Curbing C. difficile Infection in a Hospital

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This article discusses the prevalence of Clostridioides difficile (C. difficile) infection in hospitals, the progress that’s been made in recent years in reducing hospital-acquired infections, and what’s being done to mitigate the spread of this highly contagious disease in hospital settings. It also discusses an increase in community-acquired C. difficile infections and why this is important to hospitalists. The article provides some best practices that can help combat the spread of C. difficile infection in hospitals. 

According to the Centers for Disease Control and Prevention (CDC),¹ C. difficile infection is a leading cause of health care-associated infections, with significant morbidity and mortality; it is associated with 15,000-30,000 deaths annually in the U.S. 

C. difficile infections are extremely contagious, can spread in communal settings, and are one of the most common health care-associated infections in U.S. hospitals.^2,3 As a hospitalist, I have firsthand experience with the challenges of C. difficile infections, including severe outbreaks in the hospital setting and recurrence among those with C. difficile infection. 

The burden of recurrent C. difficile infection is significant⁴: one-third of infected people are likely to get the infection again, and among people with recurrent C. difficile infection, up to 84% are hospitalized within one year, with an average of about two separate hospitalizations per patient, according to a single-center study.⁵

Progress in reducing hospital-acquired infections

While hospital-acquired infections like C. difficile infection continue to be a major concern for hospitalists, health systems have made significant progress in recent years at reducing hospital-acquired infections overall. 

One of the drivers of this progress is the Hospital-Acquired Condition Reduction Program which involves the Centers for Medicare and Medicaid Services (CMS) and links Medicare payments to health care quality in the inpatient hospital setting by incentivizing health care systems to keep hospital-acquired infections down.^6,7 Other possible reasons for the decline in hospital-acquired C. difficile infections are less ribotype 027 and the reduced use of fluoroquinolone antibiotics.¹

The processes and protocols health systems have put in place to reduce hospital-acquired conditions help mitigate the spread of C. difficile infection within the hospital. However, we’re starting to see a troubling trend outside of our hospitals—an increase in community-acquired C. difficile infections. 

Increase in community-acquired C. difficile

This is important to hospitalists because an increase in community-acquired infections could lead to more cases in the hospital given the highly infectious nature of C. difficile. 

Patients who have symptom onset of C. difficile infection within 48 hours after hospital admission indicate a community-acquired C. difficile infection. If the infection with C. difficile occurs 72 hours after admission, it is deemed by CMS criteria to be hospital-acquired.^3,8,9,10 It’s important to practice diagnostic-testing prudence, to identify only true C. difficile infection and not mere colonization. Patients should have three diarrheal stools within 24 hours that cannot be explained by other causes. 

Why are C. difficile infections in the community increasing? In my opinion, there are several different reasons, including an aging population, more people living in nursing homes or skilled-nursing facilities where C. difficile is easily spread, and the fact that antibiotics are the go-to treatment for fighting many infections. 

While antibiotics can help wipe out disease-causing bacteria, including C. difficile, they can also wipe out some of the good microbes, disrupting the delicate balance of the gut microbiome, and allowing a C. difficile infection to take hold. Taking antibiotics for an extended period or using more than one antibiotic for treating an illness can raise the risk of C. difficile infection and lead to a cycle of recurring infections.^{11,12,13,14,15}

Steps to reduce the spread

The good news is that we have a clear roadmap to how we can reduce the spread of C. difficile infection in hospitals. If strictly adhered to, the steps below can help combat the spread of C. difficile infection: 

Handwashing with soap: Vigorously scrubbing hands with soap and water in between patients is one of the most important actions. While alcohol-based gels are convenient, they are not as effective as soap and water. 

Cleaning surfaces: Frequent and thorough cleaning of surfaces with U.S. Environmental Protection Agency-approved agents is extremely important in killing C. difficile spores and keeping the room environment as germ-free as possible. 

Consistent changing of PPE: Changing medical apparel between every patient encounter is critical in reducing C. difficile spore transmission. In recent years, personal protective equipment shortages have impacted the ability of health care workers to adhere to this crucial step, which can potentially result in increased spread within the hospital.

Isolating patients: It is essential to isolate patients diagnosed with hospital-acquired infections, or even suspected of carrying such infections. This does not always happen due to a lack of private rooms and appropriate ventilation. The good news is that increasingly, hospitals are being designed and changes are being made to address these specific needs. 

Antibiotic stewardship: Key policies often encourage the reduction of antibiotic use and leverage a narrow spectrum of antibiotics. Physicians should have an accurate list of current and previous medications their patient has been prescribed so they can properly assess their need for antibiotic treatment. As part of this, health care professionals should also have an antibiotic history of the patient as far back as three months, given antibiotics are the most important risk factor for C. difficile. Consistent education of patients is also critical, including the potential impact of antibiotic overuse that may result in an imbalance of your microbiome which can potentially lead to C. difficile growth.

While C. difficile infection continues to be an urgent health threat, I believe that as health care professionals we need to take the necessary steps to mitigate exposure and transference of this potentially deadly disease in our hospitals. 

The steps and processes listed help identify some of the ways we can all work together to better help contain this infection, and its impact on patients, caregivers, and the entire hospital community. 

Dr. Deruelle

Dr. Deruelle is executive director of hospital medicine with American Physician Partners, Nashville, Tenn. He’s a recognized expert on the Affordable Care Act and has been featured on television and radio talk shows, in newspapers and medical journals, and at national health care conferences. Dr. Deruelle recently published his second book, Your Healthcare Playbook: Winning the Game of Modern Medicine. 

Disclosure: Dr. Deruelle is a speaker and consultant for Ferring Pharmaceuticals, Inc. He was not compensated for this article.

References

1. Centers for Disease Control and Prevention website. 2019 Antibiotic Resistance Threats Report: Clostridioides Difficile. https://www.cdc.gov/drugresistance/pdf/threats-report/clostridioides-difficile-508.pdf. Accessed September 2, 2022.
2. Lessa FC, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med. 2015;372(9):825-834. doi:10.1056/NEJMoa1408913.
3. Guh AY, et al. Trends in U.S. burden of Clostridioides difficile infection and outcomes. N Engl J Med. 2020;2:382(14):1320-1330. doi:10.1056/NEJMoa1910215.
4. Mayo Clinic website. C. difficile – Diagnosis and treatment. https://www.mayoclinic.org/diseases-conditions/c-difficile/diagnosis-treatment/drc-20351697. Accessed September 2, 2022.
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6. Centers for Medicare and Medicaid Services website. Hospital-Acquired Condition Reduction Program. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program. Accessed September 2, 2022.
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8. MIT News. February 12, 2020. Why C. difficile infection spreads despite increased sanitation practices. https://news.mit.edu/2020/why-c-difficile-infection-continues-spread-despite-increased-sanitation-0212. Accessed September 2, 2022.
9. NEJM Journal Watch. October 21, 2019. C. diff Infections Increasingly Community-Acquired. https://www.jwatch.org/fw115981/2019/10/31/c-diff-infections-increasingly-community-acquired. Accessed September 2, 2022.
10. University of Houston. October 6, 2021. C. Difficile Is Everywhere – Even on the Bottom of Footwear https://uh.edu/news-events/stories/2021/october-2021/10062021-c-diff.php . Accessed September 2, 2022.
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