Epidemiology and Prevention
of C. difficile Infection
William A. Rutala, Ph.D., M.P.H.
Director, Hospital Epidemiology, Occupational Health and
Safety, UNC Health Care; Research Professor of Medicine,
Director, Statewide Program for Infection Control and
Epidemiology, University of North Carolina at Chapel Hill,
NC, USA
Disclosure: Clorox
LECTURE OBJECTIVES



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Understand the epidemiology and impact of C. difficile
Review the role of the environment in disease
transmission
Discuss how to prevent transmission of C. difficile via
contaminated surfaces
Identify effective preventive strategies
CLOSTRIDIUM DIFFICILE
MICROBIOLOGY

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Anaerobic bacterium
Forms spores that persist
Colonizes human GI tract
Fecal-oral spread
Toxins produce colitis
Diarrhea
 More severe disease; death


2-steps to infection
New acquisition via transmission
 Antibiotics result in vulnerability

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CDI due to BI/NAP1/027 carries high
mortality and management remains
problematic
C. difficile:
MICROBIOLOGY AND EPIDEMIOLOGY

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Gram-positive bacillus: Strict anaerobe, spore-former
Colonizes human GI tract
Increasing prevalence and incidence
New epidemic strain that hyperproduces toxins A and B
Introduction of CDI from the community into hospitals
High morbidity and mortality in elderly
Asymptomatic C. difficile carriers may be reservoir in healthcare
Inability to effectively treat fulminant CDI
Absence of a treatment that will prevent recurrence of CDI
Inability to prevent CDI
C. difficile Infection Rate, 2003-2013
Sunenshine RH, McDonald LC. Cleve Clin J Med 2006;73:187-197
C. difficile PATHOGENESIS
CDC
ANTIBIOTIC STEWARDSHIP

Encourage appropriate antibiotic use which includes:
 Avoiding antimicrobial exposure if the patient does
not have a condition for which antibiotics are
indicated
 When possible select an antibiotic associated with a
lower risk of CDI
Strategies to Prevent CDI Infections in Acute Care Hospitals: SHEA Guideline, 2014
Strategies to Prevent CDI
C. difficile shares many common epidemiologic
characteristics with other antimicrobial-resistant grampositive bacteria, such as MRSA and VRE
 Both the skin and the environment of colonized patients
becomes contaminated, and the healthcare provider
hands may become contaminated by touching the
environment or the patient.
 Major difference is C. difficile forms spores

TRANSMISSION MECHANISMS INVOLVING
THE SURFACE ENVIRONMENT
Rutala WA, Weber DJ. In:”SHEA Practical Healthcare Epidemiology”
(Lautenbach E, Woeltje KF, Malani PN, eds), 3rd ed, 2010.
FACTORS LEADING TO ENVIRONMENTAL
TRANSMISSION OF CLOSTRIDIUM DIFFICILE
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Frequent contamination of the environment
Stable in the environment
Relatively resistant to disinfectants
Low inoculating dose
Common source of infectious gastroenteritis
Susceptible population (limited immunity)
ENVIRONMENTAL CONTAMINATON

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25% (117/466) of cultures positive (<10 CFU) for C. difficile. >90% of
sites positive with incontinent patients. (Samore et al. AJM 1996;100:32)
31.4% of environmental cultures positive for C. difficile. (Kaatz et al.
AJE 1988;127:1289)
9.3% (85/910) of environmental cultures positive (floors, toilets, toilet
seats) for C. difficile. (Kim et al. JID 1981;143:42)
29% (62/216) environmental samples were positive for C. difficile. 29%
(11/38) positive cultures in rooms occupied by asymptomatic patients
and 49% (44/90) in rooms with patients who had CDAD. (NEJM
1989;320:204)

