Epidemiology and Prevention of C. difficile Infection

William A. Rutala, Ph.D., M.P.H.Director, Hospital Epidemiology, Occupational Health and

Safety, UNC Health Care; Research Professor of Medicine, Director, Statewide Program for Infection Control and

Epidemiology, University of North Carolina at Chapel Hill, NC, USA

Disclosure: Clorox

LECTURE OBJECTIVES

Understand the epidemiology and impact of C. difficile Review the role of the environment in disease

transmission Discuss how to prevent transmission of C. difficile via

contaminated surfaces Identify effective preventive strategies

CLOSTRIDIUM DIFFICILE MICROBIOLOGY

Anaerobic bacterium Forms spores that persist Colonizes human GI tract Fecal-oral spread Toxins produce colitis

Diarrhea More severe disease; death

2-steps to infection New acquisition via transmission Antibiotics result in vulnerability

CDI due to BI/NAP1/027 carries high mortality and management remains problematic

C. difficile: MICROBIOLOGY AND EPIDEMIOLOGY

Gram-positive bacillus: Strict anaerobe, spore-former Colonizes human GI tract Increasing prevalence and incidence New epidemic strain that hyperproduces toxins A and B Introduction of CDI from the community into hospitals High morbidity and mortality in elderly Asymptomatic C. difficile carriers may be reservoir in healthcare Inability to effectively treat fulminant CDI Absence of a treatment that will prevent recurrence of CDI Inability to prevent CDI

C. difficile Infection Rate, 2003-2013

Sunenshine RH, McDonald LC. Cleve Clin J Med 2006;73:187-197

C. difficile PATHOGENESIS

CDC

ANTIBIOTIC STEWARDSHIP

Encourage appropriate antibiotic use which includes: Avoiding antimicrobial exposure if the patient does

not have a condition for which antibiotics are indicated

When possible select an antibiotic associated with a lower risk of CDI

Strategies to Prevent CDI Infections in Acute Care Hospitals: SHEA Guideline, 2014

Strategies to Prevent CDI

C. difficile shares many common epidemiologic characteristics with other antimicrobial-resistant gram-positive bacteria, such as MRSA and VRE

Both the skin and the environment of colonized patients becomes contaminated, and the healthcare provider hands may become contaminated by touching the environment or the patient.

Major difference is C. difficile forms spores

TRANSMISSION MECHANISMS INVOLVING THE SURFACE ENVIRONMENT

Rutala WA, Weber DJ. In:”SHEA Practical Healthcare Epidemiology” (Lautenbach E, Woeltje KF, Malani PN, eds), 3rd ed, 2010.

FACTORS LEADING TO ENVIRONMENTAL TRANSMISSION OF CLOSTRIDIUM DIFFICILE

Frequent contamination of the environment Stable in the environment Relatively resistant to disinfectants Low inoculating dose Common source of infectious gastroenteritis Susceptible population (limited immunity)

ENVIRONMENTAL CONTAMINATON

25% (117/466) of cultures positive (<10 CFU) for C. difficile. >90% of sites positive with incontinent patients. (Samore et al. AJM 1996;100:32)

31.4% of environmental cultures positive for C. difficile. (Kaatz et al. AJE 1988;127:1289)

9.3% (85/910) of environmental cultures positive (floors, toilets, toilet seats) for C. difficile. (Kim et al. JID 1981;143:42)

29% (62/216) environmental samples were positive for C. difficile. 29% (11/38) positive cultures in rooms occupied by asymptomatic patients and 49% (44/90) in rooms with patients who had CDAD. (NEJM 1989;320:204)

10% (110/1086) environmental samples were positive for C. difficile in case-associated areas and 2.5% (14/489) in areas with no known cases. (Fekety et al. AJM 1981;70:907)

C. difficile Environmental ContaminationRutala, Weber. SHEA. 3rd Edition. 2010

• Frequency of sites found contaminated~10->50% from 13 studies-stethoscopes, bed frames/rails, call buttons, sinks, hospital charts, toys, floors, windowsills, commodes, toilets, bedsheets, scales, blood pressure cuffs, phones, door handles, electronic thermometers, flow-control devices for IV catheter, feeding tube equipment, bedpan hoppers

• C. difficile spore load is low-7 studies assessed the spore load and most found <10 colonies on surfaces found to be contaminated. Two studies reported >100; one reported a range of “1->200” and one study sampled several sites with a sponge and found 1,300 colonies C. difficile.

