Clostridium difficile (C. difficile) is a spore-forming bacterium capable of causing gastrointestinal conditions ranging from diarrhea to colitis. Twenty years ago, C. difficile infections (CDI) were primarily limited to patients who were receiving long-term antibiotic therapy. Today, C. difficile is one of the most prevalent causes of healthcare-associated infections in the United States and is considered as a top priority of 76% hospital leaders recently surveyed.1
Clostridium difficile-associated diarrhea (CDAD) places financial stress on US hospitals. A study of 170,000 discharges from 477 hospitals from 2009-2011 calculated that a CDAD case can increase a hospital stay by 4.7 days and add $7,286 to hospital costs.2 And, starting in fiscal year 2017, the Hospital-Acquired Condition (HAC) Reduction Program, mandated by the Affordable Care Act of 2010, will include penalties for “preventable” HAIs including CDI.3
Preventing CDI has become a formidable challenge, even for healthcare facilities with the most robust infection control protocols. A recent Centers for Disease Control and Prevention (CDC)-funded study reported that in the U.S., of the annual 453,000 CDI cases, almost 30,000 die within 30 days after diagnosis.4 Sixty six percent of CDI cases were healthcare-associated with 37% of those CDI cases being hospital-onset (as opposed to healthcare-associated community-onset or nursing-home-onset).4 Community-onset CDI is also increasing, with a recent study of 154 U.S. hospitals from 2008-2015 finding that these rates increased at a much higher rate than hospital-onset CDI rates.5
In the light of these findings, many facilities are re-evaluating their CDI prevention strategies. This article will focus on sporicidal disinfection selection and compliant cleaning and disinfection of environmental surfaces and medical equipment, critical first lines of defense against C. difficile and important component of a robust CDI-prevention plan.
Selecting Sporicidal Solutions
Clostridium difficile and other spore-forming bacteria such as Bacillus subtilis on environmental surfaces are among the most difficult microorganisms to kill due to their resilience to many chemical disinfectants. Studies have shown that viable C. difficile spores can persist in the healthcare environment for months if surfaces are not properly cleaned and disinfected.6
Most CDI prevention guidelines recommend the use of an Environmental Protection Agency (EPA)- registered disinfectant with sporicidal claims on environmental surfaces and medical equipment in areas housing CDI patients.7 In 2014, the EPA updated its guidance related to C. difficile testing standards to include using a clinically relevant C. difficile strain (ATCC 43598) and measuring disinfection efficacy in the presence of a three-part organic soil load which forms a protective layer around spores making disinfectant penetration more difficult.8 The new standards raise the bar for efficacy evaluation and may represent more realistic conditions, given that many studies reveal that some surfaces are frequently missed during the cleaning step required by the EPA before disinfection against C. difficile.
As of June 2016, 48 surface disinfectants in the US were EPA-registered to kill C. difficile spores on hard non-porous surfaces. The new EPA standards are currently only mandated for new registrations. But some disinfectant manufacturers have proactively tested their disinfectants against the new standards. In reviewing their facility’s CDI prevention program, healthcare professionals should review the label of their EPA-registered sporicidal disinfectant and other technical information to determine whether the new testing standards were applied. They should also familiarize themselves with the product chemistry, directions for use, and safety information, to determine the suitability of the product for their infection prevention strategy.
Integrating Sporicidal Solutions into Infection Control Protocols
Once sporicidal disinfectant solutions are selected, properly integrating them into cleaning and disinfection protocols is essential. Many protocols recommend sporicidal disinfectants for high-touch areas in CDI patient rooms and bathrooms for both daily and discharge cleaning and a recent survey of over 1,000 infection preventionists revealed that 67% of facilities were using sporicidal disinfectants in these situations.9
Use of a sporicidal disinfectant throughout a facility (and not just in CDI patient rooms) can help to eliminate environmental reservoirs of C. difficile and reduce CDI. One hospital recently reported a 70% decrease in the incidence of CDI rates and a 63% decrease in yearly mortality in patients with CDI infections after implementing a hospital-wide infection control bundle that included enhanced cleaning of all patient rooms and equipment using a sporicidal sodium hypochlorite-based disinfectant.10 However, this appears to be the exception as only 10% of healthcare facilities surveyed in 2013 used sporicidal disinfectants such as bleach for all patient rooms.9 Furthermore, non-compliance with CDI disinfection protocols – not following manufacturer’s instructions, skipping cleaning steps, not following the order of cleaning outlined in protocols and using less disinfectant or fewer wipes to reduce costs – are common problems. A recent study showing only 22% full compliance with contact isolation precautions in CDI patient rooms, increasing the risk of environmental transmission of C. difficile spores.11
The good news is that cleaning and disinfection compliance rates in hospitals range can be increased to over 80% when process improvements are made.12
Enhanced disinfection strategies, often incorporating the use of ultraviolet (UV) decontamination systems in addition to surface disinfectants can also help, especially in areas housing high-risk patient populations. One university hospital that deployed the Clorox HealthcareTM Optimum-UV System in addition to manual surface disinfection with bleach-based disinfectants in hematology/oncology units demonstrated a 25% decrease in CDI rates on the study units and saved an estimated $134,568 to $191,604 in direct medical costs during the 12 months study period.13
Planning for the future
Proactive and collaborative efforts from healthcare providers, government agencies, and industry are necessary to prevent CDI. In addition to antimicrobial stewardship efforts to reduce CDI, environmental cleaning and disinfection is also a key component of multi-modal approaches to reduce transmission of C. difficile spores.