10% (110/1086) environmental samples were positive for C. difficile in
case-associated areas and 2.5% (14/489) in areas with no known
cases. (Fekety et al. AJM 1981;70:907)
C. difficile Environmental Contamination
Rutala, Weber. SHEA. 3rd Edition. 2010
•
•
Frequency of sites found contaminated~10->50% from
13 studies-stethoscopes, bed frames/rails, call buttons,
sinks, hospital charts, toys, floors, windowsills,
commodes, toilets, bedsheets, scales, blood pressure
cuffs, phones, door handles, electronic thermometers,
flow-control devices for IV catheter, feeding tube
equipment, bedpan hoppers
C. difficile spore load is low-7 studies assessed the
spore load and most found <10 colonies on surfaces
found to be contaminated. Two studies reported >100;
one reported a range of “1->200” and one study
sampled several sites with a sponge and found 1,300
colonies C. difficile.
FREQUENCY OF ENVIRONMENTAL CONTAMINATION
AND RELATION TO HAND CONTAMINATION
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Study design: Prospective study, 1992
Setting: Tertiary care hospital
Methods: All patients with CDI assessed
with environmental cultures
Results
 Environmental contamination
frequently found (25% of sites) but
higher if patients incontinent (>90%)
 Level of contamination low (<10
colonies per plate)
 Presence on hands correlated with
prevalence of environmental sites
Samore MH, et al. Am J Med 1996;100:32-40
FREQUENCY OF ACQUISITION OF C. difficile ON GLOVED HANDS
AFTER CONTACT WITH SKIN AND ENVIRONMENTAL SITES
Guerrero et al. Am J Infect Control 2012;40:556-8
Risk of hand contamination after contact with skin and
commonly touched surfaces was identical (50% vs 50%)
PERCENT OF STOOL, SKIN, AND ENVIRONMENT
CULTURES POSITIVE FOR C. difficile
Skin (chest and abdomen) and environment (bed rail, bedside table, call button, toilet seat)
Sethi AK, et al. ICHE 2010;31:21-27
Thoroughness of Environmental Cleaning
Carling P. AJIC 2013;41:S20-S25
100
DAILY CLEANING
% Cleaned
80
TERMINAL CLEANING
>110,000
Objects
60
40
20
Mean =
32%
0
HEH
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EVALUATION OF HOSPITAL ROOM
ASSIGNMENT AND ACQUISITION OF CDI
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Study design: Retrospective
cohort analysis, 2005-2006
Setting: Medical ICU at a tertiary
care hospital
Methods: All patients evaluated for
diagnosis of CDI 48 hours after ICU
admission and within 30 days after
ICU discharge
Results (acquisition of CDI)
Admission to room previously
occupied by CDI = 11.0%
 Admission to room not previously
occupied by CDI = 4.6% (p=0.002)

Shaughnessy MK, et al. ICHE 2011;32:201-206
C. difficile spores
SURVIVAL
C. difficile

Vegetative cells
 Can survive for at least 24 h on inanimate surfaces

Spores
 Spores survive for up to 5 months. 106 CFU of C.
difficile inoculated onto a floor; marked decline within
2 days. Kim et al. J Inf Dis 1981;143:42.
DECREASING ORDER OF RESISTANCE OF
MICROORGANISMS TO DISINFECTANTS/STERILANTS
Most Resistant
Prions
Spores (C. difficile)
Mycobacteria
Non-Enveloped Viruses (norovirus)
Fungi
Bacteria (MRSA, VRE, Acinetobacter)
Enveloped Viruses
Most Susceptible
DISINFECTANTS AND ANTISEPSIS
C. difficile spores at 20 min, Rutala et al, 2006

No measurable activity (1 C. difficile strain, J9)
 CHG
 Vesphene (phenolic)
 70% isopropyl alcohol
 95% ethanol
 3% hydrogen peroxide
 Clorox disinfecting spray (65% ethanol, 0.6% QUAT)
 Lysol II disinfecting spray (79% ethanol, 0.1% QUAT)
 TBQ (0.06% QUAT); QUAT may increase sporulation capacityLancet 2000;356:1324
 Novaplus (10% povidone iodine)
 Accel (0.5% hydrogen peroxide)
DISINFECTANTS AND ANTISEPSIS
C. difficile spores at 10 and 20 min, Rutala et al, 2006