FREQUENCY OF ENVIRONMENTAL CONTAMINATION AND RELATION TO HAND CONTAMINATION

Study design: Prospective study, 1992 Setting: Tertiary care hospital Methods: All patients with CDI assessed

with environmental cultures Results

Environmental contamination frequently found (25% of sites) but higher if patients incontinent (>90%)

Level of contamination low (<10 colonies per plate)

Presence on hands correlated with prevalence of environmental sites

Samore MH, et al. Am J Med 1996;100:32-40

FREQUENCY OF ACQUISITION OF C. difficile ON GLOVED HANDS AFTER CONTACT WITH SKIN AND ENVIRONMENTAL SITES

Guerrero et al. Am J Infect Control 2012;40:556-8

Risk of hand contamination after contact with skin and commonly touched surfaces was identical (50% vs 50%)

PERCENT OF STOOL, SKIN, AND ENVIRONMENT CULTURES POSITIVE FOR C. difficile

Skin (chest and abdomen) and environment (bed rail, bedside table, call button, toilet seat) Sethi AK, et al. ICHE 2010;31:21-27

Thoroughness of Environmental CleaningCarling P. AJIC 2013;41:S20-S25

0

20

40

60

80

100

HEHSG HOSP

IOWA HOSP

OTHER HOSP

OPERATING ROOMS

NICUEMS VEHICLES

ICU DAILY

AMB CHEMO

MD CLINIC

LONG TERM

DIALYSIS

%

DAILY CLEANING

TERMINAL CLEANING

Cle

aned

Mean = 32%

>110,000 Objects

EVALUATION OF HOSPITAL ROOM ASSIGNMENT AND ACQUISITION OF CDI

Study design: Retrospective cohort analysis, 2005-2006

Setting: Medical ICU at a tertiary care hospital

Methods: All patients evaluated for diagnosis of CDI 48 hours after ICU admission and within 30 days after ICU discharge

Results (acquisition of CDI) Admission to room previously

occupied by CDI = 11.0% Admission to room not previously

occupied by CDI = 4.6% (p=0.002)

Shaughnessy MK, et al. ICHE 2011;32:201-206

C. difficile spores

SURVIVALC. difficile

Vegetative cells Can survive for at least 24 h on inanimate surfaces

Spores Spores survive for up to 5 months. 106 CFU of C.

difficile inoculated onto a floor; marked decline within 2 days. Kim et al. J Inf Dis 1981;143:42.

DECREASING ORDER OF RESISTANCE OF MICROORGANISMS TO DISINFECTANTS/STERILANTS

PrionsSpores (C. difficile)

MycobacteriaNon-Enveloped Viruses (norovirus)

FungiBacteria (MRSA, VRE, Acinetobacter)

Enveloped VirusesMost Susceptible

Most Resistant

DISINFECTANTS AND ANTISEPSISC. difficile spores at 20 min, Rutala et al, 2006

No measurable activity (1 C. difficile strain, J9) CHG Vesphene (phenolic) 70% isopropyl alcohol 95% ethanol 3% hydrogen peroxide Clorox disinfecting spray (65% ethanol, 0.6% QUAT) Lysol II disinfecting spray (79% ethanol, 0.1% QUAT) TBQ (0.06% QUAT); QUAT may increase sporulation capacity- Lancet

2000;356:1324 Novaplus (10% povidone iodine) Accel (0.5% hydrogen peroxide)

DISINFECTANTS AND ANTISEPSISC. difficile spores at 10 and 20 min, Rutala et al, 2006

