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Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals

  • Erik R. Dubberke (a1), Dale N. Gerding (a2) (a3), David Classen (a4), Kathleen M. Arias (a5), Kelly Podgorny (a6), Deverick J. Anderson (a7), Helen Burstin (a8), David P. Calfee (a9), Susan E. Coffin (a10), Victoria Fraser (a1), Frances A. Griffin (a11), Peter Gross (a12) (a13), Keith S. Kaye (a7), Michael Klompas (a14), Evelyn Lo (a15), Jonas Marschall (a1), Leonard A. Mermel (a16), Lindsay Nicolle (a15), David A. Pegues (a17), Trish M. Perl (a18), Sanjay Saint (a19), Cassandra D. Salgado (a20), Robert A. Weinstein (a21), Robert Wise (a6) and Deborah S. Yokoe (a14)...

Extract

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their Clostridium difficile infection (CDI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.

1. Increasing rates of CDI

C. difficile now rivals methicillin-resistant Staphylococcus aureus (MRSA) as the most common organism to cause healthcare-associated infections in the United States.

a. In the United States, the proportion of hospital discharges in which the patient received the International Classification of Diseases, Ninth Revision discharge diagnosis code for CDI more than doubled between 2000 and 2003, and CDI rates continued to increase in 2004 and 2005 (L. C. McDonald, MD, personal communication, July 2007). These increases have been seen in pediatric and adult populations, but elderly individuals have been disproportionately affected. CDI incidence has also increased in Canada and Europe.

b. There have been numerous reports of an increase in CDI severity.

c. Most reports of increases in the incidence and severity of CDI have been associated with the BI/NAP1/027 strain of C. difficile. This strain produces more toxins A and B in vitro than do many other strains of C. difficile, produces a third toxin (binary toxin), and is highly resistant to fluoroquinolones.

Copyright

Corresponding author

University of Chicago Press, 1427 E. 60th St., Chicago, IL 60637 (reprints@press.uchicago.edu) or contact the journal office (iche@press.uchicago.edu).

