Outbreak Of Clostridium Difficile Infection Research Articles

Predicting hospital-onset Clostridium difficile using patient mobility data: A network approach.

To examine the relationship between unit-wide Clostridium difficile infection (CDI) susceptibility and inpatient mobility and to create contagion centrality as a new predictive measure of CDI. Retrospective cohort study. A mobility network was constructed using 2 years of patient electronic health record data for a 739-bed hospital (n = 72,636 admissions). Network centrality measures were calculated for each hospital unit (node) providing clinical context for each in terms of patient transfers between units (ie, edges). Daily unit-wide CDI susceptibility scores were calculated using logistic regression and were compared to network centrality measures to determine the relationship between unit CDI susceptibility and patient mobility. Closeness centrality was a statistically significant measure associated with unit susceptibility (P < .05), highlighting the importance of incoming patient mobility in CDI prevention at the unit level. Contagion centrality (CC) was calculated using inpatient transfer rates, unit-wide susceptibility of CDI, and current hospital CDI infections. The contagion centrality measure was statistically significant (P < .05) with our outcome of hospital-onset CDI cases, and it captured the additional opportunities for transmission associated with inpatient transfers. We have used this analysis to create easily interpretable clinical tools showing this relationship as well as the risk of hospital-onset CDI in real time, and these tools can be implemented in hospital EHR systems. Quantifying and visualizing the combination of inpatient transfers, unit-wide risk, and current infections help identify hospital units at risk of developing a CDI outbreak and, thus, provide clinicians and infection prevention staff with advanced warning and specific location data to inform prevention efforts.

A two-step approach for the investigation of a Clostridium difficile outbreak by molecular methods

Abstract The recent review “How to: molecular investigation of a hospital outbreak” written by Nutman and Marchaim published in Clinical Microbiology and Infection journal summarized data on typing methods used for a hospital outbreak investigation. Regarding Clostridium difficile infection (CDI), a whole genome sequencing (WGS) was recommended as the initial and a single molecular test for characterisation of C. difficile isolates in a suspected outbreak situation. According to results from our survey on typing capacity for C. difficile in Europe, whole genome sequencing was available only in five National reference laboratories for C. difficile in 2017 in Europe. Because of limited availability of WGS, we suggest a two-step approach that includes the typing of C. difficile isolates with a high discriminatory method, capillary electrophoresis ribotyping and the subtyping of C. difficile isolates by Multilocus Variable-number Tandem-repeats Analysis (MLVA) and/or WGS when a common cluster of CDIs is confirmed. This two-step approach would provide an epidemiological relevant timeframe for confirmation of a suspected CDI outbreak as well as being cost-effective by selecting highly related C. difficile isolates for further investigation.

First outbreak of Clostridium difficile infections in Serbia: An experience of the department for orthopedic surgery

Objectives: Increased C. difficile infection rates were observed during the last decade, as well as the onset of complicated forms of the disease. The primary objective of this study was to report the first outbreak of C. difficile in a Serbian hospital, aiming to determine clinical and environmental factors associated with the outbreak. The secondary objective was to describe outbreak control measures taken.Design: The retrospective cohort study conducted from 18 April to 22 May 2013 in Serbian healthcare. Ninety-five patients hospitalized at the Department for orthopedic surgery during the CDI outbreak.Results: Prophylactic antibiotic therapy was identified among 93.3% patients with and 87.9% without C. difficile infection. The multivariate logistic regression analysis has shown that the independent risk factors for C. difficile infection incidence are the age beyond 70 (OR = 4.5; 95%CI = 1.1-18.2; p = .031) and the length of antibiotic therapy (OR = 1.5; 95%CI = 1.1-2.1; p = .017).Conclusion: The length of antibiotic prophylaxis is linked with the incidence. Orthopedic departments have a risk of C. difficileinfection. Infection control measure, antimicrobial stewardship programs and compliance to guidelines for the prescribing of antibiotics play important role in the prevention of C. difficile infection burden.

