The C. diff Solution: Collaboration and PCR
There are other complications surrounding C. difficile testing aside from the problem of colonized patients. For one, note Christopher Polage and Mark Wilcox in a recent “Point-Counterpoint" article in JCM8, there is “no reliable clinical or laboratory definition for CDI that accurately distinguishes true CDI from non-CDI-related symptoms in all patients." And then there's the issue of physicians requesting C. diff tests hoping the results will provide a level of clarity. They may fully understand that a lack of diarrhea is a sign that CDI is highly unlikely, but they also may want a way to further rule it out to help minimize the chance they'll miss a positive case.
The question for microbiologists, then, is this: What can you do if you work in an organization where CDI is a concern? Is there anything that can be done to help drive down CDI rates without the risk of over-diagnosing? The answer, if you follow the example of at least one institution—Toledo Mercy Health-St. Anne Hospital in Ohio—is a resounding “yes."
In an article for the CDC's “Safe Healthcare Blog9," Lisa Beauch, BSN, RN, CAPA, CPAN, CIC, the Regional Infection Prevention Manager at Mercy Health-St. Anne, explains how her team used a “multi-component strategy" to reduce their C. difficile infection rates to zero. CDI is “a complex and evolving battle," Beauch writes. “But it's a battle that can be won."
Beauch explains that prior to launching their CDI initiative, the 100-bed hospital's infection rate was 40% higher than would have been predicted for a facility of its type and size. Hoping to bring that number down, Beauch and her colleagues began by having each unit in the hospital share daily reports on CDI-related data, including information about confirmed and suspected cases. Next, they started tracking the locations of CDI cases and determined that nearly all originated in the intensive care unit. Knowing that, Beauch says, she and her team changed their approach to cleaning in the ICU, scrubbing down surfaces with bleach, for example, and using UV light to ensure thorough disinfection. And then they dove into staff education: Personnel were taught about “appropriate testing, the accuracy of PCR testing, and proper specimen collection," Beauch writes. “We then implemented policies to assess for diarrhea and C. difficile risk factors at the time of admission." If a patient reported having diarrhea prior to their admission, and also had another risk factor like recent antibiotic use, he or she would be isolated and a stool test would be administered. “Isolation was discontinued only if C. difficile was not detected by PCR, or if the patient did not have watery stool in a 24-hour period," Beauch notes.
Beauch's team led the charge for other changes to hospital policy, as well: A new antimicrobial stewardship program (ASP) was implemented to encourage the appropriate use of antibiotics, for example, and written reminders about policies around the use of protective gowns and gloves were placed outside of rooms of patients with CDI. In 2016, Beauch reports, her facility brought down its CDI cases to 55% less than was predicted, and in 2017 they did even better: As of last November, when she wrote her article, Mercy Health-St. Anne hadn't seen a single case of CDI.
The good news for providers and patients alike is that the most recent national data from the CDC shows an 8% decrease in C. difficile infections between 2011 and 2014.10 And facilities like Mercy Health-St. Anne, which Beauch estimates has avoided $150,000 in costs through its CDI-reduction program thus far, have shown that infection rates can be cut even more.
The take-home message for anyone with a role in the ongoing fight against C. difficile? If you take a holistic approach to combatting C. diff—combining clinician education, departmental collaboration, and sensitive and accurate testing with PCR—there's a very good chance you're going to win.