1. Epidemiology and Prevention of C. difficile Infection William A. Rutala, Ph.D., M.P.H. Director, Hospital Epidemiology, Occupational Health and Safety, UNC Health Care; Research Professor of Medicine, Director, Statewide Program for Infection Control and Epidemiology, University of North Carolina at Chapel Hill, NC, USA Disclosure: Clorox

2. LECTURE OBJECTIVES l Understand the epidemiology and impact of C. difficile l Review the role of the environment in disease transmission l Discuss how to prevent transmission of C. difficile via contaminated surfaces l Identify effective preventive strategies

3. CLOSTRIDIUM DIFFICILE MICROBIOLOGY l Anaerobic bacterium l Forms spores that persist l Colonizes human GI tract l Fecal-oral spread l Toxins produce colitis Diarrhea More severe disease; death l 2-steps to infection New acquisition via transmission Antibiotics result in vulnerability l CDI due to BI/NAP1/027 carries high mortality and management remains problematic

4. C. difficile : MICROBIOLOGY AND EPIDEMIOLOGY l Gram-positive bacillus: Strict anaerobe, spore-former l Colonizes human GI tract l Increasing prevalence and incidence l New epidemic strain that hyperproduces toxins A and B l Introduction of CDI from the community into hospitals l High morbidity and mortality in elderly l Asymptomatic C. difficile carriers may be reservoir in healthcare l Inability to effectively treat fulminant CDI l Absence of a treatment that will prevent recurrence of CDI l Inability to prevent CDI

5. C. difficile Infection Rate, 2003-2013

6. CDI Sites of Attack for Prevention and Management of CDI 5.Bolster immunity with vaccines or passive antibody strategies. 1.Keep patients out of the hospital. 2.Barrier precautions and environmental cleaning. 3.Stop unnecessary antimicrobial use. 4.Restore flora or colonize with nontoxigenic C. difficile 6.Antibiotic Rx ± Nonantibiotic Rx Now Asymptomatic C. difficile colonization Hospitalization C. difficile acquisition Antimicrobial(s) C. difficile acquisition Future Gerding and Johnson Clin Infect Dis. 2010;51:1306-13

7. Sunenshine RH, McDonald LC. Cleve Clin J Med 2006;73:187-197

9. C. difficile PATHOGENESIS CDC

10. ANTIBIOTIC STEWARDSHIP l Encourage appropriate antibiotic use which includes: Avoiding antimicrobial exposure if the patient does not have a condition for which antibiotics are indicated When possible select an antibiotic associated with a lower risk of CDI Strategies to Prevent CDI Infections in Acute Care Hospitals: SHEA Guideline, 2014

11. Strategies to Prevent CDI l C. difficile shares many common epidemiologic characteristics with other antimicrobial-resistant gram- positive bacteria, such as MRSA and VRE l Both the skin and the environment of colonized patients becomes contaminated, and the healthcare provider hands may become contaminated by touching the environment or the patient. l Major difference is C. difficile forms spores

13. TRANSMISSION MECHANISMS INVOLVING THE SURFACE ENVIRONMENT Rutala WA, Weber DJ. In:”SHEA Practical Healthcare Epidemiology” (Lautenbach E, Woeltje KF, Malani PN, eds), 3 rd ed, 2010.

14. FACTORS LEADING TO ENVIRONMENTAL TRANSMISSION OF CLOSTRIDIUM DIFFICILE l Frequent contamination of the environment l Stable in the environment l Relatively resistant to disinfectants l Low inoculating dose l Common source of infectious gastroenteritis l Susceptible population (limited immunity)

15. ENVIRONMENTAL CONTAMINATON l 25% (117/466) of cultures positive ( 90% of sites positive with incontinent patients. (Samore et al. AJM 1996;100:32) l 31.4% of environmental cultures positive for C. difficile. (Kaatz et al. AJE 1988;127:1289) l 9.3% (85/910) of environmental cultures positive (floors, toilets, toilet seats) for C. difficile. (Kim et al. JID 1981;143:42) l 29% (62/216) environmental samples were positive for C. difficile. 29% (11/38) positive cultures in rooms occupied by asymptomatic patients and 49% (44/90) in rooms with patients who had CDAD. (NEJM 1989;320:204) l 10% (110/1086) environmental samples were positive for C. difficile in case-associated areas and 2.5% (14/489) in areas with no known cases. (Fekety et al. AJM 1981;70:907)