~4 log10 reduction (3 C. difficile strains including BI-9) Clorox, 1:10, ~6,000 ppm chlorine (but not 1:50) Clorox Clean-up, ~19,100 ppm chlorine Tilex, ~25,000 ppm chlorine Steris 20 sterilant, 0.35% peracetic acid Cidex, 2.4% glutaraldehyde Cidex-OPA, 0.55% OPA Wavicide, 2.65% glutaraldehyde Aldahol, 3.4% glutaraldehyde and 26% alcohol

CONTROL MEASURESC. difficile Disinfection

In units with high endemic C. difficile infection rates or in an outbreak setting, use dilute solutions of 5.25-6.15% sodium hypochlorite (e.g., 1:10 dilution of bleach) for routine disinfection. (CDC and SHEA).

We now use chlorine solution in all CDI rooms for routine daily and terminal cleaning (formerly used QUAT in patient rooms with sporadic CDI). One application of an effective product covering all surfaces to allow a sufficient wetness for > 1 minute contact time. Chlorine solution normally takes 1-3 minutes to dry.

For semicritical equipment, glutaraldehyde (20m), OPA (12m) and peracetic acid (12m) reliably kills C. difficile spores using normal exposure times

SURFACE DISINFECTIONEffectiveness of Different Methods

Rutala, Gergen, Weber. ICHE 2012;33:1255-58

Technique (with cotton) C. difficile Log10 Reduction (1:10 Bleach)

Saturated cloth 3.90

Spray (10s) and wipe 4.48

Spray, wipe, spray (1m), wipe 4.48

Spray 3.44

Spray, wipe, spray (until dry) 4.48

5500 ppm chlorine pop-up wipe 3.98

Non-sporicidal wipe >2.9

Daily Disinfection of High-Touch SurfacesKundrapu et al. ICHE 2012;33:1039

Daily disinfection of high-touch surfaces (vs cleaned when soiled) with sporicidal disinfectant in rooms of patients with CDI and MRSA reduced acquisition of pathogens on hands after contact with surfaces and of hands caring for the patient

Effective Surface Decontamination

Practice and Product

C. difficile Spores EPA-Registered Products

List K: EPA’s Registered Antimicrobials Products Effective Against C. difficile spores, April 2014

http://www.epa.gov/oppad001/list_k_clostridium.pdf

34 registered products; most chlorine-based, some HP/PA-based, PA with silver

TRANSFER OF C. DIFFICILE SPORES BY NONSPORICIDAL WIPES AND IMPROPERLY USED HYPOCHLORITE WIPES

Study design: In vitro study that assessed efficacy of different wipes in killing of C. difficile spores (5-log10) Fresh hypochlorite wipes Used hypochlorite wipes Quaternary ammonium wipes

Results (4th transfer) Quat had no efficacy (3-log10

spores) Fresh hypochlorite worked Used hypochlorite transferred

spores in lower concentration (0.4-log10 spores)

Practice + Product = Perfection

Cadnum JL, et al. ICHE 2013;34:441-2

REDUCTION IN CDI INCIDENCE WITH ENHANCED ROOM DISINFECTION

Before-after study of CDI incidence rates in two hyperendemic wards at a 1,249 bed hospital

Intervention: Change from cleaning rooms with QUAT to bleach wipes (0.55% Cl) for both daily and terminal disinfection

Results: CDI incidence dropped 85% from 24.2 to 3.6 cases per 10,000 pt-days (p<0.001); prolonged median time between HA CDI from 8 to 80 days

Orenstein R, et alICHE 2011;32:1137

Thoroughness of Environmental CleaningCarling P. AJIC 2013;41:S20-S25

0

20

40

60

80

100

HEHSG HOSP

IOWA HOSP

OTHER HOSP

OPERATING ROOMS

NICUEMS VEHICLES

ICU DAILY

AMB CHEMO

MD CLINIC

LONG TERM

DIALYSIS

%

DAILY CLEANING

TERMINAL CLEANING

Cle

aned

Mean = 32%

>110,000 Objects

Wipes Cotton, Disposable, Microfiber, Cellulose-Based, Nonwoven Spunlace

Wipe should have sufficient wetness to achieve the disinfectant contact time (e.g. >1 minute)

