Epidemiology and Prevention of C. difficile Infection

1
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

2
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

3
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

4
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

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C. difficile Infection Rate, 2003-2013
6
Sites of Attack for Preventionand Management of
CDI

1. Barrier precautions and environmental cleaning.

1. Stop unnecessaryantimicrobial use.

Now
Future
C. difficile acquisition
C. difficile acquisition
Asymptomatic C. difficile colonization
Antimicrobial(s)
CDI

1. Restore floraor colonize withnontoxigenicC.
   difficile

Hospitalization

1. Antibiotic Rx Nonantibiotic Rx

1. Keep patients outof the hospital.

1. Bolster immunity with vaccinesor passive
   antibody strategies.

Gerding and Johnson Clin Infect Dis.
2010511306-13
7
Sunenshine RH, McDonald LC. Cleve Clin J Med
200673187-197
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C. difficile PATHOGENESIS
CDC
10
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
11
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

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TRANSMISSION MECHANISMS INVOLVING THE SURFACE
ENVIRONMENT
Rutala WA, Weber DJ. InSHEA Practical
Healthcare Epidemiology (Lautenbach E, Woeltje
KF, Malani PN, eds), 3rd ed, 2010.
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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)

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ENVIRONMENTAL CONTAMINATON

• 25 (117/466) of cultures positive (lt10 CFU) for
  C. difficile. gt90 of sites positive with
  incontinent patients. (Samore et al. AJM
  199610032)
• 31.4 of environmental cultures positive for C.
  difficile. (Kaatz et al. AJE 19881271289)
• 9.3 (85/910) of environmental cultures positive
  (floors, toilets, toilet seats) for C. difficile.
  (Kim et al. JID 198114342)
• 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 1989320204)
• 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 198170907)

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

• Frequency of sites found contaminated10-gt50
  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 lt10 colonies on
  surfaces found to be contaminated. Two studies
  reported gt100 one reported a range of 1-gt200
  and one study sampled several sites with a sponge
  and found 1,300 colonies C. difficile.

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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
  (gt90)
• Level of contamination low (lt10 colonies per
  plate)
• Presence on hands correlated with prevalence of
  environmental sites

Samore MH, et al. Am J Med 199610032-40
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FREQUENCY OF ACQUISITION OF C. difficile ON
GLOVED HANDS AFTER CONTACT WITH SKIN AND
ENVIRONMENTAL SITESGuerrero et al. Am J Infect
Control 201240556-8
Risk of hand contamination after contact with
skin and commonly touched surfaces was identical
(50 vs 50)
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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 20103121-27
20
Thoroughness of Environmental CleaningCarling P.
AJIC 201341S20-S25
gt110,000 Objects
Mean 32
21
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 (p0.002)

Shaughnessy MK, et al. ICHE 201132201-206
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C. difficile spores
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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 198114342.

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DECREASING ORDER OF RESISTANCE OF MICROORGANISMS
TO DISINFECTANTS/STERILANTS
Most Resistant

• Prions
• Spores (C. difficile)
• Mycobacteria
• Non-Enveloped Viruses (norovirus)
• Fungi
• Bacteria (MRSA, VRE, Acinetobacter)
• Enveloped Viruses

Most Susceptible
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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 20003561324
• Novaplus (10 povidone iodine)
• Accel (0.5 hydrogen peroxide)

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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, 110, 6,000 ppm chlorine (but not 150)
• 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

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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., 110 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 gt
  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

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SURFACE DISINFECTIONEffectiveness of Different
MethodsRutala, Gergen, Weber. ICHE
2012331255-58
Technique (with cotton) C. difficile Log10 Reduction (110 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 gt2.9
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Daily Disinfection of High-Touch
SurfacesKundrapu et al. ICHE 2012331039
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
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Effective Surface Decontamination

• Practice and Product

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C. difficile Spores EPA-Registered Products

• List K EPAs 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

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

• 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)

Cadnum JL, et al. ICHE 201334441-2
33
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 (plt0.001) prolonged
  median time between HA CDI from 8 to 80 days

Orenstein R, et al ICHE 2011321137
34
Thoroughness of Environmental CleaningCarling P.
AJIC 201341S20-S25
gt110,000 Objects
Mean 32
35
Wipes Cotton, Disposable, Microfiber,
Cellulose-Based, Nonwoven Spunlace
Wipe should have sufficient wetness to achieve
the disinfectant contact time (e.g. gt1 minute)
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MONITORING THE EFFECTIVENESS OF CLEANINGCooper
et al. AJIC 200735338 Carling P AJIC
201341S20-S25

• Visual assessment-not a reliable indicator of
  surface cleanliness
• ATP bioluminescence-measures organic debris
  (each unit has own reading scale, lt250-500 RLU)
• Microbiological methods-lt2.5CFUs/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)

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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 (p0.002)