~4 log10 reduction (3 C. difficile strains including BI-9)
 Clorox, 1:10, ~6,000 ppm chlorine (but not 1:50)
 Clorox Clean-up, ~19,100 ppm chlorine
 Tilex, ~25,000 ppm chlorine
 Steris 20 sterilant, 0.35% peracetic acid
 Cidex, 2.4% glutaraldehyde
 Cidex-OPA, 0.55% OPA
 Wavicide, 2.65% glutaraldehyde
 Aldahol, 3.4% glutaraldehyde and 26% alcohol
CONTROL MEASURES
C. difficile Disinfection
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In units with high endemic C. difficile infection rates or in an
outbreak setting, use dilute solutions of 5.25-6.15% sodium
hypochlorite (e.g., 1:10 dilution of bleach) for routine disinfection.
(CDC and SHEA).
We now use chlorine solution in all CDI rooms for routine daily
and terminal cleaning (formerly used QUAT in patient rooms with
sporadic CDI). One application of an effective product covering all
surfaces to allow a sufficient wetness for > 1 minute contact time.
Chlorine solution normally takes 1-3 minutes to dry.
For semicritical equipment, glutaraldehyde (20m), OPA (12m) and
peracetic acid (12m) reliably kills C. difficile spores using normal
exposure times
SURFACE DISINFECTION
Effectiveness of Different Methods
Rutala, Gergen, Weber. ICHE 2012;33:1255-58
Technique (with cotton)
C. difficile Log10 Reduction (1:10
Bleach)
Saturated cloth
3.90
Spray (10s) and wipe
4.48
Spray, wipe, spray (1m), wipe
4.48
Spray
3.44
Spray, wipe, spray (until dry)
4.48
5500 ppm chlorine pop-up wipe
3.98
Non-sporicidal wipe
>2.9
Daily Disinfection of High-Touch Surfaces
Kundrapu et al. ICHE 2012;33:1039
Daily disinfection of high-touch surfaces (vs cleaned when soiled) with sporicidal
disinfectant in rooms of patients with CDI and MRSA reduced acquisition of pathogens
on hands after contact with surfaces and of hands caring for the patient
Effective Surface
Decontamination
Practice and Product
C. difficile Spores
EPA-Registered Products
List K: EPA’s Registered Antimicrobials Products
Effective Against C. difficile spores, April 2014
 http://www.epa.gov/oppad001/list_k_clostridium.
pdf
 34 registered products; most chlorine-based,
some HP/PA-based, PA with silver

TRANSFER OF C. DIFFICILE SPORES BY NONSPORICIDAL
WIPES AND IMPROPERLY USED HYPOCHLORITE WIPES

Study design: In vitro study that
assessed efficacy of different
wipes in killing of C. difficile
spores (5-log10)
Practice + Product = Perfection
Fresh hypochlorite wipes
 Used hypochlorite wipes
 Quaternary ammonium wipes
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Results (4th transfer)
Quat had no efficacy (3-log10
spores)
 Fresh hypochlorite worked
 Used hypochlorite transferred
spores in lower concentration
(0.4-log10 spores)

Cadnum JL, et al. ICHE 2013;34:441-2
REDUCTION IN CDI INCIDENCE WITH
ENHANCED ROOM DISINFECTION
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Before-after study of CDI incidence rates in two hyperendemic wards at a
1,249 bed hospital
Intervention: Change from cleaning rooms with QUAT to bleach wipes (0.55%
Cl) for both daily and terminal disinfection
Results: CDI incidence dropped 85% from 24.2 to 3.6 cases per 10,000 pt-days
(p<0.001); prolonged median time between HA CDI from 8 to 80 days
Orenstein R, et al
ICHE 2011;32:1137
Thoroughness of Environmental Cleaning
Carling P. AJIC 2013;41:S20-S25
100
DAILY CLEANING
% Cleaned
80
TERMINAL CLEANING
>110,000
Objects
60
40
20
Mean =
32%
0
HEH
SG
IO W
OT H
OPE
NIC
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AH
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HO
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ICU
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Wipes
Cotton, Disposable, Microfiber, Cellulose-Based, Nonwoven Spunlace
Wipe should have sufficient wetness to achieve the disinfectant contact
time (e.g. >1 minute)
MONITORING THE EFFECTIVENESS OF CLEANING
Cooper et al. AJIC 2007;35:338; Carling P AJIC 2013;41:S20-S25
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Visual assessment-not a reliable indicator of surface
cleanliness
ATP bioluminescence-measures organic debris (each unit
has own reading scale, <250-500 RLU)
Microbiological methods-<2.5CFUs/cm2-pass; can be
costly and pathogen specific
Fluorescent marker-transparent, easily cleaned,
environmentally stable marking solution that fluoresces
when exposed to an ultraviolet light (applied by IP
unbeknown to EVS, after EVS cleaning, markings are
reassessed)
EVALUATION OF HOSPITAL ROOM
ASSIGNMENT AND ACQUISITION OF CDI