References

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1.McDonald, LC, Owings, M, Jernigan, DB. Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003. Emerg Infect Dis 2006;12:409415.
2.Kuijper, EJ, Coignard, B, Tull, P. Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect 2006;12(Suppl 6):218.
3.Loo, VG, Poirier, L, Miller, MA, et al.A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med 2005;353:24422449.
4.Pepin, J, Valiquette, L, Cossette, B. Mortality attributable to nosocomial Clostridium difficile-associated disease during an epidemic caused by a hypervirulent strain in Quebec. CMAJ 2005;173:10371042.
5.McDonald, LC, Killgore, GE, Thompson, A, et al.An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med 2005;353:24332441.
6.Muto, CA, Pokrywka, M, Shutt, K, et al.A large outbreak of Clostridium difficile-associated disease with an unexpected proportion of deaths and colectomies at a teaching hospital following increased fluoroquinolone use. Infect Control Hosp Epidemiol 2005;26:273280.
7.Jarvis, WR, Feldman, RA. Clostridium difficile and gastroenteritis: how strong is the association in children? Pediatr Infect Dis 1984;3:46.
8.Welch, DF, Marks, MI. Is Clostridium difficile pathogenic in infants? J Pediatr 1982;100:393395.
9.Dubberke, ER, Reske, KA, Butler, AM, et al. Attributable outcomes of Clostridium difficile-associated disease in non-surgical patients. Emerg Infect Dis (in press).
10.Kyne, L, Hamel, MB, Polavaram, R, Kelly, CP. Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile. Clin Infect Dis 2002;34:346353.
11.Dubberke, ER, Reske, KA, Olsen, MA, McDonald, LC, Fraser, VJ. Short and long term attributable cost of Clostridium difficile–associated disease in non-surgical patients. Clin Infect Dis 2008;46:497504.
12.O'Brien, JA, Lahue, BJ, Caro, JJ, Davidson, DM. The emerging infectious challenge of Clostridium difficile–associated disease in Massachusetts hospitals: clinical and economic consequences. Infect Control Hosp Epidemiol 2007;28:12191227.
13.Dubberke, ER, Reske, KA, Yan, Y, Olsen, MA, McDonald, LC, Fraser, VJ. Clostridium difficile–associated disease in a setting of endemicity: identification of novel risk factors. Clin Infect Dis 2007;45:15431549.
14.Pepin, J, Saheb, N, Coulombe, MA, et al.Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile–associated diarrhea: a cohort study during an epidemic in Quebec. Clin Infect Dis 2005;41:12541260.
15.Dial, S, Delaney, JA, Barkun, AN, Suissa, S. Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA 2005;294:29892995.
16.Beaulieu, M, Williamson, D, Pichette, G, Lachaine, J. Risk of Clostridium difficile–associated disease among patients receiving proton-pump inhibitors in a Quebec medical intensive care unit. Infect Control Hosp Epidemiol 2007;28:13051307.
17.Musher, DM, Aslam, S, Logan, N, et al.Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis 2005;40:15861590.
18.Pepin, J, Alary, ME, Valiquette, L, et al.Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada. Clin Infect Dis 2005;40:15911597.
19.Zar, FA, Bakkanagari, SR, Moorthi, KM, Davis, MB. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile–associated diarrhea, stratified by disease severity. Clin Infect Dis 2007;45:302307.
20.McDonald, LC, Coignard, B, Dubberke, E, Song, X, Horan, T, Kutty, PK. Recommendations for surveillance of Clostridium difficile–associated disease. Infect Control Hosp Epidemiol 2007;28:140145.
21.Kuijper, EJ, Coignard, B, Tull, P, ESCMID Study Group for Clostridium difficile; EU Member States; European Centre for Disease Prevention and Control. Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect 2006;(Suppl 6):218.
22.National Clostridium difficile Standards Group. National Clostridium difficile Standards Group: report to the Department of Health. J Hosp Infect 2004;56(Suppl 1):138.
23. United Kingdom Department of Health. Changes to the mandatory healthcare associated infection surveillance system for Clostridium difficile associated diarrhea from April 2007. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Professionalletters/Chiefmedicalofficerletters/DH_073767. Accessed November 28, 2007.
24.Miller, MA, Hyland, M, Ofher-Agostini, M, Gourdeau, M, Ishak, M. Morbidity, mortality, and healthcare burden of nosocomial Clostridium difficile-associated diarrhea in Canadian hospitals. Infect Control Hosp Epidemiol 2002;23:137140.
25.Fekety, R. Guidelines for the diagnosis and management of Clostridium difficile-associated diarrhea and colitis. American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 1997;92:739750.
26.Gerding, DN, Johnson, S, Peterson, LR, Mulligan, ME, Silva, J JrClostridium difficile-associated diarrhea and colitis. Infect Control Hosp Epidemiol 1995;16:459477.
27.Simor, AE, Bradley, SF, Strausbaugh, LJ, Crossley, K, Nicolle, LE. Clostridium difficile in long-term-care facilities for the elderly. Infect Control Hosp Epidemiol 2002;23:696703.
28.Tullus, K, Aronsson, B, Marcus, S, Mollby, R. Intestinal colonization with Clostridium difficile in infants up to 18 months of age. Eur J Clin Microbiol Infect Dis 1989;8:390393.
29.Merida, V, Moerman, J, Colaert, J, Lemmens, P, Vandepitte, J. Significance of Clostridium difficile and its cytotoxin in children. Eur J Pediatr 1986;144:494496.
30.Harris, AD, Bradham, DD, Baumgarten, M, Zuckerman, IH, Fink, JC, Perencevich, EN. The use and interpretation of quasi-experimental studies in infectious diseases. Clin Infect Dis 2004;38:15861591.