MONITORING THE EFFECTIVENESS OF CLEANINGCooper et al. AJIC 2007;35:338; Carling P AJIC 2013;41:S20-S25

Visual assessment-not a reliable indicator of surface cleanliness

ATP bioluminescence-measures organic debris (each unit has own reading scale, <250-500 RLU)

Microbiological methods-<2.5CFUs/cm2-pass; can be costly and pathogen specific

Fluorescent marker-transparent, easily cleaned, environmentally stable marking solution that fluoresces when exposed to an ultraviolet light (applied by IP unbeknown to EVS, after EVS cleaning, markings are reassessed)

EVALUATION OF HOSPITAL ROOM ASSIGNMENT AND ACQUISITION OF CDI

Study design: Retrospective cohort analysis, 2005-2006

Setting: Medical ICU at a tertiary care hospital

Methods: All patients evaluated for diagnosis of CDI 48 hours after ICU admission and within 30 days after ICU discharge

Results (acquisition of CDI) Admission to room previously

occupied by CDI = 11.0% Admission to room not previously

occupied by CDI = 4.6% (p=0.002)

Shaughnessy MK, et al. ICHE 2011;32:201-206

METHODS TO PREVENT CDI:BASIC PRACTICES

Encourage appropriate use of antimicrobials Use contact precautions for infected patients

Single room Don gloves and gown when entering room; remove before exiting Hand hygiene before and after glove use

Use dedicated equipment whenever possible If equipment is shared between patients do not bring into room (e.g.,

glucometer) Clean and disinfect shared equipment after use

Strategies to Prevent CDI Infections in Acute Care Hospitals: SHEA Guideline, ICHE, 2014

METHODS TO PREVENT CDI:BASIC PRACTICES

Criteria for discontinuing isolation Duration of illness (some experts recommend for at least 48 hours

after diarrhea resolves) Use an EPA-registered sporicidal agent for room disinfection in hyperendemic

and outbreak situations Ensure cleaning and disinfection of equipment and the environment as

potential reservoirs Assess adherence to protocols Implement lab-based alert system to provide immediate notification to IP and

clinical personnel Educate patients and their families about CDI Measure compliance with hand hygiene and contact precaution

recommendations

Strategies to Prevent CDI Infections in Acute Care Hospitals: SHEA Guideline, ICHE, 2014

UNC HEALTH CARE ISOLATION SIGN FOR PATIENTS WITH NOROVIRUS OR C. difficile

Use term Contact-Enteric Precautions

Requires gloves and gown when entering room

Recommends hand hygiene with soap and water (instead of alcohol-based antiseptic)

Information in English and Spanish

METHODS TO PREVENT CDI:SPECIAL APPROACHES

(CDI Incidence Remains Higher than Goal)

Intensify the assessment of compliance with process measures Compliance with hand hygiene Compliance with Contact Precautions If compliance inadequate, institute corrective actions

Perform hand hygiene with soap and water Empirically place patients with diarrhea on Contact Precautions

(remove isolation if test for C. difficile is negative) Prolong duration of contact precautions until discharge Monitor the effectiveness of room cleaning (e.g., fluorescent dye) Consider routine environmental decontamination with sodium

hypochlorite or an EPA-registered sporicidal agent

UNC routine measures are in yellowStrategies to Prevent CDI Infections in Acute Care Hospitals: SHEA Guideline, 2014

DISCONTINUING ISOLATION

CDC currently recommends contact precautions for the duration of illness when care for patients with CDI. Some experts recommend continuing contact precautions for at least

48 hours after diarrhea resolves

At this time data do NOT exist to support extending isolation as a measure to decrease CDI incidence.

ANTISEPSIS TO PREVENT C. difficile INFECTIONS

70% isopropyl showed no inactivation of C. difficile spores at exposure times of 5m, 15m, and 30m. Wullt et al. ICHE 2003;24:765.

