Up-and-Coming Prevention Methods for Clostridium difficile

During the 2016 Society for Healthcare Epidemiology of America (SHEA) Spring 2016 conference, which was held in Atlanta, Georgia from May 18-21, 2016, Contagion™ interviewed Robin Jump, MD, PhD, assistant professor in the Department of Medicine at the Case Western Reserve University regarding Clostridium difficile in the hospital setting, with regards to up-and-coming prevention methods.

How Can Healthcare Providers Work to Better Prevent C. difficile in Post-Acute Care Facilities?

“The way that healthcare providers can help improve the prevention and management of [Clostridium difficile] C. difficile in post-acute care facilities is a complex answer; this is a difficult disease. One of the keys here is prevention, and that relies in large part on antimicrobial stewardship, [such as] avoiding unnecessary antibiotic exposure, and also relies upon infection control.

Antimicrobial stewardship is a burden that falls upon both the providers in post-acute [care] as well as the hospitals themselves, and if we can all work together to minimize antibiotic exposure to our patients and our long-term care [patient] residents, that will help reduce their vulnerability, and that’s key.

Infection control both in the hospital and in post-acute care is important and is also very challenging. C. diff spores can last on surfaces for a period of months. We have evidence that says they can last for five months on surfaces. They’re also very hard to remove with routine cleaning agents, so the quaternary ammonium compounds that most hospitals and long-term care facilities use for disinfection aren’t effective against C. difficile spores, neither is the alcohol [sanitizer] that we all use. The spores are resistant to that as well, so, it’s hard to get off of hands, which means that the fundamental infection control maneuver that we have to do as healthcare workers is handwashing with soap and water. We have to do a good job of handwashing with soap and water because even soap isn’t good at getting C. diff spores off the skin; they like to hang on there. That becomes another challenge for all of us I think, to take the time and to find the time to do this well.

Another key aspect of this is to reduce transmission by having all healthcare workers wear gowns and gloves when they interact with people that have C. difficile infection and taking off that personal protective equipment well: so putting it on and then taking it off properly in the room.

Another aspect of good prevention is early contact precautions. If we think that someone may have C. diff, my preference, and I think that of many people, is to put them in contact precautions early until we’ve actually ruled out the disease. This usually takes about two days and reduces the possibility of transmitting spores to other patients or residents throughout the facility.

Another way that post-acute care facilities can prevent C. difficile infection through infection control is through really good cleaning. This is, daily disinfection with bleach, and the bleach and bleach wipes are very important here. Daily disinfection and cleaning of high-touch surfaces in residence rooms [is needed] as well as in other high-touch areas like in the nursing station.

One of the big challenges [of] post-acute care is trying to clean the resident’s room. In the hospital, once someone is known to have C. diff, they stay in contact precautions for the duration of their hospitalization and if that’s three days or five days or seven days, [cleaning the room] is not so hard. When they go, when they’re discharged, their room gets a terminal clean. In a long-term care facility this is so much more challenging because they live there and they’re supposed to be there for a long time, be it two weeks or two months or two years. We can’t change somebody’s room so they can do a cleaning of their room, so, trying to figure out the balance between maintaining that home-like environment, because it is their home, and also trying to maintain infection control and disinfection practices is a burden. Daily disinfection, using bleach to clean surfaces, will get you so far when people have a lot of personal possessions, it becomes more challenging; that’s where some of these more technologically innovative disinfection devices come into play.”

Can You Discuss Some of the More Recent Decontamination Technologies Designed for Use in Healthcare Facilities?

“There [are] two relatively recent technologies that have come on the market that are important for infection control. [They] are more widely applied in hospitals and I think they will have a space in long-term care as well. The problem, [is] that they’re very expensive, but they do seem to have some effectiveness.

One of these [technologies] is hydrogen peroxide vapor [and] people [often] use this to disinfect or decontaminate large spaces. Some of the down-sides of using hydrogen peroxide vapor [is that] we have to close off the ventilation system, close off the doors, and create a seal within the room. I haven’t looked at it in a couple of years but this is what I [am] aware of.

The UV devices seem to be more user-friendly. These are devices where all you have to do is shut the door of the room. So the device goes in, the door gets shut, the device is then programmed to disseminate UV light throughout the room, it bounces around so it can get to those difficult to reach surfaces, like underneath things and around things, and it works to kill the spores. It can take up to about 45 minutes to an hour and it may have to be done in two sessions, so one time in the room and one time in a bathroom, for example. If we’re looking at two hours to do a cleaning of a room, or two hours to get the spore burden down, it’s completely worth doing that, and that can serve as the terminal clean to then allow the resident and perhaps their roommate to be back in the room. It’s also as I said before, very, very expensive to invest in these machines.”

