1. Preventing Transmission of C. difficile: Practice Elise Tamplin, M(ASCP), MPH, CIC Brigham & Women’s Hospital

2. Objectives Discuss practical challenges in implementing infection control measures Illustrate the value of periodic assessment of compliance

3. BWH healthcare-associated CDI rates *Excludes NICU

4. CDI leading to colectomy and/or death: Nosocomial & non-nosocomial cases

5. Challenges Preventing acquisition/transmission Improving outcomes for patients with CDI

6. CDI Control Interventions Sentinel event and root cause analysis Increase case finding & early identification—quicker lab turn around time Enhance Infection Control measures Aggressive CDI management & surgical evaluation (BWH CDI Treatment Guidelines) Staff education Minimize antibiotic utilization

7. Laboratory Testing Change in test methodology –Cytotoxicity assay to EIA From 3 day TAT to same day results –Lower sensitivity –Need for clinical judgment in interpretation of negative result –Increased possibility of false negatives if specimen taken while on antibiotics

8. Basic Infection Control Practices Hand hygiene Contact precautions for infected patients Ensure cleaning and disinfection of equipment and the environment Implement a laboratory-based alert system Conduct CDI surveillance Educate patients and families about CDI

9. Special Approaches Special Approaches to prevent transmission by healthcare personnel Perform hand hygiene with soap and water after contact with a patient with CDI –Pro: –Pro: Alcohol is not sporicidal –Con: –Con: Hand hygiene compliance is lower for handwashing with soap and water vs. use of an alcohol-based hand disinfectant

10. Special Approaches Special Approaches to prevent spread through the environment Use a hypochlorite-based room cleaning agent –Pro: –Pro: Sporocidal and benefit has been reported in outbreak settings –Con: –Con: Can corrode equipment and can be a chemical irritant for patients and staff

11. Special Approaches Special Approaches to prevent transmission by healthcare personnel Prolong the duration of contact precautions after the patient becomes asymptomatic until hospital discharge –Patients may shed C. difficile in their stool after diarrhea resolves Bobulsky GS et al. Clin Infect Dis 2008; 46:447–50

12. New Infection Control Measures Enhancements to Contact Precautions Contact Precautions Plus –Soap & water hand hygiene –Hypochlorite based disinfectant- detergent upon discharge/transfer –Precautions for duration of admission

13. Plus Contact Precautions Plus Discontinuation upon cessation of symptoms problematic Administration buy-in required for continuation during entire admission Automated “flag” developed by IS like those for MRSA & VRE but expiring upon discharge Education of Admitting staff re empiric precaution status

14. Soap & Water Hand Hygiene Major change from routine use of waterless hand sanitizer Visibility of sign key issue –Several design changes Sink availability challenging –Few in central areas of inpatient units –Reluctance to use patient room sink –Hand washing 101

15. Do not remove sign until after room has been cleaned *Bleach-based

16. Hypochlorite Disinfectant Infection Control & Safety approvals Odor/symptom complaints from staff - OHS evaluation/tracking - MNA discussion re safety concerns - Evaluation of new products - Change from liquid to impregnated wipes - Adequacy of surface wetting evaluated

17. Hypochlorite Disinfectant Compliance with use –Tracking mechanisms  Daily patient log from Infection Control to Environmental Service  Some rooms still missed  Daily review/verification by ES & return to Infection Control –Signs taken down before cleaning  CPP room status added to housekeeping page

18. Staff Education Physicians –Early severe patient outcomes helped –M&M conferences, Grand Rounds, etc. Nursing –Empiric precautions –Specimen collection prior to treatment

19. Staff Education Support (Environmental Services) –Balance between emphasis on need for special measures vs. fostering undue personal safety concerns –Regroup with supervisors Administrative (Admitting) –Achieving support for empiric precautions

20. CDI Management Guidelines Consensus document –Infection Control –Infectious Disease –Medical Intensive Care –General Surgery –Microbiology –Pharmacy –Nursing

21. CDI Management Guidelines Infection Control Precautions Diagnostic testing Clinical management of patients

22. CDI Management Guidelines Clinical categories based on specific clinical criteria –Appropriate management for each  Stop non-essential medications  antimicrobials & antiperistaltics  Appropriate antibiotic therapy  Infectious Disease & Surgical consults  Rectal vancomycin (when & how)

23. BWH healthcare-associated CDI rates *Excludes NICU Contact Precautions Plus BWH Treatment Guidelines

24. Severe CDI leading to colectomy+/-death Nosocomial vs. non-nosocomial Contact Precautions Plus

25. Objectives Discuss practical challenges in implementing infection control measures Illustrate value of periodic assessment of compliance