16. C. difficile Environmental Contamination Rutala, Weber. SHEA. 3 rd Edition. 2010 Frequency of sites found contaminated~10->50% from 13 studies-stethoscopes, bed frames/rails, call buttons, sinks, hospital charts, toys, floors, windowsills, commodes, toilets, bedsheets, scales, blood pressure cuffs, phones, door handles, electronic thermometers, flow-control devices for IV catheter, feeding tube equipment, bedpan hoppers C. difficile spore load is low-7 studies assessed the spore load and most found 100; one reported a range of “1->200” and one study sampled several sites with a sponge and found 1,300 colonies C. difficile.

17. FREQUENCY OF ENVIRONMENTAL CONTAMINATION AND RELATION TO HAND CONTAMINATION l Study design: Prospective study, 1992 l Setting: Tertiary care hospital l Methods: All patients with CDI assessed with environmental cultures l Results Environmental contamination frequently found (25% of sites) but higher if patients incontinent (>90%) Level of contamination low (<10 colonies per plate) Presence on hands correlated with prevalence of environmental sites Samore MH, et al. Am J Med 1996;100:32-40

18. FREQUENCY OF ACQUISITION OF C. difficile ON GLOVED HANDS AFTER CONTACT WITH SKIN AND ENVIRONMENTAL SITES Guerrero et al. Am J Infect Control 2012;40:556-8 Risk of hand contamination after contact with skin and commonly touched surfaces was identical (50% vs 50%)

19. PERCENT OF STOOL, SKIN, AND ENVIRONMENT CULTURES POSITIVE FOR C. difficile Skin (chest and abdomen) and environment (bed rail, bedside table, call button, toilet seat) Sethi AK, et al. ICHE 2010;31:21-27

20. Thoroughness of Environmental Cleaning Carling P. AJIC 2013;41:S20-S25 Mean = 32% >110,000 Objects

21. EVALUATION OF HOSPITAL ROOM ASSIGNMENT AND ACQUISITION OF CDI l Study design: Retrospective cohort analysis, 2005-2006 l Setting: Medical ICU at a tertiary care hospital l Methods: All patients evaluated for diagnosis of CDI 48 hours after ICU admission and within 30 days after ICU discharge l Results (acquisition of CDI) Admission to room previously occupied by CDI = 11.0% Admission to room not previously occupied by CDI = 4.6% (p=0.002) Shaughnessy MK, et al. ICHE 2011;32:201-206

22. C. difficile spores

23. SURVIVAL C. difficile l Vegetative cells Can survive for at least 24 h on inanimate surfaces l Spores Spores survive for up to 5 months. 10 6 CFU of C. difficile inoculated onto a floor; marked decline within 2 days. Kim et al. J Inf Dis 1981;143:42.

24. DECREASING ORDER OF RESISTANCE OF MICROORGANISMS TO DISINFECTANTS/STERILANTS Prions Spores ( C. difficile ) Mycobacteria Non-Enveloped Viruses (norovirus) Fungi Bacteria (MRSA, VRE, Acinetobacter ) Enveloped Viruses Most Susceptible Most Resistant

25. DISINFECTANTS AND ANTISEPSIS C. difficile spores at 20 min, Rutala et al, 2006 l No measurable activity (1 C. difficile strain, J9) CHG Vesphene (phenolic) 70% isopropyl alcohol 95% ethanol 3% hydrogen peroxide Clorox disinfecting spray (65% ethanol, 0.6% QUAT) Lysol II disinfecting spray (79% ethanol, 0.1% QUAT) TBQ (0.06% QUAT); QUAT may increase sporulation capacity- Lancet 2000;356:1324 Novaplus (10% povidone iodine) Accel (0.5% hydrogen peroxide)

