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Hand hygiene ineffectiveness, confusion undercut response to deadly C. diff epidemic
Hospitals, nursing homes will 'sink or swim together'
Editor's note: In this issue we begin a two-part series on the national epidemic of Clostridium difficile (C. diff) with an overview of the current situation and a specific focus on challenges to hand hygiene. Look for the June 2010 issue of Hospital Infection Control & Prevention for the latest findings and recommendations on C. diff testing, discontinuing isolation and the difficult issue of environmental cleaning.
An epidemic of Clostridium difficle in the United States is now killing some 12,000 patients annually, in part because neither alcohol hand rubs nor soap and water used in the vast majority of hospitals can effectively remove the spore-forming bacillus from the hands of health care workers, researchers are finding.
With the pathogen practically impervious to the hand hygiene approaches used in the vast majority of hospitals, the Centers for Disease Control and Prevention is considering the radical step of recommending "universal gloving" for some situations. However, infection preventionists warn that such policies invariably lead to health care workers going from patient to patient and room to room without changing gloves an ideal scenario for disease transmission.
In short, there are no simple solutions to an increasingly complex problem, an epidemic of C. diff driven by the highly virulent NAP1 strain, which is more deadly to patients and six-fold more prevalent than the next most common C. diff strain, epidemiologists and IPs reported recently in Atlanta at the Fifth Decennial International Conference on Healthcare-Associated Infections. One study particularly underscored the dramatic rise of C. diff, noting that it has surpassed dreaded methicillin-resistant Staphylococcus aureus (MRSA) as the leading nosocomial pathogen in community hospitals in the Southeast. (See related story, p. 53.)
"Times are changing," said Becky Miller, MD, lead author of the study and an epidemiologist at Duke University Medical Center in Durham, NC. "What was once thought of as a nuisance infection has become an increasing problem, carrying increased morbidity, mortality and health care costs for patients."
A personal loss
A leading cause of diarrhea in hospitalized patients, C. diff infection can lead to serious complications such as pseudomembranous colitis, toxic megacolon, perforations of the colon and sepsis. Though a national surveillance system for C. diff is currently under development at the CDC, the latest estimates outline the formidable extent of the problem. According to extrapolated data released by the CDC at the decennial conference, hospital-acquired C. diff which includes both hospital-onset cases and post-discharge cases that occur up to 4 weeks later causes some 215,000 infections annually, resulting in 12,000 deaths and costs of $1.6 billion. The thousands of C. diff deaths were reduced to one in a personal aside by former CDC director Julie Gerberding, MD, MPH, who lost her aunt to the infection last year.
"In my own personal experience of these pathogens, the reality check of sitting in the acute setting as well as the rehab environment and watching the absurd interpretation of what contact precautions were all about from a practical perspective was really a very poignant and eye-opening experience of how ubiquitous these pathogens are and how easily they spread throughout the system," said Gerberding, president of Merck Vaccines in Whitehouse Station, NJ. "And unfortunately, how deadly because my aunt died of C. difficile."
Beyond the hospital setting, even more C. diff deaths are occurring in long term care. Nursing home-onset C. diff infections were estimated at a staggering 263,000 cases annually, with 16,500 deaths and costs of $2.2 billion. All told, that's in the ballpark of a half-million cases and 25,000 deaths in hospitals and nursing homes every year in the United States. The familiar refrain of "who gave what to whom" came up in discussions of transmission between hospitals and nursing homes, which must nevertheless work together and improve communication about patients and residents if the problem is going to be solved.
"For a community or a region to drive down C. diff rates, it's going to really require coordination between a variety of facilities," said L. Clifford McDonald, MD, FACP, a leading C. diff expert in the CDC's division of healthcare quality promotion. "Most of you are from acute care facilities, but it is clearly nursing homes that need our help. You are not going to get your rates really down until you start being concerned [about that]. You are your brother's keeper, here."
With health care reform, there's going to be a continued movement towards "bundled payments," meaning hospitals will have financial incentives to help nursing homes before their residents become patients. "Whether we like it or not there's going to be continued pressure for payment and so C. diff rates which are hospital onset somehow that is going to come back to acute care facilities," he said. "If we really want to stop the hospital onset [cases] we are going to have to [prevent] the community onset cases coming from other facilities. There's no way around it. We are either going to sink or swim together."
