5 key strategies physicians can use to help reduce Clostridium difficile inpatient rates

Ronald DworkinRonald Dworkin, M.D.
Medical director, Oregon Regional Infection Prevention Program

HO-CDI has very specific definitions and metrics, and it is a reportable hospital quality measure tracked by the Centers for Disease Control and Prevention. Many cases of HO-CDI occur due to new acquisition of Clostridium difficile (C.diff) spores during a patient’s hospital stay.

Providence’s infection prevention and quality experts (both at the Oregon level and at the system level) have established ambitious goals for our hospitals when it comes to HO-CDI. The expectation is that Providence hospitals will be in the top 25 percent of all hospitals in the U.S. Currently, our hospitals are slightly better than average. However, we can achieve this improvement through diligent effort and a multi-pronged approach.  We need active physician participation to make this happen!

HO-CDI: An overview

A hospital-onset C. diff (HO-CDI) infection is defined as a positive test result on a specimen collected more than three days after admission (date of admission being day one) and not previously positive within the past 14 days. A case is considered recurrent if more than 14 days and fewer than 56 days have passed since the last positive test. A case is facility-associated if the first positive test occurs within four weeks of discharge. Definitions are rigid, and cases fitting the definitions are carefully counted. 

C. diff spores are extremely hardy, and can be transferred via a caregiver’s hands or via the hospital environment (the dreaded “fecal patina”). In the absence of an “outbreak” of several cases on a hospital unit, C. diff origin can be difficult to trace. Some cases occur due to pre-existing gut colonization, and antibiotics given in the hospital can trigger overgrowth and the production of toxin and disease. Studies have shown that controlling the overuse of antibiotics is an important factor in effectively reducing C. diff infection (CDI).

Specific strategies for physicians/providers

Physicians and providers play a key role in reducing HO-CDI. Here are some specific strategies that we can implement to help reduce and effectively treat CDI:

  1. Think of CDI early in the hospital stay of patients with diarrhea. Don’t wait too long to test, since cases of community-onset CDI often are attributed incorrectly to hospital-onset CDI because the test is not sent until day four (or after) of the hospital stay.
  2. Do not OVER TEST. We know that the PCR (“NAAT”) test for CDI is highly sensitive, but it probably detects colonization as well as disease. The patient who is given a laxative for constipation and then develops loose stools may test positive because of colonization – thereby getting attributed incorrectly as an HO case. We are not able to adjust such cases as being colonized, rather than infected, due to the lab-based definition.
  3. Physicians should role model correct behavior around hand hygiene and use of personal protective equipment (PPE). Pay attention to isolation signage before entering a patient’s room. PPE is required, not optional! It’s required for safely caring for patients with CDI, and it must be worn whether or not you intend to touch the patient or the environment.
  4. Clean your hands with soap and water after removing PPE (often this requires hand washing inside the patient’s room). If the sink is not accessible, it is acceptable to use hand sanitizer when exiting the room, and proceed to the nearest sink to complete hand washing with soap and water.
  5. Think of yourself as a steward of a unique resource – antibiotics. They are lifesaving drugs, but they also can cause significant patient harm. Only use them when necessary, use the narrowest spectrum possible, and order for the shortest appropriate duration. All Providence hospitals in Oregon have an active antimicrobial stewardship program, which includes pharmacists, infectious disease physicians, and regular reviews of all patients receiving antibiotics. 

Other ways hospitals can prevent HO-CDI

Additional strategies to reduce HO-CDI include:

  • Timely and appropriate testing to institute isolation and reduce spread
  • Use of personal protective equipment for all caregivers entering the room
  • 100 percent use of appropriate hand hygiene (we have adopted soap and water on exiting the room, since C. diff spores are resistant to alcohol disinfection)
  • Bleach cleaning daily for high-touch surfaces and for terminal room cleaning
  • Excellent antimicrobial stewardship

In addition, new Epic tools are available to nurses to enhance documentation, such as a “best practice alert” that triggers when three or more loose stools occur in 24 hours. This alert reminds RNs to consider isolating the patient and to request that the physician consider a C. diff test. Physicians obviously must use their clinical judgment about whether a test is warranted.

A final word

CDI is a preventable infection that causes major morbidity and mortality for the patients in our care. In addition, hospitals will be on the line financially in the coming years for performance in the area of CDI. With your help, we can reduce HO-CDI and also help preserve efficacy of antibiotics by reducing bacterial drug resistance.