Why _C. diff_ Still Demands Our Attention: Highlights from SHEA Spring Conference 2023

The battle against Clostridioides difficile, or C. diff, is still underway. The Society for Healthcare Epidemiology of America (SHEA) Spring Conference 2023 showcased groundbreaking updates on how to diagnose, manage, and help prevent the spread of C. diff. With some of the most brilliant minds in healthcare gathering to share their knowledge and expertise, regular and first-time attendees, like myself, were treated to a wealth of cutting-edge research and insights. From innovative diagnostic tools to novel prevention strategies, the conference highlighted ways to tackle C. diff and keep it at bay.

Prevent exposure to help prevent infection

One aspect of C. diff that makes it so interesting is the ability of the spore to survive and thrive in environments that other bacteria can't handle. From hospital and healthcare settings to the community and your own gut, this bacterium has found ways to persist and cause havoc. With over 450,000 C. diff infections (CDI) in the U.S. each year, ¹ including a staggering 225,000 cases in hospitalized patients alone,² the toll of this microbe cannot be overstated. CDI is not only persistent, it is associated with increased length of hospital stays, high costs, and even mortality in both adult and pediatric patients.³ The latest report from the Centers for Disease Control and Prevention (CDC) Emerging Infections Program brings both good news and a concerning trend. While there has been a decrease in healthcare-associated CDI, there has been a worrying increase in community-associated CDI. This finding suggests that CDI can be lurking even before admission to the hospital and may pose a risk to other hospitalized patients. ^4,5,6

With new studies finding that C. diff can linger in hospital rooms for up to 1 year,⁷ it’s imperative that we find ways to prevent exposure altogether.Fortunately, there is promising evidence attributing improved policy compliance, rigorous antimicrobial stewardship, and meticulous infection control practices to reduced CDI rates.⁸

Essential recommendations for the prevention of CDI

SHEA, in collaboration with the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, recently published the Strategies to prevent Clostridioides difficile infections in acute-care hospitals: 2022 Update . This updated 2022 expert guidance provides concise recommendations on core infection prevention practices to prevent healthcare-associated C. diff infections.³

• Establish an antibiotic stewardship program to prevent CDI
• Utilize diagnostic stewardship practices for appropriate use and interpretation of C. diff tests
• Ensure adequate room cleaning, addressing procedures for cleaning equipment and the environment of patients with C. diff
• Use contact precautions for infected patients, with single room preferred
• Implement a timely lab-based alert system for when patients are newly diagnosed
• Measure compliance with hand hygiene and contact precautions recommendations

Surface cleaning and disinfecting to help prevent transmission

C. diff transmission in healthcare facilities likely occurs via contamination of healthcare personnel hands, the care environment, or medical equipment by C. diff spores.³ Regarding cleaning and disinfection practices, the authors of the C. diff Compendium emphasize the importance of:

• Properly diluting cleaning and disinfectant products based on product directions for use (DFUs)
• Ensuring adequate cleaning techniques such as:
  • Cleaning high-touch surfaces
  • Moving from clean to dirty areas
  • Frequently changing rags and mop water
• Developing and implementing unit-specific checklists based on protocols. For example, here is a great example of a C. diff Terminal Cleaning Protocol & Checklist.

In addition, the authors of the C. diff Compendium recommend environmental decontamination with an EPA-approved sporicidal agent, like bleach, in the event of persistent C. diff transmission. My colleague and expert Infection Preventionist (IP), Doe Kley, recommends, at a minimum, using a bleach-based cleaner-disinfectant for all discharge and isolation cleanings to ensure the highest level of clean for the next patient admitted to that room.⁹

Taken together, C. diff is one of the most urgent antibiotic-resistant public health threats. At SHEA Spring 2023, experts from around the world shared research and innovative strategies to help us fight back against this stubborn foe. Some steps that can be taken to prevent its spread in healthcare facilities include timely implementation of isolation, meticulous hand hygiene, judicious use of antibiotics, and cleaning and disinfection of both the equipment and environmental surfaces. By following the prevention and treatment strategies recommended by SHEA and other public health organizations, we can work together to help reduce the burden of C. diff infections in healthcare facilities and in our communities.

References

^1. Lessa, FC, Mu, Y, Bamberg, WM, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med 2015;372:825–834.
2. Antibiotic resistance threats in the United States, 2019. Centers for Disease Control and Prevention website. https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf. Accessed May 8, 2023.
3. Strategies to prevent Clostridioides difficile infections in acute-care hospitals: 2022 Update.  Infection Control & Hospital Epidemiology. 2023;44(4):527-549. Retrieved from https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/strategies-to-prevent-clostridioides-difficile-infections-in-acutecare-hospitals-2022-update/575A2A0C9E68BD8535D14B2E337FD0A4 on May 11, 2023.
4. Clostridioides difficile infection (CDI) tracking. Centers for Disease Control and Prevention website. https://www.cdc.gov/hai/eip/cdiff-tracking.html. Accessed May 8, 2023.
5.     Dubberke, ER, Reske, KA, Yan, Y, Olsen, MA, McDonald, LC, Fraser, VJ. Clostridium difficile–associated disease in a setting of endemicity: identification of novel risk factors. Clin Infect Dis 2007;45:1543–1549.
6. Dubberke, ER, Butler, AM, Yokoe, DS, et al. Multicenter study of Clostridium difficile infection rates from 2000 to 2006. Infect Control Hosp Epidemiol 2010;31:103–107.
7. Clostridioides difficile infection (CDI) in a previous room occupant predicts CDI in subsequent room occupants across different hospital settings. American Journal of Infection Control. https://www.ajicjournal.org/article/S0196-6553(22)00079-7/fulltext#seccesectitle0006. Accessed May 8, 2023.
8. The burden of CDI in the US: a multifactorial challenge. BMC Infectious Diseases. https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-023-08096-0. Accessed May 8, 2023.
9. Why Every Healthcare Facility Needs this Sporicidal in their Arsenal. [Internet Blog]. [Cited 2023 May 9]. Available from https://www.cloroxpro.com/blog/why-every-healthcare-facility-needs-this-sporicidal-in-their-arsenal/^