The situation is reminiscent of similar problems with transferring patients with resistant bacteria like MRSA or VRE. In such situations hospitals may be tempted to speak with "forked tongue" about the patient's status lest the long term care setting refuse to take them, observed Ruth Carrico, PhD, RN, CIC, a veteran IP and assistant professor of health promotion and behavioral sciences at the University of Louisville (KY).
"Remember, as we move individuals across the spectrum of health care it is really important to make sure that this information is communicated that they have been treated for C. diff," she said. "It is a very hard thing some times to deal with, but in our profession we have to keep our eye on the beacon: What is the in the best interest of our patients?"
Hand hygiene conundrum
Hand hygiene has always been in the best interest of patients, but C. diff is proving particularly vexing for the cardinal principle of infection control. To begin with, the 2004 emergence of epidemic C. diff followed the CDC's national switch from traditional soap and water to alcohol-based hand hygiene in the nation's hospitals. Since alcohol is generally ineffective against C. diff, some thought the timing of the ensuing national epidemic was no coincidence. McDonald disputes that notion, noting that "these are truly unrelated phenomena that occurred at the same time."
At any rate, though many hospitals had crossed the Rubicon in terms of switching over from soap to alcohol, the CDC endorsed the 2008 compendium guidelines that in an outbreak situation or in dealing with continuing C. diff transmission, health care workers should "perform hand hygiene with soap and water preferentially, instead of alcohol hand hygiene products."1 But are soap and water much better than alcohol? A study presented last year by investigators led by internationally recognized C. diff expert Dale Gerding, MD, found that soap and water doesn't effectively remove the spores.2 In that study, the only soap found effective against C. diff was an industrial soap used in manufacturing to remove substances like printer's ink. Discussing that study and others, McDonald summed up the situation the CDC is facing with C. diff and hand hygiene.
"When we really look at soap and water for C. diff it's not that good," he told conference attendees. "When we look at soap and water or alcohol-based hand sanitizers for MRSA, VRE or an E. coli strain of bacteria we are commonly seeing four-log reductions [kill rates approaching 99.99%]. You look at hand washing for C. diff using antimicrobial or regular soap it doesn't matter and you only get two-log reductions at most. Plain alcohol is like tap water. The point is that we are just not that good at getting these spores off. It seems like these spores kind of stick."
Troubling information indeed, but the fear is that further discouraging alcohol gel use may undermine overall hand hygiene programs and permit the rise of other pathogens. "When we think about what is going in the real world we know that compliance with hand hygiene with soap and water is significantly lower than with alcohol-based hand hygiene products," said Eric Dubberke, MD, an epidemiologist at Washington University School of Medicine in St. Louis, MO. "So are you really getting any net benefit by switching over to soap and water? The other consideration is that the way my hospital and others are designed, when you are washing your hands you're using the exact same sink the patient used after their last C. diff bowel movement."
A mixed message
Fearing its hand hygiene message may be completely lost in translation, the CDC is reluctant to backtrack on people that have already switched to soap and water for C. diff. "We certainly wouldn't say that anyone should move back from that necessarily," McDonald said. There is also concern that C. diff prevention efforts will drive hospitals away from the alcohol sanitizers.
"We know that alcohol is not effective in eradicating C. diff spores, so it seems a natural thing to revert to [soap] hand washing for known C. diffcases," he added. "There is this concern at CDC that there has been some undermining of our message of hand hygiene. Remember, alcohol-based hand sanitizers are highly effective and probably even more efficacious than hand washing for MRSA, VRE and all the other vegetative bacteria out there. We don't want to just focus on C. diff at the expense of other pathogens."
Given this conundrum, the CDC is considering the feasibility of universal glove use (in addition to contact precautions for patients with known C. diff) on units with high C diffrates. One rationale for this is that, asymptomatic carriers may have a role in transmission. In addition, practical screening tests are not widely available. Thus, there may be a role for universal glove use as a special approach to reducing transmission on units with longer lengths of stay and high endemic C. diff rates, McDonald said.
"When you look for epidemiologic and experimental evidence for C. diff transmission via hands, only gloves have been shown to actually interrupt transmission," he said. "So that's the point don't let the hands get contaminated in the first place. Whenever you do that of course, you have to prevent [people wearing] the same pair of gloves from room to room and throughout the day, that kind of thing. It seems when you talk to people about this idea of [universal] glove use it works, but only for a short period of time. You can do this sometimes effectively in an outbreak situation, but if you make it a long-term policy it really breaks down [into] glove abuse."