Shaughnessy MK, et al. ICHE 201132201-206
38
METHODS TO PREVENT CDIBASIC 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
39
METHODS TO PREVENT CDIBASIC 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
40
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

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METHODS TO PREVENT CDISPECIAL 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 yellow Strategies to
Prevent CDI Infections in Acute Care Hospitals
SHEA Guideline, 2014
42
BARRIER PRECAUTIONS

• Avoid use of electronic thermometers
• Use dedicated patient care items and equipment
• If equipment must be shared clean and disinfect
  between patients
• Use full barrier precautions (gowns and gloves)
  for contact with CDI patients and for contact
  with their environment (i.e., Contact
  Precautions)
• Place patient with CDI in a private room, if
  available give isolation preference to patients
  with fecal incontinence if room availability is
  limited

Strategies to Prevent CDI Infections in Acute
Care Hospitals SHEA Guideline, 2014
43
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.

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ANTISEPSIS TO PREVENT C. difficile INFECTIONS
Yes
No
70 isopropyl showed no inactivation of C.
difficile spores at exposure times of 5m, 15m,
and 30m. Wullt et al. ICHE 200324765.

• Either soap or CHG works as a handwash
• for removal of C. difficile.
• ICHE 199415697.

45
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 200930939-944
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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 30939)

• 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
  reduction
• Conclusion 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

47
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

48
Thoroughness of Environmental CleaningCarling et
al. ECCMID, Milan, Italy, May 2011
gt110,000 Objects
Mean 32
49
BEST PRACTICES FOR ROOM DISINFECTION USING
STANDARD DISINFECTANTS

• Follow the CDC Guideline for Disinfection and
  Sterilization with regard to choosing an
  appropriate germicide and best practices for
  environmental disinfection
• Appropriately train environmental service workers
  on proper use of PPE and clean/disinfection of
  the environment
• Have environmental service workers use checklists
  to ensure all room surfaces are
  cleaned/disinfected
• Assure that nursing and environmental service
  have agreed what items (e.g., sensitive
  equipment) is to be clean/disinfected by nursing
  and what items (e.g., environmental surfaces) are
  to be cleaned/disinfected by environmental
  service workers
• Use a method (e.g., fluorescent dye) to ensure
  proper cleaning

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NEW APPROACHES TO ROOM DECONTAMINATION
51
HP for Decontamination of the Hospital
EnvironmentFalagas et al. J Hosp Infect.
201178171
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
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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 gt2-3 NA 20 min Nerandzic M, et al.2
C. difficile 22,000 gt2-3 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-gt4.0 1.7-gt4.0 30-40 min Mahida N, et al.4
MRSA, VRE, MDR-A, Asp 22,000 gt4.0 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 2010311025 2BMC 201010197 3ICHE
201132737 4JHI 201384323l 5ICHE
201233507-12 6ICHE 201334466 ?Ws/cm2 min
minutes NA not available
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EFFECTIVENESS OF UV ROOM DECONTAMINATION
Rutala WA, et al. Infect Control Hosp Epidemiol.
2010311025-1029.
56
Retrospective Study on the Impact of UV on HA
MDROs Plus C. difficileHaas et al. Am J Infect
Control. 201442S86-90
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.
57
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
• Methods12 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,
  P0.03)
• Conclusion-HPV reduced the risk of acquiring
  MDROs compared to standard cleaning

Passaretti CL, et al. Clin Infect Dis
20135627-35
58
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

59
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

60
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)

61
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
20143047-53
62
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, OP,
  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.

63
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

64
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

65
THANK YOU!www.disinfectionandsterilization.org
66
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 agent

UNC routine measures are in yellow Strategies to
Prevent CDI Infections in Acute Care Hospitals
Draft SHEA Guideline, 2013
67
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., Hartmans 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

68
PHYSICAL REMOVAL VERSUS CHEMICAL INACTIVATION
Rutala WA, Gergen MF, Weber DJ. ICHE
2012331255-58
69
PROVING THAT ENVIRONMENTAL CONTAMINATION
IMPORTANT IN C. difficile TRANSMISSION

• Environmental persistence (Kim et al. JID
  198114342)
• Frequent environmental contamination (McFarland
  et al. NEJM 1989320204)
• Demonstration of HCW hand contamination (Samore
  et al. AJM 199610032)
• Environmental ? hand contamination (Samore et al.
  AJM 199610032)
• Person-to-person transmission (Raxach et al.
  ICHE 200526691))
• Transmission associated with environmental
  contamination (Samore et al. AJM 199610032)
• CDI room a risk factor (Shaughnessy et al.
  IDSA/ICAAC. Abstract K-4194)
• Improved disinfection ? ? epidemic CDI (Kaatz et
  al. AJE 19881271289)
• Improved disinfection ? ? endemic CDI (Boyce et
  al. ICHE 200829723)