Either soap or CHG works as a handwash for removal of C. difficile. ICHE 1994;15:697.

Yes

No

EFFICACY OF ALCOHOL AS A HAND HYGIENE AGENT AGAINST C. difficile

Probability of heavy contamination (TNTC) following different HH interventions: warm water and plain soap = 0, cold water and plain soap = 0, warm water and antibacterial soap = 0, antiseptic hand wipe = 0.05, alcohol-based handrub = 0.43, and no hand hygiene = 1

Oughton MT, et al. ICHE 2009;30:939-944

Hand Hygiene with Soap and Water Is Superior to Alcohol Rub and Antiseptic Wipes for Removal of C. difficile

(Oughton et al. Infect Control Hosp Epidemiol 2009; 30:939)

Objective: Evaluate HH methods for efficacy in removing C. difficile

Design: Randomized crossover comparison among 10 volunteers experimentally contaminated by 1.4x105 C. difficile (62% spores)

Methods: Interventions were evaluated for mean reductionConclusion: Handwashing with soap and water showed the greatest

efficacy in removing C. difficile and should be performed preferentially over the use of alcohol-based hand rubs when contact with C. difficile is suspected or likely

The Role of the Environment in Disease Transmission

Over the past decade there has been a growing appreciation that environmental contamination makes a contribution to HAI with MRSA, VRE, Acinetobacter, norovirus and C. difficile

Surface disinfection practices are currently not effective in eliminating environmental contamination

Inadequate terminal cleaning of rooms occupied by patients with MDR pathogens places the next patients in these rooms at increased risk of acquiring these organisms

Thoroughness of Environmental CleaningCarling et al. ECCMID, Milan, Italy, May 2011

0

20

40

60

80

100

HEHSG HOSP

IOWA HOSP

OTHER HOSP

OPERATING ROOMS

NICUEMS VEHICLES

ICU DAILY

AMB CHEMO

MD CLINIC

LONG TERM

DIALYSIS

%

DAILY CLEANING

TERMINAL CLEANING

Cle

aned

Mean = 32%

>110,000 Objects

NEW APPROACHES TO ROOM DECONTAMINATION

HP for Decontamination of the Hospital Environment

Falagas et al. J Hosp Infect. 2011;78:171

Author, Year HP System Pathogen Before HPV After HPV % Reduction

French, 2004 VHP MRSA 61/85-72% 1/85-1% 98

Bates, 2005 VHP Serratia 2/42-5% 0/24-0% 100

Jeanes, 2005 VHP MRSA 10/28-36% 0/50-0% 100

Hardy, 2007 VHP MRSA 7/29-24% 0/29-0% 100

Dryden, 2007 VHP MRSA 8/29-28% 1/29-3% 88

Otter, 2007 VHP MRSA 18/30-60% 1/30-3% 95

Boyce, 2008 VHP C. difficile 11/43-26% 0/37-0% 100

Bartels, 2008 HP dry mist MRSA 4/14-29% 0/14-0% 100

Shapey, 2008 HP dry mist C. difficile 48/203-24%; 7 7/203-3%; 0.4 88

Barbut, 2009 HP dry mist C. difficile 34/180-19% 4/180-2% 88

Otter, 2010 VHP GNR 10/21-48% 0/63-0% 100

EFFECTIVENESS OF UV-C FOR ROOM DECONTAMINATION (Inoculated Surfaces)

