If you work in health care, chances are that you’re more than familiar with the urgency of Clostridioides difficile (C. difficile). C. difficile infection has become the most common cause of healthcare-associated infections (HAI) in U.S. hospitals1, increasing hospital length of stay by 2.8 to 5.5 days2 and inpatient costs by an estimated $3,006 - $15,397 per episode2. C. difficile is also a huge problem beyond the acute care setting with 75% of infections developing outside the hospital3. Lastly, C. difficile is a major risk to patient safety with infections causing pseudomembranous colitis, resulting in diarrhea. Infections often recur and can progress to cause further complications, such as dehydration, kidney failure, toxic megacolon, bowel perforation and even death.
A spore-forming bacterium, C. difficile can be shed by people infected or colonized with the bacteria. It can also persist on inanimate surfaces making it very difficult to eradicate from the environment around us. Transmission can occur via the fecal-oral route through direct contact with another person harboring the bacteria or by a fomite carrying the bacteria. Once ingested, C. difficile can survive in the gut and under certain circumstances, multiply and produce toxins leading to gastrointestinal illness. Controlling the spread of C. difficile is a very complex and endless battle, but it is preventable.
Breaking the chain of C. difficile transmission
There are very few published guidelines on the management of C. difficile infection and only some address prevention4. Limiting antimicrobial exposure to patients through antimicrobial stewardship is a common strategy.
Infection prevention strategies help limit patient exposure to C. difficile. These efforts often include educating healthcare personnel about the epidemiology of C. difficile, avoiding the use of shared patient care items, and compliance with full-barrier precautions (gown and gloves) for contact with any patient suspected or confirmed to have an infection. The use of private rooms for these patients helps to minimize risk of transmission to others. Meticulous hand hygiene and appropriate disinfection of patient care equipment and the environment of care can also help to prevent transmission. These infection prevention strategies are a crucial part of any infection prevention program, but often are not enough to eliminate transmission.
Breaking the chain of C. difficile transmission is of the highest priority. However, the evidence is weak5 for many of the available recommendations, and the impact of these recommendations across a wide range of settings has yet to be determined. Additionally, many of our real-world efforts are reactionary after an exposure or infection is initially suspected or confirmed.
Most clinicians will agree that there is more work to be done in order to boost our C. difficile prevention efforts and identify earlier opportunities to intervene proactively before infection occurs. Scientific literature provides considerable evidence regarding risk factors for C. difficile infection. The risk for infection increases in patients with:
- Antibiotic exposure
- Previous infection or exposure to C. difficile
- Gastrointestinal surgery/manipulation
- Long length of stay in health care settings
- Serious underlying illness
- Advanced age
- Gastric acid suppressant exposure
The early identification of risk factors could help clinicians remain several steps ahead of a C. difficile infection by alerting them to high risk patients and informing targeted prevention approaches to use within these populations.
Benefits of leveraging technology & teams for earlier prevention
Risk factors for C. difficile can be identified and evaluated as part of the direct care delivered by a clinician to a patient. Once this clinical data is documented and made available within the patient’s electronic health record (EHR), the notification of critical risk factor information can be promptly shared with the larger multidisciplinary team across clinical specialty areas, hospital locations and admission encounters.
Healthcare leadership ensuring that all patient health information is made available via EHR is an important decision, but it is often not enough. Too often, clinical teams rely solely on the EHR and lose sight of the ability to utilize more advanced real-time alerting solutions which provide immediate notifications of higher risk patients and drive rapid deployment of prevention efforts. For example, if an Infection Preventionist determines that a specific group is at increased risk, real-time alerts could prompt a variety of immediate and specialized approaches to prevent C. difficile exposure and infection. These actions could include detailed antimicrobial review and stewardship, decisions with general patient care, decisions with patient placement, patient-specific educational guidance, and specific approaches to better promote complete adherence with hand hygiene and environmental disinfection.
Using the right technology, the multi-disciplinary clinical team can make the greatest impact on HAIs by responding with real-time tailored clinical practices to negate risk and improve overall care for each patient. Third-party solutions that integrate with the EHR provide this dynamic real-time clinical surveillance that employs specific types of patient alerts that clinicians need in order to be notified of patient risk, to optimize workflow and to provide the most impactful infection prevention and control efforts.
Looking beyond the EHR for real-time surveillance and robust Clostridioides difficile analytics
Third-party clinical surveillance solutions, such as Wolters Kluwer’s Sentri7®, empower clinicians to easily manage and continuously improve their infection prevention program. Here’s how:
- Infection Preventionists can personally create and customize their own clinical dashboard populated with rule-driven, patient alerts.
- All clinical patient alerts are easily managed by the Infection Prevention Program and not by their information technology colleagues. With one-click, a new rule can be implemented improving the timeliness of Infection Prevention efforts.
- Patient alerts are real-time where clinicians can be notified while at the computer or away from the office by subscribing to automatic email alerts.
- Each patient alert is accompanied by contextually relevant patient information to guide prompt action by the Infection Prevention team with suggested actions based on evidenced-based best practices.
- Dedicated clinical experts who constantly monitor the patient alerts utilized by facilities to ensure that all content and guidance are kept up-to-date as science and recommendations change.
- Surveillance solutions integrated with the EHR and offering a robust analytics application, empower Infection Preventionists to easily access and analyze large amounts of aggregated facility data so that key performance indicators related to HAIs, such as Clostridioides difficile analytics, and other metrics can be monitored and evaluated over time and guide quality improvement efforts.
With the right team working together and with access to the right tools, the early identification of high-risk patients to eliminate HAIs, such as C. difficile infection, is possible and highly beneficial for everyone involved including patients, their visitors, health care staff, and the community at large.
1. Hall AJ, Curns AT, McDonald LC, Parashar UD, Lopman BA. The roles of Clostridium difficile and norovirus among gastroenteritis-associated deaths in the United States, 1999-2007. Clin Infect Dis 2012;55:216-223
2. Dubberke ER, Olsen MA. Burden of Clostridium difficile on the healthcare system. Clin Infect Dis 2012;55(suppl 2):S88- S92.
3. Vital signs: preventing Clostridium difficile infections. MMWR Morb Mortal Wkly Rep 2012;61:157-162.
4. Dubberke ER, Carling P, Carrico R, Donskey CJ, Loo VG, McDonald LC, et al. Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update. Infect Control Hosp Epidemiol. 2014;35(s2):s48–65.
5. Butler M, Bliss D, Drekonja D, Filice G, Rector T, MacDonald R, Wilt T. Effectiveness of Early Diagnosis, Prevention, and Treatment of Clostridium difficile Infection. Comparative Effectiveness Review No. 31 (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-02-0009.) AHRQ Publication No. 11(12)-EHC051-EF. Rockville, MD. Agency for Healthcare Research and Quality. December 2011.