To ensure robust environment-focused CDI prevention efforts, Clorox Healthcare recommends:
- Reviewing your sporicidal disinfectant efficacy claims and user instructions to ensure they meetthe needs of your facility.
- Leveraging infection control best practices and guidelines to develop protocols for cleaning and disinfecting surfaces and medical equipment in areas housing CDI patients.7
- Consider expanding the use of sporicidal disinfectants to areas outside of CDI patient care areasto limit the spread of C. difficile spores and protect the entire patient population.
- Investigate the use of enhanced disinfection methods such as UV decontamination systems tosupplement your manual cleaning and disinfection protocols.
- Saint, S.; Fowler, K. E.; Krein, S. L.; Ratz, D.; Flanders, S. A.; Dubberke, E. R.; Greene, M. T. Clostridium Difficile Infection in the United States: A National Study Assessing Preventive Practices Used and Perceptions of Practice Evidence. Infect. Control Hosp. Epidemiol. 2015, 36 (8), 969–971.
- Magee, G.; Strauss, M. E.; Thomas, S. M.; Brown, H.; Baumer, D.; Broderick, K. C. Impact of Clostridium difficile-associated diarrhea on acute care length of stay, hospital costs, and readmission: A multicenter retrospective study of inpatients, 2009-2011. Am. J. Infect. Control 2015, 43 (11), 1148–1153.
- Centers for Medicare & Medicaid Serivces. Hospital Value-Based Purchasing https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital- value-based-purchasing/ (accessed Jul 12, 2016).
- Lessa, F. C.; Mu, Y.; Bamberg, W. M.; Beldavs, Z. G.; Dumyati, G. K.; Dunn, J. R.; Farley, M. M.; Holzbauer, S. M.; Meek, J. I.; Phipps, E. C.; et al. Burden of Clostridium difficile Infection in the United States. N. Engl. J. Med. 2015, 372 (9), 825–834.
- Tabak, Y.; DeRyke, C.; Gupta, V.; Sun, X.; Johannes, R.; Marcella, S. Trend of Clostridium difficile Infections by Onset Settings: A Multicenter Study. In ASM Microbe 2016; 2016; p Poster 290.
- Kramer, A.; Schwebke, I.; Kampf, G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect. Dis. 2006, 6, 130.
- Dubberke, E. R. M. M.; Carling, P. M.; Carrico, R. P. R.; Donskey, C. J. M.; Loo, V. G. M. Ms.; McDonald, L. C. M.; Maragakis, L. L. M. M.; Sandora, T. J. M. M.; Weber, D. J. M. M.; Yokoe, D. S. M. M.; et al. Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update. Infect. Control Hosp. Epidemiol. 2014, 35 (6), 628–645.
- US EPA, OCSPP, O. Guidance for the Efficacy Evaluation of Products with Sporicidal Claims Against Clostridium difficile (June 2014) https://www.epa.gov/pesticide-registration/guidance-efficacy- evaluation-products-sporicidal-claims-against-clostridium (accessed Jul 12, 2016).
- Association for Professionals in Infection Control and Epidemiology (APIC). CDI Pace of Progress survey | Clostridium difficile Educational and Consensus Conference http://cdiff2013.site.apic.org/about-the-conference/cdi-pace-of-progress-survey/ (accessed Aug 4, 2014).
- Mermel, L. A.; Jefferson, J.; Blanchard, K.; Parenteau, S.; Mathis, B.; Chapin, K.; Machan, J. T. Reducing Clostridium difficile incidence, colectomies, and mortality in the hospital setting: a successful multidisciplinary approach. Jt. Comm. J. Qual. Patient Saf. 2013, 39 (7), 298–305.
- Yanke, E.; Zellmer, C.; Van Hoof, S.; Moriarty, H.; Carayon, P.; Safdar, N. Understanding the current state of infection prevention to prevent Clostridium difficile infection: a human factors and systems engineering approach. Am. J. Infect. Control 2015, 43 (3), 241–247.
- Rupp, M. E.; Fitzgerald, T.; Sholtz, L.; Lyden, E.; Carling, P. Maintain the gain: program to sustain performance improvement in environmental cleaning. Infect. Control Hosp. Epidemiol. 2014, 35 (7), 866–868.
- Pegues, D.; Gilmar, C.; Denno, M.; Gaynes, S. Reducing Clostridium difficile Infection among Hematology-Oncology Patients Using Ultraviolet Germicidal Irradiation for Terminal Room Disinfection; In IDWeek (poster presentation), 2015.
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