C. diff more prevalent than previously believed

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A new nationwide APIC study shows the number of C. diff infections may be six to 20 times higher than previous estimates and that these infections may kill as many as 301 patients per day in hospitals across the United States. Based on prevalence rates, researchers estimated that C. diff infections cost an average of $32.1 million per day nationwide.

C. diff affects children, adults, and the elderly. And hospitals should be doing more to combat its spread, said experts at the November APIC press conference announcing the study results.

“We believe that this study should be a wake-up call for healthcare providers everywhere,” said Kathy L. Warye, CEO of APIC.

Healthcare administrators need to ensure that their facilities have adequate staff and resources and should make changes to combat infections, from bolstering environmental cleaning practices to establishing antimicrobial stewardship programs.

About the study

The goal of this study was to get a better estimate of C. diff rates nationwide.

Study authors polled representatives from APIC member hospitals, pulling responses from 12.5% of all U.S. hospitals.

ICPs were sent a comprehensive survey that asked them to provide data on the number of C. diff–infected patients at their facility on any one day they chose between May and August of 2008.

The study was a snapshot of what hospitals experience related to C. diff on a single day, said principal investigator William Jarvis, MD, president of Jason and Jarvis Associates, which has offices in California and Oregon.

Researchers found that 13 out of every 1,000 inpatients—a total of 1,443 individuals in the survey—were either infected (94.4%) or colonized with C. diff.

A further analysis of data showed that 1,062 of those patients had the following characteristics:

  • 55.9% were women, 44.1% were men
  • 84.7% were in the medical service being treated for general medical conditions
  • 10.94% had severe to complicated disease
  • 69.2% were more than 60 years old, and the risk of C. diff increased with age
  • 67.6% of patients had other conditions, such as renal failure, diabetes, or heart failure
  • 57.9% had an initial episode of mild or moderate disease

Cultures lacking

Although the study reaped detailed information about the characteristics of infected patients, there was one pressing question it could not answer: Are a larger portion of these cases being caused by a more virulent strain of C. diff called the North American pulse-field type 1 (NAP1)?

“The data suggest that the severity of illness is up. The question is whether that is due to NAP1. No one can answer that question because no one in our study was looking [at this factor],” said Jarvis. Fewer than 2% of facilities actually cultured patients with C. diff, he said. The vast majority of patients were tested for C. diff using a linked immunoassay for A and B toxins, performed by analyzing a stool sample.

Culturing for C. diff is difficult because the organism requires specific conditions to grow, said Jarvis. For example, growing C. diff requires a special medium, an anaerobic environment, and can take seven to 10 days to produce interpretable results.

Because of the difficulty involved, companies in the 1980s and 1990s developed the alternative stool test. The advantage of this second test is that it provides rapid results.

The disadvantage is that it can’t isolate strains of C. diff and is only accurate 73%–75% of the time, Jarvis said, adding that he hopes more facilities will take the time to culture patients so that experts will have more epidemiological data to draw on in the future.

A new polymer chain reaction test is slated to come out next year, and it may eliminate some of the difficulties involved with testing, Jarvis said.

However, it’s uncertain whether the new test will be able to isolate strains of C. diff to provide information on NAP1.

Steps to combat C. diff

In addition to culturing more patients, there are several other steps that facilities should take to combat infections.

It’s critical for staff members to communicate quickly and effectively if they want to get C. diff under control, said Deb Burdsall, RN, MSN, CIC, infection preventionist at Lutheran Home in Arlington Heights, IL.

Patients who present with diarrhea should automatically be put on contact precautions and only taken off those precautions after C. diff has been ruled out.

Jarvis offered the following tips for facilities to reduce the risk of transmission and infections:

  • Perform a risk assessment to determine who your high-risk patients are. Some risk factors include:
  • Age. Infections increase in individuals more than 60 years old.
  • Comorbid conditions. Patients with heart disease, diabetes, and other conditions are more likely to be affected.
  • Antibiotic use. The APIC study showed that nearly 80% of patients were exposed to antibiotics prior to the onset of symptoms.
  • Update your admitting checklist to include the question, “Do you have diarrhea?”
  • Alert nursing personnel as soon as a patient develops diarrhea and promptly place that individual on contact isolation precautions until you rule out C. diff.
  • Use soap and water instead of alcohol-based hand gels, which don’t kill C. diff spores. Soap and water don’t kill the spores either, but it rinses them off, said Jarvis.
  • Focus on patients with active infections, not colonizations. Patients primarily transmit C. diff when they have diarrhea, Jarvis said, adding that colonized patients release bacteria into the environment, but the contamination level is very low. “Screening for colonization doesn’t make much sense yet,” he said. There is no drug that can be used to decolonize someone with C. diff. Colonizations of patients tend to be short in duration, said Jarvis.
  • Use bleach during environmental cleaning to kill C. diff spores. Bleach is the only way to kill C. diff in its spore form.
  • Establish an antibiotic stewardship program. The survey found that 46.7% of facilities have a stewardship program, but these programs all meet different standards. Jarvis said he thinks a successful stewardship program should make use of an infectious disease specialist who devotes a portion of his or her time to focusing on this issue.

Final lessons

Successfully combating C. diff will require a change in philosophy at many facilities, said Warye.

All facilities should strive for zero infections, she said, and they should take the following steps to accomplish that goal, including:

  • Employ an adequate number of staff members
  • Make IC a priority
  • Take IC efforts institutionwide
  • Focus on staff education
  • Target the most successful interventions to maximize their resources

The APIC study is a call for action. “Not just for infection preventionists, but for hospital administrators as well,” said Warye. Administrators will need to provide the staff and resources for infection prevention, including money for proper environmental cleaning, stewardship programs, and IC measures.

“Healthcare institutions can get ahead of C. difficile, but if they’re going to do it, the time for action is now,” said Warye.

The full text of the study will be published in the American Journal of Infection Control in early spring 2009. The APIC has also released a new guidance on C. diff to help organizations improve their efforts in this area. The guidance is available on APIC’s Web site at