Special Edition on Infection Prevention & Control | Page 34

immunity”: If there are fewer patients at risk for CDI, fewer
will develop CDI and shed high levels of C difficile spores. To
assist hospitals with implementation, the STRIVE team also
highlighted additional potential benefits of ASPs, including
prevention of multidrug-resistant organisms, reduction of
antibiotic-associated adverse events, prevention of HAIs, and
reduction of costs. In addition, the CDC 2014 recommendation
that all acute care hospitals implement an ASP and the 2017
Joint Commission antimicrobial stewardship standard mandate
that all critical access hospitals have an ASP were emphasized.
To support generating a standard infrastructure to create
effective ASPs, we recommended the CDC core elements
of hospital antimicrobial stewardship programs (leadership
commitment, accountability, drug expertise, action, tracking,
reporting, and education).
Tier 1, Intervention 2: C difficile Testing: Promoting
early and appropriate CDI testing was the next recommended
intervention. Diagnosis of CDI is clinical, and laboratory tests
alone cannot discriminate between colonization and CDI.
Misdiagnosing colonization as infection can directly increase
CDI rates particularly in the acute-care setting, where as many
as 15 percent of patients are asymptomatically colonized with
toxigenic C difficile. With the variability in the performance of
enzyme immunoassay testing for glutamate dehydrogenase
and C difficile toxins, as well as amplified detection of
colonized patients with nucleic acid amplification, guidelines
and experts recommend a multistep approach combining
the two types of tests. In addition, repeating tests, ordering
multiple tests, and tests for cure were all not recommended.
The team recommended that CDI testing be paired with “stool
stewardship,” or only testing patients with clinically significant
diarrhea (three or more loose stools per day for at least 24 hours)
without another likely explanation (for example, laxatives) for
their symptoms. Finally, educating health care personnel on
clinical features, transmission, and epidemiology of CDI and
processes for appropriate testing was emphasized. Studies
at single centers have shown that improved stewardship of
C difficile testing such as this is associated with improved
performance on CDI metrics. The national team recognized
the tension in balancing diagnostic stewardship with the need
to quickly identify patients with CDI. Rapid identification of
patients with CDI can diminish environmental contamination
and transmission to other patients. Tier 1 thus recommended
processes to ensure early detection of patients with CDI as
well as automated laboratory alerts to notify staff of positive
results. In a single-center study done at the Cleveland Veterans
Affairs Medical Center, a process with laboratory notification
of clinicians complemented by formation of a CDI stewardship
team led to substantial reductions in delays in treatment.
Tier 1, Intervention 3: Hand Hygiene and Glove Use:
The next recommended intervention focused on preventing
transmission of C difficile spores through HH and strict glove
use. In the acute care setting, the hands of healthcare providers
are a common mode of pathogen transmission, playing a part
in an estimated 20 percent to 40 percent of HAIs. Proper HH
technique using alcohol-based hand rubs (ABHRs) or soap
and water is effective in decreasing bacterial counts on the
hands by 3- or 4-log. For most pathogens, ABHRs appears
to be more effective, accessible, and efficient in reducing
bacterial counts on the hands compared with soap and water.
This is not the case for C difficile spores, which can persist in
environments for months, are notoriously difficult to kill with
disinfectants, and regularly contaminate the hands of health
care workers. In a study of 66 healthcare workers, 24 percent
had detectable C difficile spores after routine care of patients
with CDI. Furthermore, nonclinical studies where volunteers’
hands were experimentally contaminated by nontoxigenic C
difficile spores suggest that neither ABHR nor HH with soap
and water is particularly effective in removing CDI spores. In a
study of 10 volunteers, soap and water was superior to ABHR at
mechanically removing spores (2-log reduction versus 0.06-log
reduction), with ABHR being no different than no HH. Further
confounding this issue is the overall poor rates of compliance
with HH in acute care facilities, where about one half of all HH
opportunities are missed. Recognizing these challenges, the
national team recommended competency-based training for
staff based on the World Health Organization 2009 guidelines
for HH, including the 5 Moments for Hand Hygiene and the
CDC’s Clean Hands Count campaign. In addition, donning
PPE—particularly gloves upon entry to a patient’s room—was
emphasized as a means to prevent contamination, because
this has been associated with decreased CDI rates. In a
prospective study of three hospital wards, an intervention on
one unit aimed at increasing glove use by health care providers
resulted in a decrease in CDI from 7.7 to 1.5 cases per 1,000
patient discharges, whereas the other 2 control units noted
no change in CDI rates.
Tier 1, Intervention 4: Contact Precautions and PPE:
Initiation of contact precautions when patients test positive
for CDI and maintaining such precautions for the duration
of CDI illness was the next tier 1 recommendation. Contact
precautions include the donning and doffing of gowns and
gloves. Although glove use is particularly important, gowns
also play a protective role in preventing CDI, because C difficile
spores have been isolated on hospital workers’ uniforms after
their shift. Proper use of contact precautions and PPE can
protect health care workers and patients from HAI, but suitable
technique is often lacking. In one study using fluorescent
lotion, 46 percent of 435 glove-and-gown removal simulations
were found to be associated with contamination of skin and
clothing of participants. Another important aspect of contact
precautions is dedicated medical equipment. In one study, 20
percent of electronic rectal thermometer handles were found
to be contaminated with C difficile; changing to disposable
thermometers led to a significant decrease in CDI rates. In
addition, data indicate that up to 14 percent of stethoscopes
become contaminated after being used to examine a patient
with CDI. Therefore, informed by the 2007 CDC isolation
precaution guidelines, use of dedicated or single-use patient
equipment and supplies, use of single rooms or cohort patients
with CDI, and use of full barrier PPE were emphasized in tier
1. Finally, routine competency-based training for proper use
of PPE with audits and feedback were also recommended.
Tier 1, Intervention 5: Environmental Cleaning and Disinfection:
Numerous studies have examined the contribution
of contamination of healthcare environments in hospitals and
long-term acute care hospitals to HAI, including CDI. Proper
environmental cleaning and disinfection can substantially
reduce environmental contamination and the associated risk
34 IP&C Special Edition June 2020 • www.healthcarehygienemagazine.com