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Study design: Retrospective
cohort analysis, 2005-2006
Setting: Medical ICU at a tertiary
care hospital
Methods: All patients evaluated for
diagnosis of CDI 48 hours after ICU
admission and within 30 days after
ICU discharge
Results (acquisition of CDI)
Admission to room previously
occupied by CDI = 11.0%
 Admission to room not previously
occupied by CDI = 4.6% (p=0.002)

Shaughnessy MK, et al. ICHE 2011;32:201-206
METHODS TO PREVENT CDI:
BASIC PRACTICES
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Encourage appropriate use of antimicrobials
Use contact precautions for infected patients
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Single room
Don gloves and gown when entering room; remove before exiting
Hand hygiene before and after glove use
Use dedicated equipment whenever possible
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If equipment is shared between patients do not bring into room (e.g.,
glucometer)
Clean and disinfect shared equipment after use
Strategies to Prevent CDI Infections in Acute Care Hospitals: SHEA Guideline, ICHE, 2014
METHODS TO PREVENT CDI:
BASIC PRACTICES
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Criteria for discontinuing isolation
 Duration of illness (some experts recommend for at least 48 hours
after diarrhea resolves)
Use an EPA-registered sporicidal agent for room disinfection in hyperendemic
and outbreak situations
Ensure cleaning and disinfection of equipment and the environment as
potential reservoirs
Assess adherence to protocols
Implement lab-based alert system to provide immediate notification to IP and
clinical personnel
Educate patients and their families about CDI
Measure compliance with hand hygiene and contact precaution
recommendations
Strategies to Prevent CDI Infections in Acute Care Hospitals: SHEA Guideline, ICHE, 2014
UNC HEALTH CARE ISOLATION SIGN FOR
PATIENTS WITH NOROVIRUS OR C. difficile
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Use term Contact-Enteric
Precautions
Requires gloves and gown
when entering room
Recommends hand hygiene
with soap and water (instead
of alcohol-based antiseptic)
Information in English and
Spanish
METHODS TO PREVENT CDI:
SPECIAL APPROACHES
(CDI Incidence Remains Higher than Goal)

Intensify the assessment of compliance with process measures
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Compliance with hand hygiene
Compliance with Contact Precautions
If compliance inadequate, institute corrective actions
Perform hand hygiene with soap and water
Empirically place patients with diarrhea on Contact Precautions
(remove isolation if test for C. difficile is negative)
Prolong duration of contact precautions until discharge
Monitor the effectiveness of room cleaning (e.g., fluorescent dye)
Consider routine environmental decontamination with sodium
hypochlorite or an EPA-registered sporicidal agent
UNC routine measures are in yellow
Strategies to Prevent CDI Infections in Acute Care Hospitals: SHEA Guideline, 2014
DISCONTINUING ISOLATION

CDC currently recommends contact precautions for the duration
of illness when care for patients with CDI.


