CDC report exposes out-of-hospital C diff threats

Mar 6, 2012 (CIDRAP News) – Other healthcare settings besides hospitals play a larger role than previously thought in the spread of sometimes-fatal Clostridium difficile infections, according an analysis today of new data from the US Centers for Disease Control and Prevention (CDC).

Though the CDC has seen overall healthcare-associated infection (HAI) levels tumble over the last few years, the number of C diff infections has risen. The new report, published today as part of the CDC's Vital Signs series, also reported some promising findings about the benefits of C diff prevention programs in three states.

At a media briefing today to unveil the new findings, Ileana Arias, PhD, the CDC's principal deputy director, called the release of the new findings a national call for action to make C diff prevention a higher priority. "Everyone who has a hand in patient care has a hand in prevention," she said.

She pointed out that 14,000 deaths attributed to C diff infections each year are preventable. C diff is a gram-positive bacterium—transmitted by hand contact with objects contaminated with feces—that causes diarrhea and potentially fatal conditions such as colitis, toxic megacolon, and sepsis.

The CDC's new analysis is based on 2010 data from the CDC's Emerging Infections Program, the National Healthcare Safety Network's Multidrug-Resistant Organism and Clostridium difficile Infection module, and early results from three state programs (Illinois, Massachusetts, and New York) in which hospitals collaborated to prevent HAIs, including hospital-onset C diff illnesses.

Infections are associated with previous antibiotic use and are most common in older patients and others who have been in a hospital, nursing home, or other healthcare settings. Health officials have linked much of the increased incidence and mortality to the emergence and spread of a more virulent strain known as the North American pulse-field type 1 (NAP1).

An earlier estimate of C diff burden, based on hospital billing data, showed that hospital stays linked to C diff infections have remained at historically high levels, about 337,000 per year at a cost of $1 billion, according to a CDC press release.

However, the agency said the Vital Signs report suggests that hospital estimates reveal only part of the C diff burden. The new analysis links 94% of C diff infections to medical care. In about 25% of infections, symptoms first surface in hospital patients. But in about 75%, symptoms first show in nursing home patients or in those who recently received care in doctor's offices and clinics.

The report said about half of C diff infections diagnosed in hospitals were present when the patient was admitted, typically after receiving care in other medical settings.

Clifford McDonald, MD, a medical epidemiologist at CDC and lead author of the study, told reporters that C diff is not just a hospital problem but poses a risk anywhere medical care is given. He added, though, that hospitals still play a central role in prevention, because the most potent antibiotics are given in hospital settings. Antibiotic treatment for other conditions, combined with exposure to C diff spores in medical settings, provides a window of vulnerability to C diff infection, he said.

C diff contamination at one facility can become a problem in other settings when patients circulate between clinics, nursing homes, and hospitals in the same geographic area, he said, pointing to a need for better care coordination between facilities. For example, McDonald said, medical teams can communicate with each other when patients with known C diff infections are transferred to other facilities.

When CDC researchers looked at hospital-onset C diff infections across the three prevention programs, they found that levels declined 20% in less than 2 years after implementing infection control recommendations. They said the early promising results are in line with similar efforts in England that have led to a more-than-50% drop in C diff infections in 3 years.

McDonald said the key steps for reducing C diff infections include prescribing and using antibiotics carefully; isolating infected patients; using gloves and gowns, even when performing routine care; using bleach or other spore-killing products to clean surfaces; and notifying other facilities when sick patients are transferred.

Arias said patients also have a C diff prevention role to play by taking antibiotics only as prescribed, telling the doctor when they are sick, washing their hands, and using a separate and frequently cleaned bathroom area when diarrhea symptoms are present.

Jane Harper, BSN, MS, CIC, with the Acute Disease Investigation and Control Section of the Minnesota Department of Health (MDH), told CIDRAP News that over the past few years, the MDH has been working with infection control specialists at several Minnesota hospitals to develop a roadmap and toolkit for preventing C diff infections. She said the MDH also consults with infection prevention control professionals at the state's long-term care facilities.

Part of the efforts at the healthcare facilities are aimed at communicating patients' status when infection transmission precautions are needed, she said in an e-mail. "We promote the use of the CDC's inter-facility transfer form to promote communication."

The Association for Professionals in Infection Control and Epidemiology (APIC) said in a statement today that the Vital Signs report shows that C diff is no longer just a hospital problem, and that because any antimicrobial can potentially induce a C diff infections, stewardship programs that promote their judicious use should be encouraged.

"The CDC report highlights three programs showing success in reducing C difficile rates. Continued progress is contingent upon sustained focus and resources," the group said. "APIC believes that continued use and monitoring of these strategies will support ongoing reductions in C difficile, both inside and outside the hospital."

Jan Patterson, MD, president of the Society for Healthcare Epidemiology of America (SHEA) said in a press release that about 50% of antibiotics are inappropriately prescribed. "The increased prevalence in C difficile throughout healthcare settings demonstrates the need for better control and use of antibiotics, not only to preserve the efficacy of these life saving drugs, but to prevent adverse events like C difficile infection," she said.

She added that it's important to create a public dialogue about infections such as C diff. "What they are, where they are most likely to occur and how they spread. This is a critical component of increasing our understanding of these infections and ultimately reducing rates of them."

See also:

Mar 6 CDC Vital Signs report

Mar 6 CDC press release

Mar 6 APIC press release

Mar 6 SHEA press release

MDH C diff roadmap and toolkit

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