26. DISINFECTANTS AND ANTISEPSIS C. difficile spores at 10 and 20 min, Rutala et al, 2006 l ~4 log 10 reduction (3 C. difficile strains including BI-9) Clorox, 1:10, ~6,000 ppm chlorine (but not 1:50) Clorox Clean-up, ~19,100 ppm chlorine Tilex, ~25,000 ppm chlorine Steris 20 sterilant, 0.35% peracetic acid Cidex, 2.4% glutaraldehyde Cidex-OPA, 0.55% OPA Wavicide, 2.65% glutaraldehyde Aldahol, 3.4% glutaraldehyde and 26% alcohol

27. CONTROL MEASURES C. difficile Disinfection l In units with high endemic C. difficile infection rates or in an outbreak setting, use dilute solutions of 5.25-6.15% sodium hypochlorite (e.g., 1:10 dilution of bleach) for routine disinfection. (CDC and SHEA). l We now use chlorine solution in all CDI rooms for routine daily and terminal cleaning (formerly used QUAT in patient rooms with sporadic CDI). One application of an effective product covering all surfaces to allow a sufficient wetness for > 1 minute contact time. Chlorine solution normally takes 1-3 minutes to dry. l For semicritical equipment, glutaraldehyde (20m), OPA (12m) and peracetic acid (12m) reliably kills C. difficile spores using normal exposure times

28. SURFACE DISINFECTION Effectiveness of Different Methods Rutala, Gergen, Weber. ICHE 2012;33:1255-58 Technique (with cotton) C. difficile Log 10 Reduction (1:10 Bleach) Saturated cloth3.90 Spray (10s) and wipe4.48 Spray, wipe, spray (1m), wipe4.48 Spray3.44 Spray, wipe, spray (until dry)4.48 5500 ppm chlorine pop-up wipe3.98 Non-sporicidal wipe>2.9

29. Daily Disinfection of High-Touch Surfaces Kundrapu et al. ICHE 2012;33:1039 Daily disinfection of high-touch surfaces (vs cleaned when soiled) with sporicidal disinfectant in rooms of patients with CDI and MRSA reduced acquisition of pathogens on hands after contact with surfaces and of hands caring for the patient

30. Effective Surface Decontamination Practice and Product

31. C. difficile Spores EPA-Registered Products l List K: EPA’s Registered Antimicrobials Products Effective Against C. difficile spores, April 2014 l http://www.epa.gov/oppad001/list_k_clostridium. pdf http://www.epa.gov/oppad001/list_k_clostridium. pdf l 34 registered products; most chlorine-based, some HP/PA-based, PA with silver

32. TRANSFER OF C. DIFFICILE SPORES BY NONSPORICIDAL WIPES AND IMPROPERLY USED HYPOCHLORITE WIPES l Study design: In vitro study that assessed efficacy of different wipes in killing of C. difficile spores (5-log 10 ) Fresh hypochlorite wipes Used hypochlorite wipes Quaternary ammonium wipes l Results (4 th transfer) Quat had no efficacy (3-log 10 spores) Fresh hypochlorite worked Used hypochlorite transferred spores in lower concentration (0.4-log 10 spores) Practice + Product = Perfection Cadnum JL, et al. ICHE 2013;34:441-2

33. REDUCTION IN CDI INCIDENCE WITH ENHANCED ROOM DISINFECTION l Before-after study of CDI incidence rates in two hyperendemic wards at a 1,249 bed hospital l Intervention: Change from cleaning rooms with QUAT to bleach wipes (0.55% Cl) for both daily and terminal disinfection l Results: CDI incidence dropped 85% from 24.2 to 3.6 cases per 10,000 pt-days (p<0.001); prolonged median time between HA CDI from 8 to 80 days Orenstein R, et al ICHE 2011;32:1137

34. Thoroughness of Environmental Cleaning Carling P. AJIC 2013;41:S20-S25 Mean = 32% >110,000 Objects

35. Wipes Cotton, Disposable, Microfiber, Cellulose-Based, Nonwoven Spunlace Wipe should have sufficient wetness to achieve the disinfectant contact time (e.g. >1 minute)

