Clostridium difficile is a spore-forming, gram-positive bacterium that infects the gastrointestinal tract and is the leading cause of antibiotic-associated diarrhea.[i],[ii] In recent years, C. difficile infections have become more frequent, more severe and more difficult to treat. It is not surprising that in the healthcare setting C. difficile is the bane of hospital infection control professionals' existence. It's extremely difficult to kill partly due to its ability to survive on surfaces for months[iii] on end and various modes of transmission[iv]. Despite proactive infection control measures (e.g. hand hygiene, antibiotic stewardship and environmental cleaning), C. difficile-associated disease still remains problematic.
And it's everywhere: A CDC-funded study published in 2015[v] found 450,000 C. difficile cases annually in the U.S., and another study in the American Journal of Infection Control found the incidence of C. difficile infections among hospitalized adults in the U.S. nearly doubled between 2001 and 2010.
One of the best ways to kill C. difficile spores is through use of sporicidal agents. In a Nov. 1 webinar hosted by Becker's Hospital Review and Barley Chironda, an infection control specialist with Clorox Healthcare, Mr. Chironda outlined the role environmental disinfection can play in preventing the spread of C. difficile and how the universal use of a sporicidal agent like bleach as part of an infection prevention protocol may be the best way to reduce the incidence of C. difficile infections.
According to Mr. Chironda, inpatient management of C. difficile presents major challenges to healthcare facilities. A recent report reflected the concerns of the greater medical community on the impact of C. difficile-associated infection (both financially and medically) in which 76 percent of hospital facilities reported that hospital management/leadership viewed preventing C. difficile infection as top priority[vi]. This can be attributed to such challenges as the following:
Complex transmission. There are several sources of C. difficile transmission in the hospital, including aerosolized stool from toilets, prior room occupancy by a previous patient with a C. difficile infectionvii, and asymptomatic carriers, who are colonized with C. difficile and can pass it on without showing symptoms of infection.
"There has now been an increasing body of work speaking to the role of the colonized, no-symptom patient, because that patient can continue to feed the environment and adds to the complexity of C. difficile transmission," Mr. Chironda said.
Human factors. An array of people play a role in eliminating C. difficle, from environmental service staff to transport staff to members of the clinical team and more. When so many people are involved, the situation is ripe for a communication breakdown. According to a pre-webinar survey, 40 percent of respondents reported occasional failure to use a sporicidal agent after a C. difficile case. This potentially life-threatening oversight is often caused by communication gaps between stakeholders.
Additionally, there is often a delay in identifying and isolating C. difficle-positive patients, which can aid in the spread of the bacteria.
All of these factors and more — like poor hand hygiene compliance and the simple fact that C. diffcile is notoriously tenacious and difficult to kill — "can line up to create a very difficult situation for managing of C. difficle," Mr. Chironda said.
What's the solution?
Current guidance recommends hospital workers use sporicidal agents in two instances: to mitigate a C. difficle outbreak and to clean and disinfect a room after a C. difficle-positive patient is discharged from it. However, Mr. Chironda argued for broader use of sporicidal agents.
"I would say regardless of when the status is known on the patient, whether they are symptomatic or not…or whether they test positive, the strategy is to actually go through and use sporicidal agents on all these cases," Mr. Chironda said.
As of June 2016, the chemistries registered products effective against C. difficile spores includes disinfectant wipes or liquids, one of the most common being sodium hypochlorite, and also non-touch devices like ultraviolet light, fogging systems or spray systems.
Recent studies have shown that facilitywide disinfection with a sporicide is effective — Mr. Chironda cited studies from 2013[vii] and 2014[viii] in the Journal for Healthcare Quality that linked universal use of sporicides to reductions in hospital-onset C. difficle infections.
Instituting use of a sporicidal disinfectant all the time would also eliminate some of the human factors that come up when sporicidal agents are only used some of the time. For example, there would be no confusion or delay in instituting use of such a disinfectant for a C. difficile-positive case if the agent were simply used in every case as part of infection control protocol.
For example, in one study published in Infection Control and Hospital Epidemiology, a CDI-targeted intervention strategy involving enhanced daily and terminal disinfection with a dedicated environmental services team led to a dramatic 89 percent reduction in the percentage of rooms with positive CDI cultures.[ix]
"You cannot expect people to not make mistakes when they are asked to use [sporicides] in targeted situations," he said, and universal use avoids that problem.
How to make it happen
Two main things need to happen to drive universal adoption of sporicidal use, according to Mr. Chironda.
For one, there has been a lot of great and new innovation in surface disinfectants with faster contact times that also minimize occupational health concerns and don't damage hospital surfaces. "People might consider going to sporicidal use if there was better product — better innovation on disinfectants is needed," he said.
Guidance documents from professional organizations and agencies like the CDC also need to be updated to include new data that wasn't available a few years ago. "I think it opens up an opportunity for a new dialogue and discussion" around universal sporicidal disinfectant use, Mr. Chironda said.
"Universal sporicidal disinfectant use is an effective C. difficle prevention strategy," he concluded. "This has been documented…and I urge anyone who is participating in any of these kinds of interventions to really publish, because when you publish you create that kind of repository of information that helps everyone else."
Click here to watch a recording of the webinar.
Click here to download a copy of the presentation.
[i] Bartlett JG. "Narrative Review: The New Epidemic of Clostridium difficile-associated Enteric Disease." Annals of Internal Medicine 145.10 (2006): 758-764.
[ii] Centers for Disease Control and Prevention (CDC). “Antibiotic resistance threats in the United States, 2013.” Atlanta: CDC, 23 Apr. 2013. 26 Nov. 2013. Available from: http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf.
[iii] Kramer, A.; Schwebke, I.; Kampf, G. BMC Infect. Dis. 2006, 6, 130.
[iv] Furuya-Kanamori et al. Asymptomatic Clostridium difficile colonization: epidemiology and clinical implications. BMC Infectious Diseases.2015; 15:516.
[v]Centers for Disease Control and Prevention (CDC) February 25th 2015 Press Release: “Nearly half a million Americans suffered from Clostridium difficile infections in a single year” Available: http://www.cdc.gov/media/releases/2015/p0225-clostridium-difficile.html.
[v]Mitchell BG, Dancer SJ, Anderson A, Dehn E. Risk of organism acquisition from prior room occupants: a systematic review and meta-analysis. J Hosp Infect 2015;91:211‒217.
[vi] Saint, S.; Fowler, K. E.; Krein, S. L.; Ratz, D.; Flanders, S. A.; Dubberke, E. R.; Greene, M. T. Infect. Control Hosp. Epidemiol. 2015, 36 (8), 969–971 DOI: 10.1017/ice.2015.81
[vii] Aronhalt, Kimberly C., et al. "Patient and Environmental Service Employee Satisfaction of using Germicidal Bleach Wipes for Patient Room Cleaning." Journal for Healthcare Quality 35.6 (2013): 30-6.
[viii] Koll BS, Ruiz RE, Calfee DP, Jalon HS, Stricof RL, Adams A, et al. Prevention of hospital-onset Clostridium difficile infection in the New York metropolitan region using a collaborative intervention model. J Healthc Qual 2014;36:35- 45
[ix] Sitzlar B, Deshpande A, Fertelli D, Kundrapu S, Sethi AK, and Donskey CJ. "An Environmental Disinfection Odyssey: Evaluation of Sequential Interventions to Improve Disinfection of Clostridium difficile Isolation Rooms." Infection Control and Hospital Epidemiology 34.5 (2013): 459-465.