Aim

The aim of this edition of MICKS is to review the literature surrounding the prevention and management of Clostridium difficile (C.difficile) infection and make recommendations for practice.

Introduction

Healthcare-associated infections cause a great deal of morbidity and mortality in the healthcare of today (World Health Organisation 2002). One such infection is C.difficile associated diarrhoea. Health care acquired infection is an infection for which there is no evidence of its presence or incubation at the time of admission, or any infection acquired within seventy-two hours of admission (Alexander et al 2004). C.difficile has been identified as the major cause of antibiotic-associated diarrhoea and the exclusive cause of pseudomembranous colitis (Bartlett 2006). C.difficile is a gram positive, sporulating, anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It accounts for 15-25% of all episodes of antibiotic-associated diarrhoea (Centres for Disease Control and Prevention [CDC], 2005).

However, in 3% of healthy adults C.difficile lives naturally in the gut and infection only occurs when the normal healthy intestinal bacteria are subdued by the use of antibiotics (National Statistics Quarterly Report 2006).

C.difficile infections have increased internationally in the last decade, as people live longer, and receive more advanced medication (DOH 2003). According to the literature, there were more than 2,200 deaths attributed to C.difficile on death certificates in England and Wales in 2004 (Starr 2007, Day 200, Wilcox 2002). Despite increasing awareness of the need to avoid broad-spectrum antibiotics in susceptible elderly patients, reports of C.difficile infection continue to rise in England and Wales (Wilcox et al 2002). A more virulent strain type 027, which was rare in the UK, has recently been discovered; the first in 1999 and the second in 2002. Outbreaks in Stoke Mandeville Hospital in 2004 and 2005 found the type 027 to be predominating in the cases (DOH 2002). Dancer (1999) proclaims that in an average size general hospital, where there are an average of 100 cases of C.difficile annually, there are 2,100 lost bed days and an extra cost of £400,000.

The themes that will be discussed in terms of control controlling this infection are: environmental cleaning and decontamination, the use of detergents and disinfectants and lastly hand hygiene.

Environmental Cleaning and decontamination

Healthcare acquired infections are partly a reflection of poor hygiene standards and unsuitable environments for healthcare, and these two factors have a negative influence on the overall quality of healthcare services (Liyanage et al 2004) (Welsh Assembly Government [WAG] 2004).

Wilcox et al (2002) recognises that environmental contamination is considered an important factor in hospital-acquired infection. Spores may persist in the hospital environment for months and are resistant to many commonly used cleaning agents. C.difficile is one of the organisms that produces spores which protects the bacterium in adverse conditions; hence the difficulty of removing the same from surfaces when undertaking cleaning and disinfecting procedures, be it from the environment, or on the hands of all those who come into contact with the environment (Starr 2007). Vegetative cells of C.difficile can survive for at least 24 hours and spores survive up to 5 months in the environment; therefore, patients can become contaminated from the hands of hospital staff and from inanimate surfaces (Kampf and Kramer 2004). Voth & Ballard (2005) proclaims that C.difficile disease has increased, with hospitals becoming contaminated with spores, making infection of susceptible patients more probable. If an organism can find an appropriate niche in which to survive, it will do so, whatever the origin, careful and conscientious cleaning provides the opportunity to eliminate such niches, thus disrupting the chain of transmission (Dancer 1999).

The Epic2 National Evidence-based Guidelines for Preventing Healthcare Associated Infections in the NHS Hospitals in England (Pratt et al 2007) recommends, the use of hypo-chlorite and detergent in outbreaks of infection, where the pathogen concerned survives in the environment and environmental contamination may be contributing to the spread. Hanna et al (2000) stipulated, that recently several studies emphasized the role of environmental contamination in perpetuating an outbreak, highlighting the importance of environmental cleaning and disinfection of patient rooms and equipment, as well as identification and treatment of asymptomatic carriers.