36. MONITORING THE EFFECTIVENESS OF CLEANING Cooper et al. AJIC 2007;35:338; Carling P AJIC 2013;41:S20-S25 l Visual assessment-not a reliable indicator of surface cleanliness l ATP bioluminescence-measures organic debris (each unit has own reading scale, <250-500 RLU) l Microbiological methods-<2.5CFUs/cm 2 -pass; can be costly and pathogen specific l Fluorescent marker-transparent, easily cleaned, environmentally stable marking solution that fluoresces when exposed to an ultraviolet light (applied by IP unbeknown to EVS, after EVS cleaning, markings are reassessed)

37. EVALUATION OF HOSPITAL ROOM ASSIGNMENT AND ACQUISITION OF CDI l Study design: Retrospective cohort analysis, 2005-2006 l Setting: Medical ICU at a tertiary care hospital l Methods: All patients evaluated for diagnosis of CDI 48 hours after ICU admission and within 30 days after ICU discharge l Results (acquisition of CDI) Admission to room previously occupied by CDI = 11.0% Admission to room not previously occupied by CDI = 4.6% (p=0.002) Shaughnessy MK, et al. ICHE 2011;32:201-206

38. METHODS TO PREVENT CDI: BASIC PRACTICES l Encourage appropriate use of antimicrobials l Use contact precautions for infected patients Single room Don gloves and gown when entering room; remove before exiting Hand hygiene before and after glove use l Use dedicated equipment whenever possible If equipment is shared between patients do not bring into room (e.g., glucometer) Clean and disinfect shared equipment after use Strategies to Prevent CDI Infections in Acute Care Hospitals: SHEA Guideline, ICHE, 2014

39. METHODS TO PREVENT CDI: BASIC PRACTICES l Criteria for discontinuing isolation Duration of illness (some experts recommend for at least 48 hours after diarrhea resolves) l Use an EPA-registered sporicidal agent for room disinfection in hyperendemic and outbreak situations l Ensure cleaning and disinfection of equipment and the environment as potential reservoirs l Assess adherence to protocols l Implement lab-based alert system to provide immediate notification to IP and clinical personnel l Educate patients and their families about CDI l Measure compliance with hand hygiene and contact precaution recommendations Strategies to Prevent CDI Infections in Acute Care Hospitals: SHEA Guideline, ICHE, 2014

40. UNC HEALTH CARE ISOLATION SIGN FOR PATIENTS WITH NOROVIRUS OR C. difficile l Use term Contact-Enteric Precautions l Requires gloves and gown when entering room l Recommends hand hygiene with soap and water (instead of alcohol-based antiseptic) l Information in English and Spanish

41. METHODS TO PREVENT CDI: SPECIAL APPROACHES (CDI Incidence Remains Higher than Goal) l Intensify the assessment of compliance with process measures Compliance with hand hygiene Compliance with Contact Precautions If compliance inadequate, institute corrective actions l Perform hand hygiene with soap and water l Empirically place patients with diarrhea on Contact Precautions (remove isolation if test for C. difficile is negative) l Prolong duration of contact precautions until discharge l Monitor the effectiveness of room cleaning (e.g., fluorescent dye) l Consider routine environmental decontamination with sodium hypochlorite or an EPA-registered sporicidal agent UNC routine measures are in yellow Strategies to Prevent CDI Infections in Acute Care Hospitals: SHEA Guideline, 2014

42. BARRIER PRECAUTIONS l Avoid use of electronic thermometers l Use dedicated patient care items and equipment l If equipment must be shared; clean and disinfect between patients l Use full barrier precautions (gowns and gloves) for contact with CDI patients and for contact with their environment (i.e., Contact Precautions) l Place patient with CDI in a private room, if available; give isolation preference to patients with fecal incontinence if room availability is limited Strategies to Prevent CDI Infections in Acute Care Hospitals: SHEA Guideline, 2014

43. DISCONTINUING ISOLATION l CDC currently recommends contact precautions for the duration of illness when care for patients with CDI. Some experts recommend continuing contact precautions for at least 48 hours after diarrhea resolves l At this time data do NOT exist to support extending isolation as a measure to decrease CDI incidence.

