Special challenges in C. difficile infection control

Abstract number: 1732_145

Kuijper E., Vonberg R., Wilcox M., Gastmeier P.

Clostridium difficile is an anaerobic bacterium capable of forming spores which confer resistance to heating, drying and chemical agents, including disinfectants. Spores of CD may survive in the environment for long periods and are resistant to alcohol. More than 150 PCR ribotypes and 24 toxinotypes have been recognized; epidemic ribotypes may have enhanced sporulation. The spectrum of C. difficile-associated disease ranges from asymptomatic carriage to fulminant, relapsing and potentially fatal colitis. Since 2003, increasing rates of CDAD have been reported in North America and Europe involving a more severe course, higher mortality, increased risk of relapse and more complications. The outbreaks are difficult to control and require a multifaceted approach. The most important infection control measures act on interruption of transmission of spores to vulnerable patients from infected patients and from the environment. Vulnerable patients are mainly patients who receive antimicrobial treatment, and therefore fewer antibiotic prescriptions should lead to less vulnerable patients. At present, no sufficient evidence exists to propagate the use of probiotics to vulnerable patients for prevention of CDAD. Transmission of spores occurs mainly via contact of contaminated healthcare workers to patients, directly by patient-to-patient transmission or by transmission from the contaminated environment to patients. There is no evidence that patients or healthcare workers who are symptom-free but colonised with C. difficile in the intestinal tract are significant sources of infection. Airborne transmission of infection is unlikely to occur based on recent reviews of the literature. Early diagnosis of CDAD, prompt isolation of symptomatic patients and reducing antimicrobial treatment are essential first steps. The infection control measures include recommendations to isolate infected patient on a single room with designated toilet, to apply proper hand hygiene with soap and water, to use appropriate protective clothing (gloves and aprons or gowns), to intensify environmental cleaning with a chlorine containing disinfectant and to take specific precautions for the use of devices (disposable or dedicated to individual patient). Patient isolation must continue at least until diarrhoea has ceased. Each hospital should have an appropriate surveillance system to recognize an increase of the incidence of CDAD in an early stage. All infection control measures should be written in a local protocol so that additional measures can be carried out as soon as a problem with CDAD arises. When outbreaks occur, additional recommendations include a reinforcement of general and hand washing measures, intensifying of testing patients with diarrhoea for C. difficile, reinforcement of environmental cleaning, information and education of healthcare workers, cleaning department and visitors, cohorting of infected patients, and eventually closure of the unit followed by intensive environmental cleaning. Restricted antibiotic prescribing is also highly recommended to reduce polypharmacy and duration of administration. Second and third generations cephalosporins, clindamycin and more recently fluoroquinolones have been identified as potential risk factors. Although some hospitals report successes for enhanced environmental cleaning with potentially effective agents such as hydrogen peroxide vapour, the evidence is too scarce to consider this as an evidence-based approach.