Clinical Context

Clostridium difficile remains a significant source of morbidity and mortality among hospitalized adults, as well as a major financial burden on the healthcare system. The authors of the current study provide a review of the microbiology and effect of C difficile.

C difficile is a Gram-positive bacterium that is transmitted via the fecal-oral route. The use of antibiotics raises the risk for C difficile infection (CDI), as do older age, hospitalization, immunosuppression, gastrointestinal surgery, and the use of proton pump inhibitors.

There are approximately 500,000 cases of CDI in the US annually, and hospital-acquired CDIs are a major quality metric for health systems. Members of the healthcare team, including physicians, nurses nurse practitioners, physician assistants, pharmacists, and infectious disease specialists, each play an important role in the prevention and management of CDI. The current study describes the multifaceted infection control program against CDI at a single US community hospital, as well as the efficacy of that intervention.

Study Synopsis and Perspective

Teamwork by a wide range of professional staff, coupled with support from leadership, enabled a single academic community hospital to cut its rate of hospital-onset CDIs (HO-CDIs) by almost two thirds in 1 year and by more than three quarters in 3 years, a study published in the American Journal of Infection Control reports.^[1]

"The interventions and outcomes of the project improved patient care by ensuring early testing, diagnosis, treatment if warranted, and proper isolation, which helped reduce C difficile transmission to staff and other patients," lead study author Cherith Walter, MSN, RN, a clinical nurse specialist at Emory Saint Joseph's Hospital in Atlanta, Georgia, told Medscape Medical News. "Had we not worked together as a team, we would not have had the ability to carry out such a robust project," she added in an email.

Each HO-CDI case costs a healthcare system an estimated $12,313, and high rates of HO-CDIs incur fines from the Hospital-Acquired Condition Reduction Program of the Centers for Medicare & Medicaid Services (CMS), the authors write.

A Diverse Staff Team Collaborated

Emory Saint Joseph's, a 410-bed hospital in Atlanta, had a history of being above the national CMS benchmark for HO-CDIs. To reduce these infections, comply with CMS requirements, and avoid fines, Walter and colleagues launched a quality improvement project between 2015 and 2020.

With the approval of the chief nursing officer, chief quality officer, and hospital board, researchers mobilized a diverse team of professionals: a clinical nurse specialist, a physician champion, unit nurse champions, a hospital epidemiologist, an infection preventionist, a clinical microbiologist, an antimicrobial stewardship pharmacist, and an environmental services representative.

The team investigated what caused their hospital's HO-CDIs from 2014 through 2016 and developed appropriate, evidence-based infection prevention interventions. The integrated approach involved:

• Diagnostic stewardship, including a diarrhea decision tree algorithm that enabled nurses to order tests of any loose or unformed stool for C difficile during the first 3 days of admission.
• Enhanced environmental cleaning, which involved switching from sporicidal disinfectant only in isolation rooms to using a more effective, Environmental Protection Agency-approved sporicidal disinfectant containing hydrogen peroxide and peracetic acid in all patient rooms for daily cleaning and after discharge.
• Antimicrobial stewardship. Formulary fluoroquinolones were removed as standalone orders and made available only through order sets with built-in clinical decision support.
• Education of staff on best practices through emails, flyers, meetings, and training sessions. Two nurses needed to approve the appropriateness of testing specific specimens for CDI. All HO-CDIs were reviewed and the findings presented at CDI team meetings.
• Accountability. Staff on the team and units received emailed notices about compliance issues and held meetings to discuss how to improve compliance.

After 1 year, HO-CDI incidence dropped 63% from baseline, from above 12 cases per 10,000 patient-days to 4.72 per 10,000 patient-days. And after 3 years, infections dropped 77% to 2.80 per 10,000 patient-days.

The hospital's HO-CDI standardized infection ratio, or the total number of infections divided by the National Healthcare Safety Network's risk-adjusted predicted number of infections, dropped below the national benchmark, going from 1.11 in 2015 to 0.43 in 2020.

The hospital also increased testing of appropriate patients for CDI within the first 3 days of admission, going from 54% in 2014 to 81% in late 2019.

"By testing patients within 3 days of admission, we discovered that many had acquired C difficile before admission," Walter said. "I don't think we realized how prevalent C difficile was in the community."