Some experts recommend continuing contact precautions for at least
48 hours after diarrhea resolves
At this time data do NOT exist to support extending isolation as a
measure to decrease CDI incidence.
ANTISEPSIS TO PREVENT C. difficile INFECTIONS
Yes
No
Either soap or CHG works as a handwash 70% isopropyl showed no inactivation of
C. difficile spores at exposure times of
for removal of C. difficile.
5m, 15m, and 30m.
ICHE 1994;15:697.
Wullt et al. ICHE 2003;24:765.
EFFICACY OF ALCOHOL AS A HAND
HYGIENE AGENT AGAINST C. difficile

Probability of heavy contamination (TNTC) following different HH
interventions: warm water and plain soap = 0, cold water and plain soap =
0, warm water and antibacterial soap = 0, antiseptic hand wipe = 0.05,
alcohol-based handrub = 0.43, and no hand hygiene = 1
Oughton MT, et al. ICHE 2009;30:939-944
Hand Hygiene with Soap and Water Is Superior to Alcohol Rub and
Antiseptic Wipes for Removal of C. difficile
(Oughton et al. Infect Control Hosp Epidemiol 2009; 30:939)
Objective: Evaluate HH methods for efficacy in removing C. difficile
Design: Randomized crossover comparison among 10 volunteers
experimentally contaminated by 1.4x105 C. difficile (62% spores)
Methods: Interventions were evaluated for mean reduction
Conclusion: Handwashing with soap and water showed the greatest
efficacy in removing C. difficile and should be performed
preferentially over the use of alcohol-based hand rubs when
contact with C. difficile is suspected or likely
The Role of the Environment in Disease
Transmission
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Over the past decade there has been a growing appreciation that
environmental contamination makes a contribution to HAI with
MRSA, VRE, Acinetobacter, norovirus and C. difficile
Surface disinfection practices are currently not effective in
eliminating environmental contamination
Inadequate terminal cleaning of rooms occupied by patients with
MDR pathogens places the next patients in these rooms at
increased risk of acquiring these organisms
Thoroughness of Environmental Cleaning
Carling et al. ECCMID, Milan, Italy, May 2011
100
DAILY CLEANING
% Cleaned
80
TERMINAL CLEANING
>110,000
Objects
60
40
20
Mean =
32%
0
HEH
SG
IO W
OT H
OPE
NIC
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AH
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TIN
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HO
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SP
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NEW APPROACHES TO ROOM DECONTAMINATION
HP for Decontamination of the Hospital
Environment
Falagas et al. J Hosp Infect. 2011;78:171
Author, Year
HP System
Pathogen
Before HPV
After HPV
% Reduction
French, 2004
VHP
MRSA
61/85-72%
1/85-1%
98
Bates, 2005
VHP
Serratia
2/42-5%
0/24-0%
100
Jeanes, 2005
VHP
MRSA
10/28-36%
0/50-0%
100
Hardy, 2007
VHP
MRSA
7/29-24%
0/29-0%
100
Dryden, 2007
VHP
MRSA
8/29-28%
1/29-3%
88
Otter, 2007
VHP
MRSA
18/30-60%
1/30-3%
95
Boyce, 2008
VHP
C. difficile
11/43-26%
0/37-0%
100
Bartels, 2008
HP dry mist
MRSA
4/14-29%
0/14-0%
100
Shapey, 2008
HP dry mist
C. difficile
48/203-24%; 7
7/203-3%; 0.4
88
Barbut, 2009
HP dry mist
C. difficile
34/180-19%
4/180-2%
88
Otter, 2010
VHP
GNR
10/21-48%
0/63-0%
100
EFFECTIVENESS OF UV-C FOR ROOM
DECONTAMINATION (Inoculated Surfaces)
Pathogens
Dose*
MRSA, VRE, MDR-A
Mean log10
Reduction
Line of Sight
Mean log10
Reduction
Shadow
Time
Reference
12,000 3.90-4.31
3.25-3.85
~15 min
Rutala W, et al.1
C. difficile
36,000 4.04
2.43
~50 min
Rutala W, et al.1
MRSA, VRE
12,000 >2-3
NA
~20 min
Nerandzic M, et al.2
C. difficile
22,000 >2-3
NA
~45 min
Nerandzic M, et al.2
C. difficle
22,000
2.3 overall
67.8 min
Boyce J, et al.3
MRSA, VRE, MDR-A, Asp 12,000 3.-5->4.0
1.7->4.0
30-40 min
Mahida N, et al.4
MRSA, VRE, MDR-A, Asp 22,000 >4.0*
1.0-3.5
60-90 min
Mahida N, et al.4
C. difficile, G. stear
spore
22,000
overall
73 min
Havill N et al5
VRE, MRSA, MDR-A
12,000 1.61
1.18
25 min
Anderson et al6
1ICHE
2.2
2010;31:1025; 2BMC 2010;10:197; 3ICHE 2011;32:737; 4JHI 2013;84:323l 5ICHE 2012;33:507-12 6ICHE
2013;34:466
* Ws/cm2; min = minutes; NA = not available
EFFECTIVENESS OF UV ROOM
DECONTAMINATION
Rutala WA, et al. Infect Control Hosp Epidemiol. 2010;31:1025-1029.
Retrospective Study on the Impact of UV
on HA MDROs Plus C. difficile
Haas et al. Am J Infect Control. 2014;42:S86-90
During the UV period (pulsed Xenon), significant decrease in HA MDRO plus C.
difficile. UV used for 76% of Contact Precaution discharges. 20% decrease in
HA MDRO plus C. difficile during the 22-m UV period compared to 30-m pre-UV
period.
USE OF HPV TO REDUCE RISK OF
ACQUISITION OF MDROs
•
•
•
•
Design: 30 mo prospective cohort study with hydrogen peroxide vapor (HPV)
intervention to assess risks of colonization or infection with MDROs
Methods:12 mo pre-intervention phase followed by HPV use on 3 units for
terminal disinfection
Results
 Prior room occupant colonized or infected with MDRO in 22% of cases
 Patients admitted to HPV decontaminated rooms 64% less likely to acquire
any MDRO (95% CI, 0.19-0.70) and 80% less likely to acquire VRE (95% CI,
0.08-0.52)
 Risk of C. difficile, MRSA and MDR-GNRs individually reduced but not
significantly
 Proportion of rooms environmentally contaminated with MDROs
significantly reduced (RR, 0.65, P=0.03)
Conclusion-HPV reduced the risk of acquiring MDROs compared to standard
cleaning
Passaretti CL, et al. Clin Infect Dis 2013;56:27-35
LECTURE OBJECTIVES