44. ANTISEPSIS TO PREVENT C. difficile INFECTIONS 70% isopropyl showed no inactivation of C. difficile spores at exposure times of 5m, 15m, and 30m. Wullt et al. ICHE 2003;24:765. Either soap or CHG works as a handwash for removal of C. difficile. ICHE 1994;15:697. Yes No

45. EFFICACY OF ALCOHOL AS A HAND HYGIENE AGENT AGAINST C. difficile l Probability of heavy contamination (TNTC) following different HH interventions: warm water and plain soap = 0, cold water and plain soap = 0, warm water and antibacterial soap = 0, antiseptic hand wipe = 0.05, alcohol-based handrub = 0.43, and no hand hygiene = 1 Oughton MT, et al. ICHE 2009;30:939-944

46. Hand Hygiene with Soap and Water Is Superior to Alcohol Rub and Antiseptic Wipes for Removal of C. difficile (Oughton et al. Infect Control Hosp Epidemiol 2009; 30:939) Objective: Evaluate HH methods for efficacy in removing C. difficile Design: Randomized crossover comparison among 10 volunteers experimentally contaminated by 1.4x10 5 C. difficile (62% spores) Methods: Interventions were evaluated for mean reduction Conclusion: Handwashing with soap and water showed the greatest efficacy in removing C. difficile and should be performed preferentially over the use of alcohol-based hand rubs when contact with C. difficile is suspected or likely

47. The Role of the Environment in Disease Transmission l Over the past decade there has been a growing appreciation that environmental contamination makes a contribution to HAI with MRSA, VRE, Acinetobacter, norovirus and C. difficile l Surface disinfection practices are currently not effective in eliminating environmental contamination l Inadequate terminal cleaning of rooms occupied by patients with MDR pathogens places the next patients in these rooms at increased risk of acquiring these organisms

48. Thoroughness of Environmental Cleaning Carling et al. ECCMID, Milan, Italy, May 2011 Mean = 32% >110,000 Objects

49. BEST PRACTICES FOR ROOM DISINFECTION USING STANDARD DISINFECTANTS l Follow the CDC Guideline for Disinfection and Sterilization with regard to choosing an appropriate germicide and best practices for environmental disinfection l Appropriately train environmental service workers on proper use of PPE and clean/disinfection of the environment l Have environmental service workers use checklists to ensure all room surfaces are cleaned/disinfected l Assure that nursing and environmental service have agreed what items (e.g., sensitive equipment) is to be clean/disinfected by nursing and what items (e.g., environmental surfaces) are to be cleaned/disinfected by environmental service workers l Use a method (e.g., fluorescent dye) to ensure proper cleaning

50. NEW APPROACHES TO ROOM DECONTAMINATION

51. HP for Decontamination of the Hospital Environment Falagas et al. J Hosp Infect. 2011;78:171 Author, YearHP SystemPathogenBefore HPVAfter HPV% Reduction French, 2004VHPMRSA61/85-72%1/85-1% 98 Bates, 2005VHP Serratia 2/42-5%0/24-0%100 Jeanes, 2005VHPMRSA10/28-36%0/50-0%100 Hardy, 2007VHPMRSA7/29-24%0/29-0%100 Dryden, 2007VHPMRSA8/29-28%1/29-3% 88 Otter, 2007VHPMRSA18/30-60%1/30-3% 95 Boyce, 2008VHP C. difficile 11/43-26%0/37-0%100 Bartels, 2008HP dry mistMRSA4/14-29%0/14-0%100 Shapey, 2008HP dry mist C. difficile 48/203-24%; 77/203-3%; 0.4 88 Barbut, 2009HP dry mist C. difficile 34/180-19%4/180-2% 88 Otter, 2010VHPGNR10/21-48%0/63-0%100