31.Stone, SP, Cooper, BS, Kibbler, CC, et al.The ORION statement: guidelines for transparent reporting of outbreak reports and intervention studies of nosocomial infection. J Antimicrob Chemother 2007;59:833840.
32.Fowler, S, Webber, A, Cooper, BS, et al.Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: a controlled interrupted time series. J Antimicrob Chemother 2007;59:990995.
33.Shadel, BN, Puzniak, LA, Gillespie, KN, Lawrence, SJ, Kollef, M, Mundy, LM. Surveillance for vancomycin-resistant enterococci: type, rates, costs, and implications. Infect Control Hosp Epidemiol 2006;27:10681075.
34.Boyce, JM, Pittet, D. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep 2002;51:145, quiz.
35.Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J 1979;121:11931254.
36. Centers for Disease Control and Prevention. C. difficile frequently asked questions information for healthcare providers. 2005. Available at: http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html. Accessed August 18, 2007.
37.Dubberke, ER, Reske, KA, Noble-Wang, J, et al.Prevalence of Clostridium difficile environmental contamination and strain variability in multiple health care facilities. Am J Infect Control 2007;35:315318.
38.Johnson, S, Clabots, CR, Linn, FV, Olson, MM, Peterson, LR, Gerding, DN. Nosocomial Clostridium difficile colonisation and disease. Lancet 1990;336:97100.
39.McFarland, LV, Mulligan, ME, Kwok, RY, Stamm, WE. Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 1989;320:204210.
40.Sehulster, L, Chinn, RY. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep 2003;52:142.
41.Perez, J, Springthorpe, VS, Sattar, SA. Activity of selected oxidizing microbicides against the spores of Clostridium difficile: relevance to environmental control. Am J Infect Control 2005;33:320325.
42.Garner, JS. Guideline for isolation precautions in hospitals. The Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1996;17:5380.
43.Siegel, JD, Rhinehart, E, Jackson, M, Chiarello, L, Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. June 2007. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf. Accessed December 13, 2007.
44.Lewis, AM, Gammon, J, Hosein, I. The pros and cons of isolation and containment. J Hosp Infect 1999;43:1923.
45.Boyce, JM, Ligi, C, Kohan, C, Dumigan, D, Havill, NL. Lack of association between the increased incidence of Clostridium difficile–associated disease and the increasing use of alcohol-based hand rubs. Infect Control Hosp Epidemiol 2006;27:479483.
46.Riggs, MM, Sethi, AK, Zabarsky, TF, Eckstein, EC, Jump, RL, Donskey, CJ. Asymptomatic carriers are a potential source of transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis 2007;45:992998.
47.Wenisch, C, Parschalk, B, Hasenhündl, M, Hirschl, AM, Graninger, W. Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of Clostridium difficile–associated diarrhea. Clin Infect Dis 1996;22:813818.
48.Surawicz, CM, McFarland, LV, Greenberg, RN, et al.The search for a better treatment for recurrent Clostridium difficile disease: use of high-dose vancomycin combined with Saccharomyces boulardii. Clin Infect Dis 2000;31:10121017.
49.Wilcox, MH, Fawley, WN, Parnell, P. Value of lysozyme agar incorporation and alkaline thioglycollate exposure for the environmental recovery of Clostridium difficile. J Hosp Infect 2000;44:6569.
50.Kaatz, GW, Gitlin, SD, Schaberg, DR, et al.Acquisition of Clostridium difficile from the hospital environment. Am J Epidemiol 1988;127:12891294.
51.Wilcox, MH, Fawley, WN, Wigglesworth, N, et al.Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection. J Hosp Infect 2003;54:109114.
52.Mayfield, JL, Leet, T, Miller, J, Mundy, LM. Environmental control to reduce transmission of Clostridium difficile. Clin Infect Dis 2000;31:9951000.
53.McDonald, LC. Confronting Clostridium difficile in inpatient healthcare facilities. Clin Infect Dis 2007;45:12741276.
54.Valiquette, L, Cossette, B, Garant, MP, Diab, H, Pepin, J. Impact of reduction in the use of high-risk antibiotics on the course of an epidemic of Clostridium difficile–associated disease caused by the hypervirulent NAP1/027 strain. Clin Infect Dis 2007;45:S112S121.
55.Pear, SM, Williamson, TH, Bettin, KM, Gerding, DN, Galgiani, JN. Decrease in nosocomial Clostridium difficile–associated diarrhea by restricting clindamycin use. Ann Intern Med 1994;120:272277.
56.Johnson, S, Homann, SR, Bettin, KM, et al.Treatment of asymptomatic Clostridium difficile carriers (fecal excretors) with vancomycin or metronidazole: a randomized, placebo-controlled trial. Ann Intern Med 1992;117:297302.
57.Siegel, JD, Rhinehart, E, Jackson, M, Chiarello, L, Healthcare Infection Control Practices Advisory Committee. Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings 2007. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf. Accessed January 15, 2008.
58.Wong, ES, Rupp, ME, Mermel, L, et al.Public disclosure of healthcare-associated infections: the role of the Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol 2005;26:210212.
59.McKibben, L, Horan, TC, Tokars, JI, et al.Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 2005;26:580587.
60. Healthcare-Associated Infection Working Group of the Joint Public Policy Committee. Essentials of public reporting of healthcare-associated infections: a tool kit. January 2007. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/ar/06_107498_Essentials_Tool_Kit.pdf. Accessed April 6, 2007.
61.The National Quality Forum. National voluntary consensus standards, endorsed November 15, 2007. Available at: http://www.qualityforum.org/pdf/news/lsCSACMeasures.pdf. Accessed December 20, 2007.
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