“It Takes A Village” Re: Clostridium difficile (C.diff.) and Healthcare-Associated Infections, By Dr. Rosie D. Lyles, MD,MHA,MSc

“It Takes a Village”
By: Rosie D. Lyles, MD, MHA, MSc, Head of Clinical Affairs for Clorox Healthcare
September 21, 2015

With increasing rates of Clostridium difficile infections (CDI), C. difficile now rivals methicillin-resistance Staphylococcus aureus (MRSA) as the most common organism to cause healthcare-associated infections (HAIs) in the United States. (1) The prevalence of C. difficile infections has more than doubled in U.S. hospitals from 2000 to 2009 (2) and CDI is regarded as one of the serious, expensive, and potentially avoidable consequences of hospitalization. The cost of treating CDI in the hospital is $3427-$9960 (in 2012), and the cost of treating patients with recurrent CDI is $11,631, for a total cost of more than $1.2 billion annually in the United States. (3-4)

In June 2015, the White House spearheaded an executive call to action focused on implementing and improving antibiotic stewardship programs (ASPs) across the continuum of care (acute care facilities, outpatient clinics, doctors’ offices and long-term care facilities). The urgency around this issue stems from the increasing number of antibiotics prescribed, which subsequently breeds multi-drug resistant organisms (MDROs) like C. difficile. Unnecessary or excessive antibiotic use combined with poor infection control practices may increase the spread of C. difficile within a facility and across facilities when infected patients transfer, such as from a hospital to a nursing home. Increasing evidence suggests that contaminated surfaces in healthcare facilities play an important role in the transmission of several key pathogens including C. difficile, vancomycin – resistant enterococci (VRE), MRSA, Acinetobacter baumannii, and norovirus.

In order to reduce HAIs, all hands on deck are required to support a successful infection prevention strategy. In other words, “it takes a village.” Growing up, I remember hearing the phrase, “it takes a village to raise a child,” meaning there is a partnership within a community with several individuals playing a role in the maturation of a youth. Within a hospital, it’s a collaborative team across several departments that implements evidence-based protocols, continues to educate staff and patients, and maintains compliance of infection control strategies/approaches to reduce the risk of a broad range of infections, including CDI. From the C-suite (administrators and senior management) to direct healthcare providers (such as physicians, nurses, aides, and therapists) and environmental staff (EVS); everyone with direct or indirect contact with a patient’s care plays an essential role.

As a healthcare professional, it’s very important for hospitals to focus on the bigger picture when it comes to infection prevention strategy and control. Prioritizing infection control measures for just one or two pathogens of concern is insufficient. At the end of the day, one pathogen doesn’t trump another because patients don’t want an HAI from ANY pathogen! The horizontal approaches aim to reduce the risk of infections due to a broad array of pathogens through implementation of standardized practices that do not depend on patient-specific conditions:

• Proper hand hygiene
Hand hygiene practices in compliance with the Centers for Disease Control and Prevention (CDC) or World Health Organization (WHO) guidelines are a key component in preventing and controlling C. difficile, in addition to many other HAI-causing pathogens.
• Universal use of gloves or gloves and gowns
Donning the correct protective equipment minimizes contact with pathogens. It is also important to follow protocols for properly discarding this equipment.
• Universal decolonization (daily optimal bathing with chlorhexidine gluconate (CHG))
CHG bathing has been shown to decrease the bioburden of microorganisms on the patient, the environment, and the hands of healthcare personnel.
• Antimicrobial stewardship program
Ensuring every patient receives an antibiotic only when needed: the right agent, at the right dose, for the right duration.
• Evidence-based environmental cleaning and disinfection products
At a minimum, effective environmental cleaning involves using cleaners & disinfectants that are registered by the Environmental Protection Agency (EPA). Supplementing manual cleaning with new technology like ultraviolet (UV) light provides an extra layer of protection and the most comprehensive approach. UV has the highest-energy form that can inactivate dangerous and persistent pathogens by eradicating microorganism deoxyribonucleic acid (DNA) that may be left on surfaces, which can be missed with traditional cleaning. Finally, because C. difficile has been found in non-CDI patient rooms, using an EPA-registered sporicidal surface disinfectant to clean all patient rooms (daily and terminal) is great strategy to prevent the spread of the bacteria.

I had the pleasure of attending the CDC’s Environmental Hygiene for Ebola and Other Emerging Pathogens meeting on September 14, 2015, with attendees from academia, private industry, federal employees and health organizations, participated in a roundtable discussion on the research framework needed to determine the public health significance of non-critical environmental surface contamination and provide guidance to healthcare facilities about the methods to reduce the contamination of non-critical environmental surfaces reliably in order to improve patient safety. Every participant present at the meeting agreed that, due to the challenges/barriers that hospitals face with preventing HAIs (both from emerging pathogens and more common pathogens like C. difficile), it takes a village to successfully implement evidence-based protocols, continue to educate and maintain compliance with infection prevention protocols.

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About Rosie D. Lyles, MD, MHA, MSc, Head of Clinical Affairs for Clorox Healthcare

Rosie D. Lyles, MD, MHA, MSc is the Head of Clinical Affairs for the Clorox Professional Products Company where she serves as a research fellow and primary medical science liaison for the healthcare business, supporting all scientific research as well as clinical and product intervention design and development.
Dr. Lyles previously served as a physician researcher and study director for multiple epidemiologic research initiatives in the Division of Infectious Diseases at the Cook County Health and Hospitals System, investigating healthcare-associated infections with a particular focus on the epidemiology and prevention of multidrug-resistant organisms and infections in intensive care units and in long-term acute care hospitals. She has directed numerous clinical studies and interventions for the Centers for Disease Control and Prevention (CDC) and the Chicago Antimicrobial Resistance and Infection Prevention Epicenter.
During her nine years as a study director and physician researcher at Hektoen Institute for Medical Research, Dr. Lyles’ work included CDC Epicenters Prevention program studies on bloodstream infections, Clostridium difficile infections and case-control studies of community-acquired Methicillin-resistant Staphylococcus aureus (MRSA). She also performed surveillance studies of Klebsiella pneumoniae carbapenemase (KPC) positive patients, examining universal contact isolation and patient skin antisepsis protocols to identify ways to optimize standard infection control measures.
Dr. Lyles received her medical degree from St. Matthew’s University School of Medicine and holds a Master of Health Service Administration from St. Joseph College. She also recently completed a Master of Science in Clinical Research and Translational Sciences through the University of Illinois at Chicago. She is an active member of the Association of Professionals in Infection Control and Epidemiology, the Infectious Disease Society of America, the Society for Healthcare Epidemiology of America and has served as a peer reviewer for the National Institutes of Health, New England Journal of Medicine, and American Journal of Infection Control.
References:
1. Dubberke, ER, et al. Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update. Infect Control Hosp Epidemiol. 2014, V35:S48-S65
2. Tabak et al., Predicting the Risk for Hospital-onset Clostridium difficile Infection (HO-CDI) at the Time if Inpatient Admission: HO-CDI Risk Score. Infect Control Hosp Epidemiol. 2015, 36: 6; 695-701
3. Magill, SS. et al. “Multistate Point-Prevalence Survey of Health Care-Associated Infections.” The New England Journal of Medicine 370.13 (2014): 1198–1208.
4. Dubberke, ER, and Olsen, MA. “Burden of Clostridium Difficile on the Healthcare System.” Clinical infectious diseases 55 Suppl. 2 (2012): S88–92.
5. Septimus, E., et al. “Approaches for preventing Healthcare-associated Infections: Go Long or Go Wide?” Infect Control Hosp Epidemiol. 2014. 35: 7; 797-801