Pathogens Dose* Mean log10 Reduction Line of Sight

Mean log10 Reduction Shadow

Time Reference

MRSA, VRE, MDR-A 12,000 3.90-4.31 3.25-3.85 ~15 min Rutala W, et al.1

C. difficile 36,000 4.04 2.43 ~50 min Rutala W, et al.1

MRSA, VRE 12,000 >2-3 NA ~20 min Nerandzic M, et al.2

C. difficile 22,000 >2-3 NA ~45 min Nerandzic M, et al.2

C. difficle 22,000 2.3 overall 67.8 min Boyce J, et al.3

MRSA, VRE, MDR-A, Asp 12,000 3.-5->4.0 1.7->4.0 30-40 min Mahida N, et al.4

MRSA, VRE, MDR-A, Asp 22,000 >4.0* 1.0-3.5 60-90 min Mahida N, et al.4

C. difficile, G. stear spore 22,000 2.2

overall 73 min Havill N et al5

VRE, MRSA, MDR-A 12,000 1.61 1.18 25 min Anderson et al6

1ICHE 2010;31:1025; 2BMC 2010;10:197; 3ICHE 2011;32:737; 4JHI 2013;84:323l 5ICHE 2012;33:507-12 6ICHE 2013;34:466 * Ws/cm2; min = minutes; NA = not available

EFFECTIVENESS OF UV ROOM DECONTAMINATION

Rutala WA, et al. Infect Control Hosp Epidemiol. 2010;31:1025-1029.

Retrospective Study on the Impact of UV on HA MDROs Plus C. difficileHaas et al. Am J Infect Control. 2014;42:S86-90

During the UV period (pulsed Xenon), significant decrease in HA MDRO plus C. difficile. UV used for 76% of Contact Precaution discharges. 20% decrease in HA MDRO plus C. difficile during the 22-m UV period compared to 30-m pre-UV period.

USE OF HPV TO REDUCE RISK OF ACQUISITION OF MDROs

• Design: 30 mo prospective cohort study with hydrogen peroxide vapor (HPV) intervention to assess risks of colonization or infection with MDROs

• Methods:12 mo pre-intervention phase followed by HPV use on 3 units for terminal disinfection

• Results Prior room occupant colonized or infected with MDRO in 22% of cases Patients admitted to HPV decontaminated rooms 64% less likely to acquire any

MDRO (95% CI, 0.19-0.70) and 80% less likely to acquire VRE (95% CI, 0.08-0.52) Risk of C. difficile, MRSA and MDR-GNRs individually reduced but not

significantly Proportion of rooms environmentally contaminated with MDROs significantly

reduced (RR, 0.65, P=0.03)• Conclusion-HPV reduced the risk of acquiring MDROs compared to standard

cleaning

Passaretti CL, et al. Clin Infect Dis 2013;56:27-35

LECTURE OBJECTIVES

Understand the epidemiology and impact of C. difficile Review the role of the environment in disease

transmission Discuss how to prevent transmission of C. difficile via

contaminated surfaces Identify effective preventive strategies

C. difficile: Prevention Measures

New Enteric Contact Isolation sign-promote soap and water and sporicidal disinfectant

Enhanced nursing education-ICLs Daily/terminal bleach disinfection of all C. difficile

patient rooms Bleach wipes-shared equipment Monitoring thoroughness of cleaning Isolation until no symptoms and end of treatment

C. difficile: Prevention Measures

Use fidaxomicin in selected CDI patients to reduce recurrences

Prescribe and use antibiotics carefully Follow surgical prophylaxis guidelines (max 24h) Test for C. difficile when patients have diarrhea

while on antibiotics or recent antibiotics (60d) Use new PCR test as part of diagnostic algorithm

(which increases sensitivity of diagnosis)

FECAL MICROBIOTA TRANSPLANTATION (FMT) FOR CDI

Gut microbiota alterations key abnormality in CDI FMT demonstrated excellent cure rate (80-90%) in severe and

recurrent cases with good acceptability by patients and physicians Active reporting of adverse events lacking, although few AEs

reported in most studiees Long-term effects of FMT still unexplored FMT should follow traditional pathways of new therapy and

caution in recommending FMT is warranted until mechanisms and risks of procedure are clear

Vecchio AL, Cohen MB. Curr Opin Gastroenterol 2014;30:47-53

Fecal Transplants for Refractory C. difficile Infection

Criteria for eligibility -failed standard therapy, no contraindication to colonoscopy, confirmed C. difficile toxin positive, etc

