Gone viral: controlling Clostridium difficile

According to the US Centers for Disease Control and Prevention (CDC), one in every 20 hospitalised patients contracts a hospital-acquired infection (HAI). Within this, Clostridium difficile infections (CDI) kill an estimated 14,000 Americans each year, making its prevalence and virulence not only a tragedy at the individual and family level, but also a huge burden on the US healthcare system.

In fact, the Association for Professionals in Infection Control and Epidemiology (APIC) calculates that the average total cost for a single inpatient CDI is more than $35,000 and the estimated annual cost to the US healthcare system exceeds $3 billion.

Clearly, then, tackling CDI infection is, and should be, a priority for US healthcare institutions. Yet, as Dr Ruth M Carrico, associate professor with the University of Louisville School of Medicine and former APIC board member argues, the US's record on controlling and minimising CDI is not as good as it should (or could) be.

"Morbidity and mortality from CDI continues to ravage our population. Even though rates have begun to come down, they are still higher than we have seen historically. The systems we have are not as good as they need to be for our particular population," she explains.

"A lot of attention, too, has been put on tackling CDI, the living organism, through the use of antibiotics, for instance. But where we have perhaps failed to give adequate consideration is the wider health environment which can, in some respects, be seen as a living organism. CDI can live successfully in the environment for long periods of time," she adds.

Current teachings

Certainly, despite the much greater resources proportionally available to the US healthcare system, the success the UK NHS has had in tackling HAIs and CDI is startling. At the beginning of 2012, for example, monthly statistics from the then Health Protection Agency (now part of Public Health England) showed that, for the first time since mandatory surveillance began in 2001, MRSA bloodstream infections across the NHS had been sustained at under 100 reported cases a month, for the previous six months.

At the same time, the NHS set ambitious targets for 2013: to reduce MRSA infections by a further 29% and CDI rates, specifically, by a further 17%.

"A lot of what we have learned in the US about CDI has come from our partners in the UK, they generally seems to have been more successful at implementing activities than we have been in the US. We have not been able to achieve the successes we should be able to achieve," says Carrico.

"Patient outcomes in the UK seem to have improved to a greater degree than they have in the US. Neither of us is where we'd like to be, but it does seem to be the attention to detail given to this in the UK that is making a difference, especially when it comes to giving attention to the healthcare environment. So we have to ask ourselves: are we doing a good enough job when it comes to antimicrobial stewardship? Are we focusing entirely on the antimicrobial agents administered to patients and minimising the same type of stewardship that should be applied to the environment?" she adds.

Seeking answers

In many respects, the answers are not complicated: it's about communication, education, awareness (public and professional), repetitive and constant best practice and, ultimately, leadership, Carrico contends.

"We are gaining new-found respect and appreciation for the living health environment and the necessary training and education that we must give those responsible for its care. It is no different to emphasising the need for the right care or the right drug, or the right dose; patients have to have the right environment," she says.

"There is also the question of are we developing the right mindset among those individuals who are making decisions about the care of the health environment? It is a question of leadership. Are we, for example, giving people the proper training to do their job, and are there adequate numbers of people on the ground to do a proper job?

"We know that the environment is involved in transmission, so what are we doing to equip patients and minimise acquisition, for example, in training healthcare personnel to ensure that the patients wash their hands before taking medication?

"We need to step back, stop and say 'wait a minute this could be me or my family'; we need to take it seriously and, crucially, we need to be consistent in our practice. Our healthcare system is good, but with CDI good is not good enough," she adds.

Shared learning

Sharing knowledge - what's worked and (perhaps even more importantly) what lessons have been learned when things have gone wrong - is another vital part of the prevention "mix", Carrico advises.

"We need to actively look at opportunities to learn from each other. At the moment, there is not a lot of sharing of experiences. We do, of course, speak to colleagues in the UK, but there could be more discussion, for example, about the patient room, what it looks like, how it is managed, how you approach environmental hygiene and so on.

"It is important that we ensure that we are doing enough to tackle the practical aspects of prevention; the devil, as they say, is in the detail. So can we truly say that we know what to do and that we repeat it day-in, day-out, in the practical application, but also put the skill, knowledge and competency into action?

"If things are being done well, we have to be saying so and encouraging people to learn from that example. We have to be open about our activities and be prepared to have our activities scrutinised and validated. It is, after all, about patient safety," she adds.

Doing the homework

Research, especially research and study of the healthcare environment and its association with or relationship to CDI and HAIs, is a further area that needs to be given greater priority.

"There is a lot of laboratory-based research, but we need more research into environmental outcomes as well as patient outcomes. We need to understand the configuration of the patient room, the materials that are used, the real-time intervention and the actions of people.

"Tackling CDI is not just about infection prevention, although that is an important part. It is about understanding what is happening, the facilities, and being involved in improving practice at a day-to-day level, says Carrico.

The right education

Carrico does believe that governments, or in this case, the US Government, has a part to play in this, too. She highlights the Occupational Safety and Health Administration as an example, as it enforces a high level of compliance around hepatitis B. But she questions how, in turn, there is less government involvement and expectation concerning CDI. Though this is changing, Carrico thinks the change is too slow.

"I think one way we can show we are serious is to fund research that helps us understand how to apply what has been learned in the lab about CDI and the patient environment," Carrico continues, "just what it is that we are supposed to be doing? We need to ensure that we are encouraging an environment that seeks to identify solutions rather than one that punishes or blames. Conversely, we cannot tolerate people who choose not to adhere to best practice. If it is a system issue, let's fix the system, but we cannot afford clinicians who elect to bypass or disregard best practices. Those patient safety decisions cannot be tolerated.

"We know we can do this, but it does come back to leadership. We have to adopt a mindset that says failing is not an option. We need to keep figuring out how we are going to approach this. In the healthcare environment, inevitably, you are dealing with complex environments and situations, but it is unacceptable to have patients die from preventable diseases. It is incumbent on the profession to keep pushing forward on this.

"We cannot accept that preventable harm occurs, so the focus needs to move away from just 'am I getting through all the tasks that I need to get through today?' to 'am I delivering the best quality care that I can and am I having the conversations that need to occur?'. We have got to be unafraid to bring this agenda forward in a relentless way," concludes Carrico.