Gastrointestinal Infection
Preventing Clostridium Difficile Infection Robert Orenstein, DO, FIDSA
Associate Professor of Medicine, Division of Infectious Diseases, Mayo Clinic Arizona
Abstract
Clostridium difficile infection (CDI) has become the leading healthcare-associated infection in US hospitals. Control of this infection has been a challenge since many of the patients who acquire this have significant comorbidities and often require antimicrobial therapy. Prevention of healthcare-acquired CDI can be achieved by preventing transmission within healthcare facilities. Despite high rates of hand hygiene and contact isolation, environmental contamination may provide the reservoir for transmission. Recently, several studies have demonstrated the effectiveness of chlorine bleach-based environmental disinfection as a means of preventing healthcare-acquired CDI. This article reviews a highly effective intervention using chlorine bleach impregnated wipes.
Keywords Clostridium difficile, environmental, bleach, healthcare-acquired infection
Disclosure: The author has no conflicts of interest to declare. Acknowledgment: The project was completely designed and funded by Mayo Clinic. Clorox Corporation provided the bleach wipes to Mayo Clinic for the initial phase of this project. Received: March 10, 2011 Accepted: May 26, 2011 Citation: US Gastroenterology & Hepatology Review, 2011;7(1):66–7 Correspondence: Robert Orenstein, DO, FIDSA, Division of Infectious Diseases, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054. E:
Orenstein.robert@
mayo.edu
Clostridium difficile infection (CDI) has become an increasing menace in healthcare facilities around the globe. In the US, it has surpassed methicillin-resistant Staphylococcus aureus (MRSA) to become the top healthcare-acquired pathogen. It now accounts for over 165,000 hospital onset cases in US hospitals, affects another 50,000 persons after discharge, and over 263 million nursing home residents. Its economic and social impact is staggering, particularly in the elderly.
highlights the paucity of evidence-based knowledge regarding prevention. This meta-analysis really found nothing substantive that has not been recommended for years, even prior to the current epidemic of CDI.
C. difficile presents a significant threat to our public health. The disease is seen and managed by numerous physicians besides gastroenterologists and infectious disease specialists, and the lack of evidence-based guidelines has led to inconsistent practices in management of the acute illness and prevention of disease and recurrence. Recently, the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA), have sorted through the available evidence to create guidelines and provide a roadmap for future studies. A recent meta-analysis1
Two well-established modifiable factors to prevent CDI are reducing antimicrobial exposure and reducing healthcare transmission of C. difficile. Nationally recommended strategies have focused on enhanced isolation practices (contact isolation), and hand hygiene compliance. Although necessary, these are clearly insufficient to control the epidemic spread. More recent research2–5
suggests that a
multimodal approach including better testing, an early alert system of notification, antimicrobial stewardship, and environmental cleaning4 may reduce transmission.
C. difficile is an anaerobic, toxin-producing organism that colonizes the lower gastrointestinal tract. To get to its niche, it must be ingested and some recent data suggests this may be a foodborne illness.6,7
Loss of
Yet despite its rise in incidence and severity, we lack a public health approach to control of this disease. Traditional management has focused on the treatment of individual patients that has overshadowed preventive approaches. There remains a lack of data on the best methods for preventing acquisition. This article focuses on the modification of environmental factors to reduce the spread of this epidemic.
66
protective defenses such as gastric acidity or dysmotility may play a role. The frequency of colonization is dependent upon healthcare and antimicrobial exposures, the host’s immune state, and the competitive fecal biome. Disruption of any one of these factors may enhance the risk for acquisition and disease due to this organism. Thus, approaches to prevention may focus on: preventing acquisition from the environment; preventing colonization of the gut; enhancing the host’s immune defenses; and providing early, effective treatment associated with low relapse rates.
The current standard for care of patients with CDI is to place them in contact isolation once the organism is identified on stool testing and maintain this while they are having diarrhea. A problem with this approach is that depending on the sensitivity of the C. difficile testing,
© TOUCH BRIEFINGS 2011
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76