The Healthcare Commission carried out an investigation from 2005 to April 2006 after two outbreaks by the bacterium C.difficile in Stoke Mandeville Hospital, where over 30 people died. The report found cleanliness, decontamination and hand hygiene to be crucial elements in controlling C.difficile in the day-to-day management and in an outbreak setting. The Healthcare Commission Audit (2006) concluded that one of the contributing factors for the first outbreak was a consequence of a poor environment for caring for patients. The importance of environmental cleanliness and hand hygiene to manage infectious patients and prevent onward transmission cannot be overstated. Hopefully, in return this will reduce the number of all bacterial infections including C.difficile due to cross infection from direct or indirect contact (Liyanage et al 2004).

The use of disinfectants for environmental decontamination

Cleaning, disinfection and sterilization are used to remove micro-organisms from the hospital environment and from equipment used for patient care. Disinfections reduce the number of micro-organisms to a level that is not harmful. Spores will not usually be destroyed in this process (Bartlett 2006). Studies that have looked at whether the use of hypochlorite solution can reduce environmental C.difficile and C.difficile associated diarrhoea rates have mixed results (Wilcox et al 2002). Historically, the use of a 1: 10 dilution of bleach in health care settings have been shown to be somewhat effective in decreasing C.difficile rates (Bartlett 2006). For example, McCullen et al (2007) noted an increase rate of C.difficile associated diarrhoea in two intensive care units in Barnes Jewish Hospital in St Louis in mid 2002. McCullen (2007) was able to demonstrate a significant reduction in an outbreak situation through appropriate environmental cleaning with a 1: 10 mixture of household bleach and water from 16.6 cases per 1000 patient bed days in June 2002 to 3.7 cases in December 2002. When cleaning with bleach was used less frequently, he further reduced the endemic number from 5.3 cases per 1000 patient days to 2.8 cases in the Medical Intensive Care Unit and from 3.9 to 2.2 in the Surgical Intensive Care Unit.

A further study undertaken by Kaatz (1998) showed that environmental cleaning with hypochlorite solution had a positive effect in an outbreak setting; however, in a non- outbreak setting, C.difficile may persist after environmental cleaning with hypochlorite. Perez et al (2005) study suggested that with a high concentration of bleach you could inactivate spores on hard environmental surfaces within 10 to 15 minutes. A two year study carried out by Wilcox et al (2002), comparing detergents and hypochlorite disinfectant in two medical wards, found that it was extremely difficult to come to a conclusion as there was so many confounding factors, such as age, length of stay, use of antibiotics and hand hygiene compliance. The study found that the one disadvantage of using hypochlorite based disinfection alone was that it reduced effectiveness to clean surfaces; therefore a combined product of detergent and disinfectant would be far more effective in removing C.difficile and its spores.

However, 40 infection control scientists from 18 countries have recently written that there is insufficient data to justify recommendations of routine surface disinfection in hospitals other than 'on high-risk areas (e.g. isolation units), or possibly to prevent transmission of high-risk organisms (Cookson 2005). The study pointed to the possible side effects of biocides to patients and healthcare workers and the risk to the environment of non-biodegradable compounds and others found that they release carcinogens. Proposed standards have been made recently (Dancer 2004). They will need a more scientific evidence base before they can be implemented (Cookson 2005).

Hand hygiene

The Department of Health (2002) recognised five key elements as being necessary to reduce the incidence of C.difficile, one of these being enhanced environmental cleaning with a chlorine based disinfectant and another hand washing. As vegetative cells of C.difficile can survive for at least 24 hours and spores survive up to 5 months in the environment, it is possible that patients can become contaminated from the hands of hospital staff and from inanimate surfaces (Kampf and Kramer 2004).

Hands can act as vectors for transmission of infection and patients can be infected through exogenous means, as nosocomial pathogens can survive for months on surfaces if no regular preventative surface disinfection is carried out (Kramer et al 2006). Not withstanding this, endogenous infection is possible because patients carry the bacteria in the gut, as mentioned earlier.

Hand washing is the most important and most basic and effective technique in preventing and controlling the transmission of pathogens and in this case C.difficile, although compliance is unacceptably low (Storr and Clayton-Kent 2004, Hugonett and Pittet 2000). It is therefore, recognised as the leading measure to prevent transmission of bacteria and to reduce the incidence of health care acquired infection (Pittet et a1 2004, Lam 2004).