Genomic Study of a Clostridium difficile Multidrug Resistant Outbreak-Related Clone Reveals Novel Determinants of Resistance.

Background: Clostridium difficile infection (CDI) is prevalent in healthcare settings. The emergence of hypervirulent and antibiotic resistant strains has led to an increase in CDI incidence and frequent outbreaks. While the main virulence factors are the TcdA and TcdB toxins, antibiotic resistance is thought to play a key role in the infection by and dissemination of C. difficile.Methods: A CDI outbreak involving 12 patients was detected in a tertiary care hospital, in Lisbon, which extended from January to July, with a peak in February, in 2016. The C. difficile isolates, obtained from anaerobic culture of stool samples, were subjected to antimicrobial susceptibility testing with Etest®strips against 11 antibiotics, determination of toxin genes profile, PCR-ribotyping, multilocus variable-number tandem-repeat analysis (MLVA) and whole genome sequencing (WGS).Results: Of the 12 CDI cases detected, 11 isolates from 11 patients were characterized. All isolates were tcdA-/tcdB+ and belonged to ribotype 017, and showed high level resistance to clindamycin, erythromycin, gentamicin, imipenem, moxifloxacin, rifampicin and tetracycline. The isolates belonged to four genetically related MLVA types, with six isolates forming a clonal cluster. Three outbreak isolates, each from a different MLVA type, were selected for WGS. Bioinformatics analysis showed the presence of several antibiotic resistance determinants, including the Thr82Ile substitution in gyrA, conferring moxifloxacin resistance, the substitutions His502Asn and Arg505Lys in rpoB for rifampicin resistance, the tetM gene, associated with tetracycline resistance, and two genes encoding putative aminoglycoside-modifying enzymes, aadE and aac(6′)-aph(2″). Furthermore, a not previously described 61.3 kb putative mobile element was identified, presenting a mosaic structure and containing the genes ermG, mefA/msrD and vat, associated with macrolide, lincosamide and streptogramins resistance. A substitution found in a class B penicillin-binding protein, Cys721Ser, is thought to contribute to imipenem resistance.Conclusion: We describe an epidemic, tcdA-/tcdB+, multidrug resistant clone of C. difficile from ribotype 017 associated with a hospital outbreak, providing further evidence that the lack of TcdA does not impair the infectious potential of these strains. We identified several determinants of antimicrobial resistance, including new ones located in mobile elements, highlighting the importance of horizontal gene transfer in the pathogenicity and epidemiological success of C. difficile.

Detection and Isolation of Clostridium difficile Asymptomatic Carriers During Clostridium difficile Infection Outbreaks: An Exploratory Study.

During 4 Clostridium difficile infection outbreaks, unit-wide screening of 114 patients led to detection and isolation of 15 (13%) C. difficile asymptomatic carriers. Carriage prevalence varied between outbreaks, from 0% to 29% (P = .004). Isolating carriers was not associated with significantly shorter outbreak durations, compared with historical controls.

Laboratory diagnosis of Clostridium difficile infection

Clostridium difficile infection (CDI) is a serious and sometimes life-threatening illness caused by toxin release from Clostridium difficile (CD), a gram-positive anaerobic bacterium. Infection with CD can cause clinical manifestations in a spectrum from asymptomatic carrier states to pseudomembranous colitis and toxic megacolon. Accurate diagnosis of CDI depends on early recognition of clinical symptoms of diarrhea, fever, and cramps especially after antibiotic use. Bacterial culture can be performed for epidemiological and antibiogram purposes during outbreaks of CDI. Culture, enzyme immunoassays (EIA), and molecular assays are useful for diagnosis of CDI. Toxigenic culture is useful to determine the cytopathic effect of the bacteria. Current Infectious Disease Society of America (IDSA) and American College of Gastroenterology (ACG) guidelines recommend using nucleic acid amplification tests or glutamate dehydrogenase (GDH) antigen followed by EIA testing for CD toxin A and B. Future studies for CDI diagnosis are looking toward toxin identification and the use of metabolomic analysis.