Understand the epidemiology and impact of C. difficile
Review the role of the environment in disease
transmission
Discuss how to prevent transmission of C. difficile via
contaminated surfaces
Identify effective preventive strategies
C. difficile: Prevention Measures
New Enteric Contact Isolation sign-promote soap
and water and sporicidal disinfectant
 Enhanced nursing education-ICLs
 Daily/terminal bleach disinfection of all C. difficile
patient rooms
 Bleach wipes-shared equipment
 Monitoring thoroughness of cleaning
 Isolation until no symptoms and end of treatment

C. difficile: Prevention Measures
Use fidaxomicin in selected CDI patients to
reduce recurrences
 Prescribe and use antibiotics carefully
 Follow surgical prophylaxis guidelines (max 24h)
 Test for C. difficile when patients have diarrhea
while on antibiotics or recent antibiotics (60d)
 Use new PCR test as part of diagnostic algorithm
(which increases sensitivity of diagnosis)

FECAL MICROBIOTA TRANSPLANTATION
(FMT) FOR CDI





Gut microbiota alterations key abnormality in CDI
FMT demonstrated excellent cure rate (80-90%) in severe and
recurrent cases with good acceptability by patients and
physicians
Active reporting of adverse events lacking, although few AEs
reported in most studiees
Long-term effects of FMT still unexplored
FMT should follow traditional pathways of new therapy and
caution in recommending FMT is warranted until mechanisms and
risks of procedure are clear
Vecchio AL, Cohen MB. Curr Opin Gastroenterol 2014;30:47-53
Fecal Transplants for Refractory
C. difficile Infection


