmental Cleaning, there are both core and supplemental CDI prevention strategies that healthcare professionals can follow.  They are outlined below:
1. Hand hygiene using soap and water instead of hand rubs in compliance with the CDC and the World Health Organization.
2. Rapidly report and implement isolation for patients with positive CDI lab results.
3. Implement contact precautions for duration of diarrhea.
4. Properly clean and disinfect equipment and the patient-care environment, due to the formation of spores, it is recommended to use a U.S. Environmental Protection Agency (EPA) registered bleach-based product (sodium hypochlorite) for cleaning and disinfection.
5. Educate healthcare personnel, housekeeping, administration, patients, and families by providing information on prevention, as well as signs and symptoms of CDI.

Supplemental Prevention Strategies
Implementation of additional prevention strategies is advised when infection rates rise, transmission occurs or outbreaks appear despite strict adherence to core prevention strategies. If your facility CDI rate is more than five cases per 10,000 patient days, then it will be considered endemic and the following additional interventions should be considered.
1. Extend use of contact precautions beyond duration of diarrhea (i.e., 48 hours).
2. Presumptive isolation for symptomatic patients pending confirmation of CDI/presumptive isolation for patients with three or more unformed stools within 24 hours.
3. Implement soap and water for hand hygiene before exiting the room of a patient with CDI.
4. Use an Environmental Protection Agency (EPA)-registered sporicidal or bleach (sodium hypochlorite) cleaning agent for environmental cleaning to kill CDI spores.
For other helpful educational materials, visit the Clorox Healthcare website at  to download a free C. difficile Prevention Tool Kit.

In sum, infection preventionists need a systematic method for disseminating and implementing evidence-based processes with illustrations of specific techniques to prevent CDI (and other HAIs) at their home institutions.  Until these methods are further developed, for now, PREVENTION of CDI still bears all the scrutiny we can muster.

Irena L. Kenneley, PhD, APHRN-BC, CIC is assistant professor of nursing at the Frances Payne Bolton School of Nursing, Case Western Reserve University. She serves as the national chair of the Association for Professionals in Infection Control and Epidemiologys (APIC) Research Council, and she is an official spokesperson for APIC as an expert in infection prevention.