C. diff, the common shorthand for the pathogenic bacterium Clostridioides difficile (formerly Clostridium difficile), is not a bug you want to pass around. Infection with C. difficile causes debilitating diarrhea and intestinal inflammation—leading to death in 15,000 patients in the U.S. each year. It is notoriously difficult to treat. Often after years of struggle with the microbe, many patients with C. diff infections have to resort to fecal microbiota transplants to completely revamp their microbiomes. That is, the feces of a healthy donor must be inserted into the gastrointestinal tract of the patient to allow a healthy mix of beneficial, protective microbes to recolonize the intestinal microenvironment. Ironically, this bacterial destroyer of intestinal health is most likely to be found in the very place patients visit to get well: the hospital.
C. difficile, Hospital-Acquired Infection #1
C. difficile infection (CDI) is among the most serious of nosocomial infections, affecting nearly half a million Americans each year. The leading cause of hospital-acquired diarrheal infection, C. difficile spreads via spores that are highly resistant to physical and biochemical cleaning agents. Approximately 75 percent of CDI cases are acquired in hospitals. Ironically, CDIs are strongly associated with antibiotic use. This is because, when systemic antibiotics are administered, they kill beneficial gut bacteria that protect against CDI. When these beneficial bacteria are eliminated by antibiotics, it paves the way for an easy takeover by C. difficile. Limiting the use of antibiotics therefore forms a cornerstone of the CDC’s recommendations for preventing CDIs.
Another approach to protect against CDIs is preventive administration of probiotics, and there has been moderate evidence indicating that probiotic therapy can be helpful. However, the human microbiome is a highly diverse micro-ecosystem containing thousands of different types of microbes; most probiotics contain only a handful of species—not even close to what is needed to build a healthy, gastrointestinal microenvironment. (Fecal transplantation is effective precisely because a fecal sample contains the full diversity of a healthy donor’s microbiome.) So, while probiotics are never a bad idea, the best approach for the prevention of CDI is prevention of transmission.
Stopping the Spread of C. difficile: the CDC’s New Guidelines
With CDIs accounting for nearly 500,000 cases and 15,000 deaths in the United States each year, prevention of transmission is of critical importance. Along with judicious use of antibiotics and isolation of patients with suspected or confirmed CDIs, the CDC recommends that rooms be cleaned daily and upon patient discharge and then disinfected with a spore-killing disinfectant. The disinfectant should be EPA-approved, and all surfaces should be thoroughly cleaned, in line with environmental infection-control guidelines. Any shared medical equipment should also be cleaned, and disposable items (such as single-use thermometers) should be used when possible.
The CDC also recommends that clinicians use gloves and gowns when caring for patients with C. diff. After removing gloves, clinicians should wash their hands with soap and water. Alcohol does not kill C. diff spores, so thorough washing with soap and water is recommended. C. diff spores are harder to remove than other common pathogens, so it is important to rigorously follow the specific recommendations for handwashing. For soap and water, hands should be first wet with water, then soap should be applied, then hands should be rubbed together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. The importance of being meticulous about hand hygiene after caring for patients with CDIs cannot be overstated.
Surface cleaning of patient rooms has long been emphasized as a cornerstone of hospital hygiene. However, it is arguably more likely for a bacterial pathogen to be transmitted by skin-to-skin touch rather than via environmental surfaces. Up to 59 percent of healthcare workers’ hands have been found to be contaminated with C. difficile after caring for a patient with a CDI. Therefore, stringent hand hygiene is of paramount importance in preventing the spread of C. difficile.
Supporting Handwashing Compliance
Compliance with handwashing guidelines is easier said than done. Although most healthcare workers understand the importance of hand hygiene when it comes to pathogens like C. difficile, there are a number of reasons for handwashing failure. These include understaffing, lack of supportive infrastructure for handwashing, skin irritation and simple forgetfulness. Institutions must therefore prioritize hand hygiene, providing convenient sinks and supplies (such as soap and paper towels, as well as lotions to ameliorate skin irritation), and actively support a hospital culture that values the importance of hand hygiene.
In addition, there are some specific steps that can be taken to increase handwashing compliance. One is tracking dispenser activity using a Smart Dispenser, which provides information on exact soap and sanitizer usage. Another is workflow monitoring via automated technology that records hand hygiene event frequencies along with all entries and exits from a patient’s room.
Central to these is continuous monitoring and feedback. Since hand hygiene failures are most often not deliberate, monitoring and feedback are of critical importance; poor handwashing can be rectified only if it is brought to the attention of the healthcare worker.
Technological solutions can be extremely helpful, providing immediate individual data and overall data that can be acted upon. For example, if a smart dispenser indicates that too little soap is being used in a room, the workers in that room can be reminded about handwashing.
No one wants to contract C. difficile or pass it along to others. C. diff is among the toughest pathogens around, but through a combination of education, motivation, and technology, we can make it the very rare occurrence it should be.
Dr. CS Copeland holds a BA in neuropsychology from the University of California at San Diego and a PhD in molecular and cellular biology from Tulane University, specializing in parasitology and virology, with postdoctoral research in molecular entomology and computational genomics.
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