Outcomes of intrahospital antimicrobial stewardship programs related to prevention of Clostridium difficile infection outbreaks

Aim To synthesize evidence about the influence of individual antimicrobial stewardship programs (ASP) related to the prevention of Clostridium difficile (C. difficile) infection on primary and secondary outcomes. Methods Relevant databases such as Medline, PUBMED, COCHRANE library and EBSCO were searched from 1 April to 27 April 2017. Additional studies were reached by the manual search for original articles in relevant journals. We included all randomized controlled, quasi-experimental and observational studies, published in the English language from 2007 onward, that evaluated effectiveness of ASP in preventing and controlling C. difficile associated disease (CDAD) among adult inpatients. Results Implementation of ASP interventions was associated with CDAD incidence reduction in 62.5% studies, but no significant differences were reported for the duration of hospitalization, readmission and mortality rate. Improvements in prescribing patterns (decreased antimicrobial use or increased rational use) and microbial outcomes (decreased rates of selected antimicrobial-resistant bacteria) were reported. Evidence on the effects of ASP is mainly limited to the results of studies low in methodological quality with great heterogeneity of outcomes, interventions, and units in which CDAD incidence data were reported. Conclusion Despite the low strength of evidence of reviewed studies, consistency of findings suggest the positive impact of antimicrobial stewardship programs on the prevention and control of nosocomial CDAD. The significance of this problem imposes randomized control trial use as the best instrument to provide highquality evidence. Further studies need to systematically analyse changes in all antibiotic use and its outcomes.

Surveillance of antibiotic resistance among common Clostridium difficile ribotypes in Hong Kong

Incidence of Clostridium difficile infection (CDI) is rapidly increasing and it poses a major health burden globally. However, data regarding the epidemiology of CDI in Asia are limited. We aimed to characterize the antimicrobial susceptibility patterns of common ribotypes of toxigenic C. difficile in Hong Kong. Fifty-three PCR ribotypes were identified among 284 toxigenic C. difficile clinical isolates. The five most prevalent ribotypes were 002 (13%), 017 (12%), 014 (10%), 012 (9.2%), and 020 (9.5%). All tested C. difficile strains remained susceptible to metronidazole, vancomycin, meropenem and piperacillin/tazobactam, but highly resistant to cephalosporins. Of the fluoroquinolones, highest resistance to ciprofloxacin was observed (99%), followed by levofloxacin (43%) and moxifloxacin (23%). The two newly emerged PCR ribotypes, 017 and 002, demonstrated high levels of co-resistance towards clindamycin, tetracycline, erythromycin and moxifloxacin. PCR ribotypes 017 and 002 with multi-drug resistance are rapidly emerging and continuous surveillance is important to monitor the epidemiology of C. difficile to prevent outbreaks of CDI.

BERBERINE HYDROCHLORIDE COULD PROVE TO BE A PROMISING BULLET AGAINST CLOSTRIDIUM DIFFICILE INFECTION: A PRELIMINARY STUDY FROM SOUTH INDIA

Objective: Recurrent Clostridium difficile infection (CDI) and the emergence of strains with reduced susceptibility to metronidazole and vancomycinwarrants alternative therapy. Hence, we tested the potential efficacy of the natural compound berberine hydrochloride (BBRHCl) against toxigenicC. difficile.Methods: Three representative polymerase chain reaction confirmed, toxin-positive strains were included in the study. Pulsed-field gel electrophoresis(PFGE) profile and antibiogram of the strains were analyzed along with 10 other toxin positive isolates. Efficacy of BBRHCl against toxigenic C. difficilewas determined using agar diffusion by punch well method.Results: PFGE grouped the test strains into three clusters with unique susceptibility pattern toward standard antibiotics. BBRHCl was efficaciousagainst the test strains at a concentration ranging between 6.25 μg/ml and 10 mg/ml. BBRHCl’s breakpoint point inhibitory zone diameter wasequivalent (p&lt;0.001) to the epidemiological cutoff values for teicoplanin, vancomycin and 2% black seed oil. Although the predicted concentration ofBBRHCl for breakpoint zone diameter equivalent to European Committee on Antimicrobial Susceptibility Testing’s epidemiological cutoff value formetronidazole was observed to fall outside the tested concentration range; it was still within the safe dosage for humans.Conclusion: The present study is promising in considering BBRHCl as a potent substitute or adjunct not only for metronidazole, vancomycin andteicoplanin but also for natural compounds like 2% black seed oil for managing resistant cases of CDI. Owing to BBRHCl’s direct antibacterial and antiinflammatoryaction, further investigations will aid in the proper characterization of the therapeutic effects of similar plant compounds, to developsafe and effective drugs against the epidemiological outbreak of CDI.