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Criteria for eligibility -failed standard therapy, no contraindication to
colonoscopy, confirmed C. difficile toxin positive, etc
Self-identified donor-donor will respond to eligibility questions: no GI
cancer, no metabolic disease, no prior use of illicit drugs, etc
Donor Testing-Stool-C. difficile toxin, O&P, bacterial pathogen panel
(Salmonella, Shigella, Giardia, norovirus, etc). Serum-RPR, HIV-1, HIV-2,
HCV Ab, CMV viral load, HAV IgM and IgG, HBsAg, liver tests, etc
Stool preparation-fresh sample into 1 liter sterile bottle, 500ml saline
added, vigorously shaking to liquefy, solid pieces removed with sterile
gauze so sample is liquid, liquid stool drawn up into 7 sterile 50ml
syringes, injected into terminal ileum, cecum, ascending colon, traverse
colon, descending colon, sigmoid colon. Colonoscope reprocessed by
HLD.
LECTURE OBJECTIVES

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Understand the epidemiology and impact of C. difficile
Review the role of the environment in disease
transmission
Discuss how to prevent transmission of C. difficile via
contaminated surfaces
Identify effective preventive strategies
CONCLUSIONS
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Contaminated environment likely important for C. difficile
Some disinfectants are effective but surfaces must be thoroughly
wiped to eliminate environmental contamination
Inadequate terminal cleaning of rooms occupied by patients with
C. difficile pathogens places the next patients in these rooms at
increased risk of acquiring these organisms
Eliminating the environment as a source for transmission of
nosocomial pathogens requires: adherence to proper room
cleaning and disinfection protocols (thoroughness), effective
product, hand hygiene, and institution of Isolation Precautions
THANK YOU!
www.disinfectionandsterilization.org
SPECIAL APPROACHES FOR
PREVENTING CDI
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Intensify the assessment of compliance with process measures
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Compliance with hand hygiene
Compliance with Contact Precautions
If compliance inadequate, institute corrective actions
Perform hand hygiene with soap and water
Empirically place patients with diarrhea on Contact Precautions
(remove isolation if test for C. difficile is negative)
Create a unit specific check list for room disinfection
Monitor the effectiveness of room cleaning (e.g., fluorescent dye)
Consider routine environmental decontamination with sodium
hypochlorite or an EPA-registered sporicidal agent
UNC routine measures are in yellow
Strategies to Prevent CDI Infections in Acute Care Hospitals: Draft SHEA Guideline, 2013
COMMENTS ON THERAPY
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Oral vancomycin superior to oral metronidazole
Can reduce cost of vancomycin by using compounding IV preparation into a
PO liquid medication
 In patients in whom oral antibiotics cannot reach a segment of the colon (e.g.,
Hartman’s pouch, ileostomy, colon diversion) vancomycin should be
delivered via enema
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No clinical evidence from RCTs that IV metronidazole is effective
Fidaxomicin demonstrated to have a lower risk of CDI recurrences (25d)
but similar efficacy in initial therapy with oral vancomycin
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Consider for therapy if patient relapses
Consider tigecycline when patients fail to respond to standard therapy
Unclear whether probiotics work for prophylaxis or therapy
No evidence to support use of IVIG
PHYSICAL REMOVAL VERSUS CHEMICAL
INACTIVATION
Rutala WA, Gergen MF, Weber DJ. ICHE 2012;33:1255-58
PROVING THAT ENVIRONMENTAL CONTAMINATION
IMPORTANT IN C. difficile TRANSMISSION
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Environmental persistence (Kim et al. JID 1981;14342)
Frequent environmental contamination (McFarland et al. NEJM 1989;320:204)
Demonstration of HCW hand contamination (Samore et al. AJM 1996;100:32)
Environmental  hand contamination (Samore et al. AJM 1996;100:32)
Person-to-person transmission (Raxach et al. ICHE 2005;26:691))
Transmission associated with environmental contamination (Samore et
al. AJM 1996;100:32)
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CDI room a risk factor (Shaughnessy et al. IDSA/ICAAC. Abstract K-4194)
Improved disinfection   epidemic CDI (Kaatz et al. AJE 1988;127:1289)
Improved disinfection   endemic CDI (Boyce et al. ICHE 2008;29:723)