Stronger Hand Hygiene & Environmental Cleaning Best Combination for Reducing C. diff

A model-based economic evaluation conducted in Australia has found that a bundled approach consisting of stronger hand hygiene and improved environmental cleaning proved to be the best combination of health benefits and cost-savings for reducing C. diff.

“Combining efforts to improve hand hygiene compliance at the same time as improving environmental cleaning practices results in a larger decrease in C. diff cases than delivering those interventions on their own,” lead author David Brain, PhD, MPH, told our sister publication MD Magazine in a recent interview.

Responsible for about 15% to 25% of antibiotic-associated diarrhea, C. diff continues to be a major challenge for health care providers; in fact, the Centers for Disease Control and Prevention reports that the infection is estimated to cause about half a million infections in the United States in 2011 alone. Furthermore, the cost of primary infection ranges from $3,400 to $16,300 per case. About 83,000 of patients who develop C. diff will experience recurrent infection and treatment of a recurrent infection can cost between $13,700 to $18,000.

“The most effective approach to reducing C. diff transmission is to implement interventions in a bundled manner,’’ said Dr. Brain, a research fellow at the Australian Centre for Health Services Innovation, Queensland University of Technology, in Brisbane.

At the same time, deaths attributable to C. diff have increased from pre-2000 estimates of 1.5% mortality to anywhere between 4.5% and 5.7% mortality in recent years, according to the paper published in PLOS ONE by Brain and a team from Australia and the UK.

“The clinical aspects of the infection have been well described across many different settings globally, but there is very little information from an economic perspective,’’ Dr. Brain said.

However, that is beginning to change as interest in cost-effectiveness analyses has spiked in recent years. According to Dr. Brian, health care decision-makers are trying to manage the increased demand for services with a limited health care budget.

To assess the costs and benefits of various C. diff-fighting strategies, Dr. Brain and his team considered data from Australian hospitals, the natural history of the disease, and literature on the efficacy of various methods.

"Most hospitals employ a mixed approach that combines antimicrobial stewardship, hand hygiene, environmental cleaning, and fecal bacteriotherapy,” the authors wrote.

However, the team found a lack of economic evidence to support current practice.

“The majority of guidelines are built solely on clinical evidence, with no consideration of the costs and health returns from alternative strategies of infection control,’’ they said.

To find the most effective approach to reducing CDI, the authors’ model examined both health outcomes and costs. To assess health, they considered the effectiveness of an intervention and its subsequent impact on a patient’s quality of life. They categorized costs as intervention-related (such as staff and equipment expenses) and infection-related (which included the price of diagnosis, treatment, and hospital stays).

After assessing 10 different approaches, Dr. Brain and his team found that the one that was most successful combined stronger hand hygiene practices with improved environmental cleaning — a bundle the researchers called "hygiene improvement.’’ This strategy resulted in decreased disease incidence—going to 1.1 per 1000 bed days from 3.2 per 1000 bed days.

“Hygiene improvement achieved the greatest health benefits, with 127 quality-adjusted life years (QALYs) gained and the lowest costs, with over $2 million saved,” they found.

Interestingly, grouping hygiene improvement with another intervention, such as antimicrobial stewardship (AMS), yielded little additional benefit.

“Antimicrobial stewardship programs, which are a common intervention that is designed to reduce the number of C. difficile infections, were not always successful in achieving a reduction,” Dr. Brain said. In fact, AMS on its own resulted in only a small reduction in C. diff incidence to 2.3 per 1000 bed days from 2.8 per 1000 bed days.

Fecal transplant also was an ineffective control tool, the team found. On its own, the procedure reduced C. diff incidence to just 2.4 per 1000 bed days from 2.5 per 1000 bed days. The technique also appeared to have little impact when combined with other transmission-reduction strategies.

Such analyses can lead to improved decision making, according to Dr. Brain. For instance, infectious disease physicians, ward managers, and others might divert limited resources from an approach such as AMS to a bundle of hand hygiene and environmental cleaning to achieve better clinical outcomes.

How might such findings inform C. diff control in US hospitals?

“The 2 health systems (Australia and US) are quite different from a funding perspective, so I think that the approach to costing would be quite different,” Dr. Brain explained. Instead of using a health care perspective, as the current study did, the United States might look at the cost to insurers or users’ out-of pocket-costs, he said.

“There may also be other interventions that would be more locally appropriate to include in the model,’’ Dr. Brain added, noting that economic modeling is useful because it can be updated when new data become available.

“I do think that the clinical outcomes are quite transferable, though, especially if there is little information currently available from US-based studies,” he said.

As for what’s next? Dr. Brian’s team is now focusing on quantifying the economic burden of C. diff in the Australian hospital setting. To date, the extended length of stay attributable to C. diff has been difficult to pin down due to irregularities in the way information is collected, he said.

“We hope that the methods will be transferable to other settings, like the United States and the United Kingdom so that we can contribute to the international evidence base,” Dr. Brain concluded.

A previous version of this article has appeared on MDMagazine.com.