Analysis of two Clostridium difficile outbreaks in an acute health care facility

BACKGROUND: Many Clostridium difficile infection (CDI) cases are classified as health care–associated (HA)-CDI using standard definitions. However, this classification may not be accurate and may lead to the declaration of outbreaks when the acquisition of C. difficile is not HA, and the source of infection or strain type are unknown. OBJECTIVE: To characterize C. difficile ribotypes to establish the relationship between CDI cases involved in two outbreaks at a Canadian hospital, and to determine whether there was a common source of infection between the outbreaks. METHODS: C. difficile isolates from infected patients involved in two CDI outbreaks affecting two wards (A and B) were analyzed using ribotyping and mutlilocus sequence typing (MLST) techniques. Antibiotic use and length of hospital stay for the CDI cases during the outbreaks were also analyzed by reviewing patient charts. RESULTS: C. difficile was isolated from 19 of 22 CDI patients. Twelve patients in ward A carried 10 different ribotypes, of which eight were isolated once. Similarly, seven patients in ward B carried five different ribotypes, of which four were isolated once. Only three ribotypes – 027, 056, and 106 – were isolated in both wards, of which at least two isolates of ribotype 027 and ribotype 056 belonged to different MLST groups, indicating genetic diversity, even among the shared ribotypes between the two wards. All CDI patients were isolated throughout their hospital stay. The CDI cases did not show an association with the length of hospital stay. Antibiotic use was also documented before and after the onset of HA-CDI. A common pattern of exposure to multiple antibiotics and proton pump inhibitors was noticed before the onset of CDI that continued afterward. CONCLUSION: Two concurrent CDI outbreaks in two separate wards involving 22 patients admitted to a Canadian acute health care facility in 2012 are reported. On examining these two outbreaks, there was no evidence to support ongoing nosocomial transmission of C. difficile among these patients. The genetic diversity of recovered C. difficile isolates suggested that the outbreaks could not be attributed to a common source or sustained transmission of an outbreak strain.

Vancomycin Prophylaxis for Prevention of Clostridium difficile Infection Recurrence in Renal Transplant Patients.

Incidence of primary and recurrent Clostridium difficile infection (CDI) is higher in solid-organ transplant recipients than in the average hospitalized patient. Strategies for preventing recurrent CDI are limited. Prophylaxis with oral vancomycin (VPPx) for preventing recurrent CDI may be beneficial, but there is limited evidence supporting its use. To examine the impact of VPPx (125 mg twice daily) for the prevention of recurrent CDI in renal transplant recipients (RTX) receiving high-risk broad spectrum antibiotics (BSAs). Adult RTX with history of CDI, hospitalized with receipt of BSAs during a unit-specific CDI outbreak period-January 1, 2012, to December 31, 2015-were divided into 2 matched cohorts: patients who received VPPx concomitantly with BSAs and patients who did not. The primary objective was incidence of CDI recurrence, defined as CDI occurring ≤30 days after receipt of BSAs but ≥48 hours after beginning VPPx. Univariate analysis was performed. Baseline characteristics were similar; however, the VPPx group had more severe primary CDI and were receiving BSAs for more severe infections. There were no cases of CDI recurrence in the VPPx group (0% [0/12] vs 8% [2/24], P = 0.54). Although sufficient power was not obtained to detect statistically significant differences between the intervention and control groups, a 0% incidence of recurrent CDI while receiving VPPx in this high-risk patient population is compelling because it pertains to the avoidance of CDI-related morbidity and mortality in transplant recipients. Future prospective studies are needed to better evaluate the impact of this preventive strategy.