Self-identified donor-donor will respond to eligibility questions: no GI cancer, no metabolic disease, no prior use of illicit drugs, etc

Donor Testing-Stool-C. difficile toxin, O&P, bacterial pathogen panel (Salmonella, Shigella, Giardia, norovirus, etc). Serum-RPR, HIV-1, HIV-2, HCV Ab, CMV viral load, HAV IgM and IgG, HBsAg, liver tests, etc

Stool preparation-fresh sample into 1 liter sterile bottle, 500ml saline added, vigorously shaking to liquefy, solid pieces removed with sterile gauze so sample is liquid, liquid stool drawn up into 7 sterile 50ml syringes, injected into terminal ileum, cecum, ascending colon, traverse colon, descending colon, sigmoid colon. Colonoscope reprocessed by HLD.

LECTURE OBJECTIVES

Understand the epidemiology and impact of C. difficile Review the role of the environment in disease

transmission Discuss how to prevent transmission of C. difficile via

contaminated surfaces Identify effective preventive strategies

CONCLUSIONS

Contaminated environment likely important for C. difficile Some disinfectants are effective but surfaces must be thoroughly

wiped to eliminate environmental contamination Inadequate terminal cleaning of rooms occupied by patients with

C. difficile pathogens places the next patients in these rooms at increased risk of acquiring these organisms

Eliminating the environment as a source for transmission of nosocomial pathogens requires: adherence to proper room cleaning and disinfection protocols (thoroughness), effective product, hand hygiene, and institution of Isolation Precautions

THANK YOU!www.disinfectionandsterilization.org

SPECIAL APPROACHES FOR PREVENTING CDI

Intensify the assessment of compliance with process measures Compliance with hand hygiene Compliance with Contact Precautions If compliance inadequate, institute corrective actions

Perform hand hygiene with soap and water Empirically place patients with diarrhea on Contact Precautions

(remove isolation if test for C. difficile is negative) Create a unit specific check list for room disinfection Monitor the effectiveness of room cleaning (e.g., fluorescent dye) Consider routine environmental decontamination with sodium

hypochlorite or an EPA-registered sporicidal agentUNC routine measures are in yellowStrategies to Prevent CDI Infections in Acute Care Hospitals: Draft SHEA Guideline, 2013

COMMENTS ON THERAPY

Oral vancomycin superior to oral metronidazole Can reduce cost of vancomycin by using compounding IV preparation into a

PO liquid medication In patients in whom oral antibiotics cannot reach a segment of the colon (e.g.,

Hartman’s pouch, ileostomy, colon diversion) vancomycin should be delivered via enema

No clinical evidence from RCTs that IV metronidazole is effective Fidaxomicin demonstrated to have a lower risk of CDI recurrences (25d)

but similar efficacy in initial therapy with oral vancomycin Consider for therapy if patient relapses

Consider tigecycline when patients fail to respond to standard therapy Unclear whether probiotics work for prophylaxis or therapy No evidence to support use of IVIG

PHYSICAL REMOVAL VERSUS CHEMICAL INACTIVATION

Rutala WA, Gergen MF, Weber DJ. ICHE 2012;33:1255-58

PROVING THAT ENVIRONMENTAL CONTAMINATION IMPORTANT IN C. difficile TRANSMISSION

Environmental persistence (Kim et al. JID 1981;14342)

Frequent environmental contamination (McFarland et al. NEJM 1989;320:204)

Demonstration of HCW hand contamination (Samore et al. AJM 1996;100:32)

Environmental hand contamination (Samore et al. AJM 1996;100:32)

Person-to-person transmission (Raxach et al. ICHE 2005;26:691))

Transmission associated with environmental contamination (Samore et al. AJM 1996;100:32)

CDI room a risk factor (Shaughnessy et al. IDSA/ICAAC. Abstract K-4194)

Improved disinfection epidemic CDI (Kaatz et al. AJE 1988;127:1289)

Improved disinfection endemic CDI (Boyce et al. ICHE 2008;29:723)