Preventing Transmission of C difficile Practice Elise Tamplin

Preventing Transmission of C. difficile: Practice Elise Tamplin, M(ASCP), MPH, CIC Brigham & Women’s Hospital

Objectives • Discuss practical challenges in implementing infection control measures • Illustrate the value of periodic assessment of compliance

BWH healthcare-associated CDI rates *Excludes NICU

CDI leading to colectomy and/or death: Nosocomial & non-nosocomial cases

Challenges • Preventing acquisition/transmission • Improving outcomes for patients with CDI

CDI Control Interventions • Sentinel event and root cause analysis • Increase case finding & early identification— quicker lab turn around time • Enhance Infection Control measures • Aggressive CDI management & surgical evaluation (BWH CDI Treatment Guidelines) • Staff education • Minimize antibiotic utilization

Laboratory Testing • Change in test methodology – Cytotoxicity assay to EIA • From 3 day TAT to same day results – Lower sensitivity – Need for clinical judgment in interpretation of negative result – Increased possibility of false negatives if specimen taken while on antibiotics

Basic Infection Control Practices • Hand hygiene • Contact precautions for infected patients • Ensure cleaning and disinfection of equipment and the environment • Implement a laboratory-based alert system • Conduct CDI surveillance • Educate patients and families about CDI

Special Approaches to prevent transmission by healthcare personnel • Perform hand hygiene with soap and water after contact with a patient with CDI – Pro: Alcohol is not sporicidal – Con: Hand hygiene compliance is lower for handwashing with soap and water vs. use of an alcohol-based hand disinfectant

Special Approaches to prevent spread through the environment • Use a hypochlorite-based room cleaning agent – Pro: Sporocidal and benefit has been reported in outbreak settings – Con: Can corrode equipment and can be a chemical irritant for patients and staff

Special Approaches to prevent transmission by healthcare personnel • Prolong the duration of contact precautions after the patient becomes asymptomatic until hospital discharge – Patients may shed C. difficile in their stool after diarrhea resolves Bobulsky GS et al. Clin Infect Dis 2008; 46: 447– 50

New Infection Control Measures • Enhancements to Contact Precautions • Contact Precautions Plus – Soap & water hand hygiene – Hypochlorite based disinfectantdetergent upon discharge/transfer – Precautions for duration of admission

Contact Precautions Plus • Discontinuation upon cessation of symptoms problematic • Administration buy-in required for continuation during entire admission • Automated “flag” developed by IS like those for MRSA & VRE but expiring upon discharge • Education of Admitting staff re empiric precaution status

Soap & Water Hand Hygiene • Major change from routine use of waterless hand sanitizer • Visibility of sign key issue – Several design changes • Sink availability challenging – Few in central areas of inpatient units – Reluctance to use patient room sink – Hand washing 101

*Bleach-based Do not remove sign until after room has been cleaned

Hypochlorite Disinfectant • Infection Control & Safety approvals • Odor/symptom complaints from staff - OHS evaluation/tracking - MNA discussion re safety concerns - Evaluation of new products - Change from liquid to impregnated wipes - Adequacy of surface wetting evaluated

Hypochlorite Disinfectant • Compliance with use – Tracking mechanisms ØDaily patient log from Infection Control to Environmental Service ØSome rooms still missed ØDaily review/verification by ES & return to Infection Control – Signs taken down before cleaning ØCPP room status added to housekeeping page

Staff Education • Physicians – Early severe patient outcomes helped – M&M conferences, Grand Rounds, etc. • Nursing – Empiric precautions – Specimen collection prior to treatment

Staff Education • Support (Environmental Services) – Balance between emphasis on need for special measures vs. fostering undue personal safety concerns – Regroup with supervisors • Administrative (Admitting) – Achieving support for empiric precautions

CDI Management Guidelines • Consensus document – Infection Control – Infectious Disease – Medical Intensive Care – General Surgery – Microbiology – Pharmacy – Nursing

CDI Management Guidelines • Infection Control Precautions • Diagnostic testing • Clinical management of patients

CDI Management Guidelines • Clinical categories based on specific clinical criteria – Appropriate management for each ØStop non-essential medications § antimicrobials & antiperistaltics ØAppropriate antibiotic therapy ØInfectious Disease & Surgical consults ØRectal vancomycin (when & how)

BWH healthcare-associated CDI rates Contact Precautions Plus BWH Treatment Guidelines *Excludes NICU

Severe CDI leading to colectomy+/-death Nosocomial vs. non-nosocomial Contact Precautions Plus

Objectives • Discuss practical challenges in implementing infection control measures • Illustrate value of periodic assessment of compliance