"Effective collaboration within the healthcare setting is a highly effective way to implement and sustain evidence-based practices related to infection reduction. When buy-in is obtained from the top, and pertinent stakeholders are engaged for their expertise, we can see sustainable change and improved patient outcomes," Galvan, who was not involved in the study, said in an email.

Douglas S. Paauw, MD, a professor of medicine and chair for patient-centered clinical education at the University of Washington School of Medicine in Seattle, told Medscape Medical News that the team's most important interventions were changing the environmental cleaning protocol and using agents that kill C difficile spores.

"We know that as many as 10% to 20% of hospitalized patients carry C difficile. Cleaning only the rooms where you know you have C difficile (isolation rooms) will miss most of it," said Dr Paauw, who was also not involved in the study. "Cleaning every room with cleaners that actually work is very important but costs money."

Handwashing With Soap and Water Works; Alcohol Hand Gels Do Not

"We know that handwashing with soap and water is the most important way to prevent hospital C difficile transmission," Dr Paauw noted. "Handwashing protocols implemented prior to the study were probably a big part of the team's success."

Handwashing with soap and water works, but alcohol hand gels do not, he cautioned.

The authors plan to conduct further related research.

The study was not funded. All study authors, as well as Galvan and Dr Paauw, have reported no relevant financial interests.

Am J Infect Control. Published online May 11, 2022.

Study Highlights

• The study was conducted at a single community hospital that is part of an academic health system. Rates of HO-CDI were elevated above national benchmarks in 2014 to 2016. The current study reports on the intervention undertaken from 2015 to 2020 to address this problem, as well as the results of these efforts.
• An interprofessional team to address HO-CDI was recruited in 2015. It was led by a clinical nurse specialist and included a physician, a hospital epidemiologist, an infection prevention expert, nurse champions, an antimicrobial stewardship pharmacist, and an environmental service representative. Interventions from this team were adopted in 2016 to 2018.
• The team developed a C difficile testingalgorithm to better identify community-acquired CDI (CA-CDI) in the first 3 days of admission. Testing for C difficile was considered appropriate after 3 or more stools in 24 hours, with no laxative use within 48 hours, plus at least one other symptom or risk factor for CDI. Laboratories could cancel specimens that featured formed stools. Finally, a 2-step test was initiated in 2019 in which cases with a positive nucleic acid amplification test for C difficile toxin A/B genes were augmented with testing for C difficile-specific enzyme glutamate dehydrogenase, as well as toxins A/B. This additional testing could distinguish active infection from colonization.
• In 2018 environmental services started using sporicidal disinfectant in all patient rooms instead of isolation rooms only. For antimicrobial stewardship, warnings were added to orders for antibiotics associated with a high risk for CDI, such as fluoroquinolones.
• The CDI reduction efforts were communicated to staff in a variety of ways, including meetings, emails, flyers, and team huddles. New employees were educated on CDI during orientation. Eventually, 2 nurses were required to cosign orders for CDI testing and nurses were encouraged to discuss inappropriate orders with the provider.
• The main study outcomes were the incidence rate of HO-CDI and the standard infection ratio. Researchers also followed the rate of testing for C difficile.
• The rate of HO-CDI before the quality improvement program exceeded 12 cases per 10,000 admission days. At year 1 of the QI implementation, the rate of HO-CDI was 4.72 per 10,000 patient days, and the rate decreased further to 2.8 cases per 10,000 patient days by 3 years after QI implementation.
• The standardized infection ratio was 1.11 in 2015 and 0.43 in 2020, a significant improvement.
• The number of orders for C difficile lab assessment increased between 2015 and 2020, but this increase was driven by a higher number of orders on the first 3 days of admission.
• The median days of prescriptions for levofloxacin fell by half in comparing the pre- and postantibiotic stewardship periods.
• Overall, adherence to the diarrhea decision tree algorithm increased to 80% by 2020.

Clinical Implications

• C difficile is a Gram-positive bacterium that is transmitted via the fecal-oral route. The use of antibiotics raises the risk for CDI, as do older age, hospitalization, immunosuppression, gastrointestinal surgery, and the use of proton pump inhibitors. There are approximately 500,000 cases of CDI in the US annually.
• In the current study, a multidisciplinary intervention that comprised a new testing algorithm, antibiotic stewardship, enhanced cleaning of surfaces, and staff education improved rates of HO-CDI.

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