52. EFFECTIVENESS OF UV-C FOR ROOM DECONTAMINATION (Inoculated Surfaces) PathogensDose*Mean log 10 Reduction Line of Sight Mean log 10 Reduction Shadow TimeReference MRSA, VRE, MDR-A12,0003.90-4.313.25-3.85~15 minRutala W, et al. 1 C. difficile 36,0004.042.43~50 minRutala W, et al. 1 MRSA, VRE12,000>2-3NA~20 minNerandzic M, et al. 2 C. difficile 22,000>2-3NA~45 minNerandzic M, et al. 2 C. difficle 22,000 2.3overall67.8 minBoyce J, et al. 3 MRSA, VRE, MDR-A, Asp 12,0003.-5->4.01.7->4.030-40 minMahida N, et al. 4 MRSA, VRE, MDR-A, Asp 22,000>4.0*1.0-3.560-90 minMahida N, et al. 4 C. difficile, G. stear spore 22,000 2.2 overall73 minHavill N et al 5 VRE, MRSA, MDR-A12,0001.611.1825 minAnderson et al 6 1 ICHE 2010;31:1025; 2 BMC 2010;10:197; 3 ICHE 2011;32:737; 4 JHI 2013;84:323l 5 ICHE 2012;33:507-12 6 ICHE 2013;34:466 *  Ws/cm 2 ; min = minutes; NA = not available

55. EFFECTIVENESS OF UV ROOM DECONTAMINATION Rutala WA, et al. Infect Control Hosp Epidemiol. 2010;31:1025-1029.

56. Retrospective Study on the Impact of UV on HA MDROs Plus C. difficile Haas et al. Am J Infect Control. 2014;42:S86-90 During the UV period (pulsed Xenon), significant decrease in HA MDRO plus C. difficile. UV used for 76% of Contact Precaution discharges. 20% decrease in HA MDRO plus C. difficile during the 22-m UV period compared to 30-m pre-UV period.

57. USE OF HPV TO REDUCE RISK OF ACQUISITION OF MDROs Design: 30 mo prospective cohort study with hydrogen peroxide vapor (HPV) intervention to assess risks of colonization or infection with MDROs Methods:12 mo pre-intervention phase followed by HPV use on 3 units for terminal disinfection Results Prior room occupant colonized or infected with MDRO in 22% of cases Patients admitted to HPV decontaminated rooms 64% less likely to acquire any MDRO (95% CI, 0.19-0.70) and 80% less likely to acquire VRE (95% CI, 0.08-0.52) Risk of C. difficile, MRSA and MDR-GNRs individually reduced but not significantly Proportion of rooms environmentally contaminated with MDROs significantly reduced (RR, 0.65, P=0.03) Conclusion-HPV reduced the risk of acquiring MDROs compared to standard cleaning Passaretti CL, et al. Clin Infect Dis 2013;56:27-35

58. LECTURE OBJECTIVES l Understand the epidemiology and impact of C. difficile l Review the role of the environment in disease transmission l Discuss how to prevent transmission of C. difficile via contaminated surfaces l Identify effective preventive strategies

59. C. difficile : Prevention Measures l New Enteric Contact Isolation sign-promote soap and water and sporicidal disinfectant l Enhanced nursing education-ICLs l Daily/terminal bleach disinfection of all C. difficile patient rooms l Bleach wipes-shared equipment l Monitoring thoroughness of cleaning l Isolation until no symptoms and end of treatment

60. C. difficile : Prevention Measures l Use fidaxomicin in selected CDI patients to reduce recurrences l Prescribe and use antibiotics carefully l Follow surgical prophylaxis guidelines (max 24h) l Test for C. difficile when patients have diarrhea while on antibiotics or recent antibiotics (60d) l Use new PCR test as part of diagnostic algorithm (which increases sensitivity of diagnosis)

61. FECAL MICROBIOTA TRANSPLANTATION (FMT) FOR CDI l Gut microbiota alterations key abnormality in CDI l FMT demonstrated excellent cure rate (80-90%) in severe and recurrent cases with good acceptability by patients and physicians l Active reporting of adverse events lacking, although few AEs reported in most studiees l Long-term effects of FMT still unexplored l FMT should follow traditional pathways of new therapy and caution in recommending FMT is warranted until mechanisms and risks of procedure are clear Vecchio AL, Cohen MB. Curr Opin Gastroenterol 2014;30:47-53