The Department of Health in the UK (DOH 2002) recommends hand washing with soap and water before and after each patient contact to avoid transmission of Clostridia and its spores. Also, although alcohol based hand rubs have proven to be an efficient and effective method for improving hand hygiene in a healthcare setting (Pratt et al, 2007), its use in the control of C.difficile is limited, because alcohol is ineffective against this organism, as the spores survive alcohol; therefore soap and running water is recommended (Bartlett 2006, Boyce & Pittet 2002). A recent study by Owens (2007) confirmed this and has proven that hand washing in a sink with soap and running water is more effective as alcohol hand rubs to do not remove spores or organic matter.

Implications for Practice

For the prevention and control of C.difficile, the National Clostridium difficile Standard Group UK (2003) recommends that Health Care providers should be encouraged to promote practices known to reduce the incidence of C.difficile through environmental cleaning and hand washing.

Patients expect wards to be clean and people judge the quality of the service by the way it presents itself at first glance. The hospital environment must be visibly clean~ free from dust and soilage and acceptable to patients~ their visitors and staff (Pratt et al 2007).

The National Guidelines in the UK for Environmental Cleanliness for hospitals (2003) were published as a result of a number of issues related to the cleaning of healthcare facilities as identified earlier by Liyanage et al (2004) and WAG (2004). The physical removal of C.difficile and its spores from the environment is of paramount importance to avoid cross contamination. Also, the education of personnel has a vital role to play and has always been an integral part of Infection Prevention and Control, but it has been recognised that it must be conducted in such a way that practices are altered within the realms of the behavioural sciences (Raven & Haley 1982).

Conclusion

It is recognised that Hospital Acquired Infections, one being C.difficile, cause significant morbidity and mortality and cost hospitals a considerable amount of money (Plowman et al 2000, Starr 2007, Day 2007, Wilcox 2002). C.difficile infections have increase in the last decade, as people live longer through modem health care interventions; today's health care brings risks as well as benefits, no risk is more fundamental than the risk of infection (DOH 2003). However, the literature suggests it could be reduced by fifteen per cent by simple procedures such as hand washing and environmental decontamination (Plowman et al 2000). Therefore, suitable control measures, including environmental cleanliness and hand decontamination are of paramount importance in the prevention and control of infections such as C.difficile. All healthcare workers have an individual responsibility for maintaining a safe care environment for patients and staff and need to be clear about their specific responsibility for cleaning equipment and clinical areas. In addition, they must be educated about the importance of ensuring the hospital environment is clean and that opportunities for microbial contamination is minimised. (Pratt et al 2007). Hand Hygiene is recognised as the leading measure to prevent transmission of bacteria and to reduce the incidence of health care acquired infection (Pittet et al 2004, Lam 2004) and yet studies consistently demonstrate that compliance is poor (Storr and Clayton-Kent 2004, Hugonett and Pittet 2000).

Continuous education is required of all healthcare personnel to ensure that standards of hand hygiene and environmental decontamination are maintained. The literature has identified that there is inconsistent evidence supporting the use of disinfectants unless outbreaks are present (McCullen 2007, Kaatz 1998, Wilcox 2006). Therefore, research into the efficacy of disinfectants relating to C.difficile in general needs to be commissioned. Future research into C.difficile bacteria could look at non-chlorine based disinfectants to decrease the risk of biocides to patients and staff.

Secondly, there is a need for a hand decontamination rub at the point of care that would be effective against Clostridia spores, to ensure hand hygiene is carried out at the right place at the right time every time; thus reducing the spread of infection through hand decontamination. Alternatives to alcohol should be investigated.

Thirdly, a C.difficile e-learning package would benefit healthcare workers, as not all healthcare workers are aware of how the infection occurs, how it is spread and the importance of environmental and equipment decontamination in the prevention of transmission. Other factors that are of relevance would be isolation personal protective clothing and single use equipment.