Can You Comment on the Study,“Effect of Detecting and Isolating Clostridium difficile Carriers at Hospital Admission on the Incidence of C difficile Infections: A Quasi-Experimental Controlled Study.”

“These efforts to screen asymptomatic [Clostridium difficile] carriers and their admission to the hospital are an extension of what has been done already with methicillin-resistant Staphylococcus aureus, or MRSA, and it’s a fantastic idea; I am pleased to see that [clinicians] were able to show a decrease in the expected rate of C. diff cases. They estimated based on their study outcomes that they prevented 63 of 101 healthcare associated C. difficile cases, which is fantastic and commendable. To achieve this, the numbers estimate that they had to screen about 120 people on admission to the hospital and isolate 6 asymptomatic carriers to prevent those cases of C. difficile. This seems to be a very rational approach and I like it.

I expect that based on what it costs to screen people, including the microbiology laboratory time and doing the actual cultures versus having a case of C. diff in the hospital, I expect that it’s very cost effective. Patients may not like it; they don’t always like being on contact precautions for MRSA either but in the public health setting this seems to make sense and it seems to be where we have to go at this point given the burden of drug-resistant organisms.

It [also] seems to make good sense to isolate preemptively rather than wait until after we know that someone is sick or to isolate preemptively rather than wait until after we know someone is sick or to isolate preemptively so that someone who is a carrier doesn’t lead to healthcare workers spreading spores to other patients and making them sick as well.

I think some of the barriers to implementing active surveillance and putting asymptomatic carriers in isolation pertain to cost and the effort that’s required on the part of the nursing staff, because they are the ones that will have to do this. There may be also some reluctance on the part of the patients, too, because this is different from getting your nose swabbed; this is a different part of the body that has to get swabbed, and that’s not always something that we are very comfortable with. I don’t think I would be upon admission to the hospital. A second potential barrier may be that this is [just] one study and [though] I think that it is worthwhile pursuing, there may be a call for more evidence before we can start making this a widespread investment into healthcare infection control and prevention.”

What is ‘Careful Observation’ and How Can it Improve Infection Prevention in Healthcare Settings?

“So another missed opportunity for doing better infection prevention with C. difficile, relates to antibiotic use [by] the public. The public has a perception that antibiotics will make them feel better, which is not always the case. The public will often demand or request antibiotics for a viral infection and that won’t make them feel better physically, but it often makes [them] feel better psychologically, because now [they’ve] been given something by the doctor that makes us feel better. Having [an antibiotic] prescribed by the physician, there’s some weight to that, [which] we can’t [psychologically feel] when we [take medications] that come over the counter from the drugstore somehow.

I think we have to help educate the public about the differences between viruses and bacteria. We have to, all of us, not just patients, but all of us in healthcare as well, become more willing to delay starting an antibiotic [regimen] and engage in what some people have called 'watchful waiting'. I like to call [it] 'careful observation,' [because] when we say 'watchful waiting' it sounds like we’re not doing anything and that’s not the case, we actually are carefully observing people, and this is especially true for people who are in long-term care and post-acute care facilities.

Often it’s not clear if an older adult truly has an infection so if we can wait 6 hours, 12 hours, 24 hours [or] 48 hours before starting an antibiotic, and offer them more hydration, review their medicines, make sure they’ve gotten a good night’s sleep, talk to them and see what else might be going on, [then] there might not be a need for an antibiotic. That spares them the exposure to a potentially harmful medication, which is fantastic.”

How Can Healthcare Providers Improve C. diff Infection Control in Long-term Care Facilities?

“Some other ways that we can improve infection control of [Clostridium difficile] C. diff in long-term care facilities [is] to consider extending the isolation time. Some places have policies where once someone is continent of stool after 48 hours, they come out of contact precautions or isolation precautions. That may not be long enough. Sometimes the C. diff will recur; that happens often among older adults, up to 30% of the time. By the time [this has] recurred they’ve become an infectious risk again and that poses a problem for everyone else in the facility.

What one facility in my area has done, with great success, is they keep a stool chart. They monitor for up to two weeks after someone has been off of therapy for C. difficile how often [patients] are going to the bathroom, and if they see early signs of diarrhea, they [are put] right back on the contact precautions and they start thinking about [if] they need to reinitiate therapy for C. difficile. They’ve had great success; I think it’s a fantastic and practical approach.

Another innovation from this particular facility is that they put all of their C. diff patients or residents that are going to participate in rehab [and] they schedule those folks at the end of the day so that all [of] the equipment can be wiped down thoroughly with bleach and they don’t have to worry about getting the next person in. [Therefore], they can do a really thorough job and all [of] the equipment is clean and ready to go the next morning.”