62. Fecal Transplants for Refractory C. difficile Infection l Criteria for eligibility -failed standard therapy, no contraindication to colonoscopy, confirmed C. difficile toxin positive, etc l Self-identified donor-donor will respond to eligibility questions: no GI cancer, no metabolic disease, no prior use of illicit drugs, etc l Donor Testing-Stool-C. difficile toxin, O&P, bacterial pathogen panel ( Salmonella, Shigella, Giardia, norovirus, etc). Serum-RPR, HIV-1, HIV-2, HCV Ab, CMV viral load, HAV IgM and IgG, HBsAg, liver tests, etc l Stool preparation-fresh sample into 1 liter sterile bottle, 500ml saline added, vigorously shaking to liquefy, solid pieces removed with sterile gauze so sample is liquid, liquid stool drawn up into 7 sterile 50ml syringes, injected into terminal ileum, cecum, ascending colon, traverse colon, descending colon, sigmoid colon. Colonoscope reprocessed by HLD.

63. LECTURE OBJECTIVES l Understand the epidemiology and impact of C. difficile l Review the role of the environment in disease transmission l Discuss how to prevent transmission of C. difficile via contaminated surfaces l Identify effective preventive strategies

64. CONCLUSIONS l Contaminated environment likely important for C. difficile l Some disinfectants are effective but surfaces must be thoroughly wiped to eliminate environmental contamination l Inadequate terminal cleaning of rooms occupied by patients with C. difficile pathogens places the next patients in these rooms at increased risk of acquiring these organisms l Eliminating the environment as a source for transmission of nosocomial pathogens requires: adherence to proper room cleaning and disinfection protocols (thoroughness), effective product, hand hygiene, and institution of Isolation Precautions

65. THANK YOU! www.disinfectionandsterilization.org

66. SPECIAL APPROACHES FOR PREVENTING CDI l Intensify the assessment of compliance with process measures Compliance with hand hygiene Compliance with Contact Precautions If compliance inadequate, institute corrective actions l Perform hand hygiene with soap and water l Empirically place patients with diarrhea on Contact Precautions (remove isolation if test for C. difficile is negative) l Create a unit specific check list for room disinfection l Monitor the effectiveness of room cleaning (e.g., fluorescent dye) l Consider routine environmental decontamination with sodium hypochlorite or an EPA-registered sporicidal agent UNC routine measures are in yellow Strategies to Prevent CDI Infections in Acute Care Hospitals: Draft SHEA Guideline, 2013

67. COMMENTS ON THERAPY l Oral vancomycin superior to oral metronidazole Can reduce cost of vancomycin by using compounding IV preparation into a PO liquid medication In patients in whom oral antibiotics cannot reach a segment of the colon (e.g., Hartman’s pouch, ileostomy, colon diversion) vancomycin should be delivered via enema l No clinical evidence from RCTs that IV metronidazole is effective l Fidaxomicin demonstrated to have a lower risk of CDI recurrences (25d) but similar efficacy in initial therapy with oral vancomycin Consider for therapy if patient relapses l Consider tigecycline when patients fail to respond to standard therapy l Unclear whether probiotics work for prophylaxis or therapy l No evidence to support use of IVIG

68. PHYSICAL REMOVAL VERSUS CHEMICAL INACTIVATION Rutala WA, Gergen MF, Weber DJ. ICHE 2012;33:1255-58

69. PROVING THAT ENVIRONMENTAL CONTAMINATION IMPORTANT IN C. difficile TRANSMISSION l Environmental persistence (Kim et al. JID 1981;14342) l Frequent environmental contamination (McFarland et al. NEJM 1989;320:204) l Demonstration of HCW hand contamination (Samore et al. AJM 1996;100:32) l Environmental  hand contamination (Samore et al. AJM 1996;100:32) l Person-to-person transmission (Raxach et al. ICHE 2005;26:691)) l Transmission associated with environmental contamination (Samore et al. AJM 1996;100:32) l CDI room a risk factor (Shaughnessy et al. IDSA/ICAAC. Abstract K-4194) l Improved disinfection   epidemic CDI (Kaatz et al. AJE 1988;127:1289) l Improved disinfection   endemic CDI (Boyce et al. ICHE 2008;29:723)