10 Facts Every Healthcare Provider Should Know About C. Difficile

The prevention of healthcare-associated infections (HAI’s) is a key focus of hospitals and health care facilities, and an increasingly prevalent component of Joint Commission and CMS surveys aimed at improving the safety and quality of care. In this era of “smarter,” more resistant pathogens, environmentally mediated bacteria and viruses present ever increasing risks of HAI’s that can negatively impact patient care and devastate a hospitals bottom line. It is well known in current literature that many of the most common, and preventable, HAI’s are caused by bacteria including C. difficile (CDAD), E. coli (UTI, wound infections), and many other bacteria, viruses, and pathogens that originate from the GI tract. Of these, one of the most commonly implicated, and least understood, is C. difficile , which accounts for a significant percentage of the estimated 2 million preventable HAI’s and excess costs up to $45 billion annually.

Recent reports indicate that risks of C. difficile continue to rise, with rates more than doubling in some areas, and CDC reports of C. difficile costs and mortality reaching “Historic Highs.” So how does this happen despite more than 2 decades of enhanced focus on infection prevention, including hand hygiene and emphasis on reducing antibiotic exposure in the fight against C. difficile?

Despite many advances in antibiotic control measures and increased emphasis on hand hygiene compliance initiatives, we still have a long way to go as we continue to gain understanding of this infectious pathogen. Our current experiences show us that to truly contain and prevent HAI’s, including those caused by C. difficile , requires an ongoing commitment to gaining knowledge about these pathogens. Enhancing awareness of the means by which bacteria and pathogens work and spread throughout the care environment is critical to assessing the adequacy of processes and control measures at all levels across the care spectrum. It should be the ongoing goal of any health care facility and organization to identify and eliminate “weak links” in the chain of transmission of this important pathogen.

When considering HAI risks within the continuum of care, facilities should start by identifying and confining potential sources of infectious bacteria and pathogens, and implement processes and protocols to interrupt opportunities for exposure to patients, staff, and surfaces throughout the hospital environment. For example, as commonly implicated bacteria like C. difficile ultimately originate in the GI tract of colonized or infected patients, efforts should be made to contain GI secretions, fluids, or contamination in areas of a facility where predictably or frequently encountered, and prevent inadvertent cross-transmission to patients or surfaces in other areas of the hospital.

It is recommended and accepted practice for a patient admitted for known diarrhea to be proactively placed in contact isolation precautions, with enhanced contact transmission protocols in place. Isolation (enhanced focus on hand hygiene and implementation of enhanced barrier precautions including the use of gowns and gloves for staff and visitors) is intended to reduce the risks of contact and/or cross transmission of any potential GI pathogens (C. difficile , norovirus, E. coli, etc) to other patients or care areas. This not only makes clinical sense, but also common sense right? Of course it does, as we know that diarrhea increases the shedding of GI bacteria and increases the chance of transmission to the surrounding environment where it can quickly be spread to other parts of the facility. After all, such is the purpose of isolation precautions, and the infection prevention case for keeping GI bacteria (which inherently has a high potential for extensive environmental dissemination) contained and confined within a controlled environment before it would have the opportunity to spread.

So what would happen if a patient was wheeled out of an isolation room on their same bed and moved down the hallway to a room with another patient just a few feet away? What if outpatients passed through 2 or 3 care areas on their way to an appointment, even though all of the inpatients had undergone MRSA screening on admission to rule out risks of exposure to other patients or the facility?

Either of these scenarios would make an Infection Preventionist or Risk Manager cringe, as these compromise the effectiveness of any efforts made up to that point in time. Though seemingly unthinkable, occurrences like this take place every day in any procedure or care area where tools and processes are either not available or not implemented to achieve a level of prevention that meets the level of risk.

Consider the under-recognized risks of HAI-causing bacteria that can be introduced to your facility through procedures performed in an ambulatory surgery area. Unlike inpatients, where screening for MRSA is increasingly performed via nasal swab prior to admission, very little is typically known about the potential “carrier” or colonization status of outpatients in ambulatory areas. Factors including procedural or care specific risks of generating or encountering fluids or secretions, proximity or sharing of care areas (i.e.: procedural areas, PACU) and transport equipment, and procedure or care flow should be carefully considered in development of facility wide risk reduction strategies.

Take for instance an endoscopy or GI procedure area, where GI secretions and bacteria are predictably encountered on virtually every procedure performed. Protocols are in place for the reprocessing of flexible endoscopes and the use of PPE based on the perceived level of risk of encountering blood, bacteria and body fluids. However, current risks and infection trends involving uncontrolled and environmentally mediated GI bacteria and pathogens confirm the need for enhancing contact transmission precautions within the immediate procedure area to confine bacteria and secretions within the procedure room. Upon completion of a procedure, the used scope is sealed or contained and taken for reprocessing, and PPE is removed and disposed of, while at the same time the gurney, linens, and even patient surfaces contacted or exposed during the procedure are moved out into PACU to be unwarily placed in close proximity to other patients, staff, or family members.

What if a patient in this scenario was unknowingly colonized with C. difficile ? Or E. Coli? Or some other GI borne bacteria, virus, or other pathogen? Consider the cross-transmission risks in the case of an inpatient transported from PACU to a patient care floor on the same procedure gurney after recovery. Consider the significant reduction in these risks if the clock could be turned back, and bacteria and secretions contained within the procedure room, confined prior to ever moving this patient to recovery.

Though endoscopy areas are by no means the only area within a health care facility where GI bacteria can be encountered, it is arguably one of the most predictable. Eliminating sources of bacteria and pathogens before they have the opportunity to be spread is a critical first step in breaking the chain of infection. When developing a facility-wide “battle plan” for reducing the risks for HAI’s caused by GI mediated bacteria, isn’t looking at procedures where GI-borne bacteria is predictably encountered a good place to start?