An outbreak of Clostridium difficile infections due to new PCR ribotype 826: epidemiologic and microbiologic analyses

ObjectivesTo investigate an unusual outbreak of five patients with a total of eight episodes of a Clostridium difficile infection on a gastrointestinal surgical ward of a Dutch tertiary-care, university-affiliated hospital. MethodsClinical case investigations and laboratory analyses were performed. Laboratory analyses included PCR ribotyping, multiple-locus variable-number tandem repeat analysis typing, toxin typing, antimicrobial susceptibility testing and whole genome sequencing. ResultsThe outbreak was associated with recurrent and severe disease in two of five patients. All episodes were due to a unique ribotype that was not recognized in the collection of an international network of reference laboratories and was assigned PCR ribotype 826. PCR ribotype 826 is a toxin A–, toxin B– and binary toxin–positive ribotype which according to molecular typing belongs to clade 5 and resembles the so-called hypervirulent ribotype 078. The presence of a clonal outbreak was confirmed by whole genome sequencing, yet the source of this newly identified ribotype remained unclear. ConclusionsThis newly identified C. difficile PCR ribotype 826 is part of clade 5 and might also have increased virulence. The recognition of this outbreak highlights the need for ongoing C. difficile infection surveillance to monitor new circulating ribotypes with assumed increased virulence.

An outbreak of Clostridium difficile PCR ribotype 027 in Spain: risk factors for recurrence and a novel treatment strategy.

An outbreak of Clostridium difficile infection (CDI) caused by ribotype 027 (B1/NAP1) began in our hospital in November 2014, and produced 141 episodes in the following months. The aim of this study is to describe this outbreak, assess risk factors for recurrence of CDI-027 and to analyze the implementation of a novel treatment strategy. This is a prospective study of all patients with CDI-027, from November 2014 to November 2015. The epidemiological data were collected daily for each patient. We compared clinical characteristics and treatment between patients with and without recurrence of CDI-027. Interestingly, liver cirrhosis was present in 22% of the patients, and most of them received prophylaxis for hepatic encephalopathy with rifaximin. Patients were also taking antimicrobial drugs (93.6%) and proton pump inhibitors (80.1%). Overall, 27 (23.5%) patients had a first recurrence of CDI-027. Liver cirrhosis increased the risk of recurrence (44.4% vs 14.8%). Patients treated with a prolonged oral vancomycin regimen vs the conventional regimen (oral metronidazole or 10days of vancomycin) had fewer recurrences (8.6 versus 44.7% [p≤0.01]; OR, 0.91; 95% CI, 0.028-0.294) and less attributable mortality (0% versus 7.1%; p=0.058). We report an outbreak of CDI-027, mainly in patients with liver cirrhosis. Recurrence of CDI-027 was more common in those patients. A novel approach involving high-dose prolonged vancomycin taper as a first-line treatment, together with a bundle of outbreak measures, seemed to reduce the number of cases of CDI-027, recurrences, and attributable mortality. Nevertheless, this approach warrants further investigation.

Analysis of toxin and multilocus sequence typing of Clostridium difficile strains isolated from China-Japan Friendship Hospital

Objective To analyze the characteristics of toxin, the PCR-ribotyping(RT) and the multilocus sequence typing(MLST) of Clostridium difficile strains isolated from China-Japan Friendship Hospital in order to provide a basis for monitoring the outbreak of nosocomial Clostridium difficile infection. Methods A total of 321 samples were collected from the patients with suspected Clostridium difficile infection(CDI) in China-Japan Friendship Hospital(CJFH) during 2012 to 2013. All Clostridium difficile strains were isolated and identified by the standard phenotypic culture method. Cytotoxicity test was performed to detect toxin B. Toxin genes (tcdA and tcdB) and binary toxin genes (cdtA and cdtB) harbored by those strains were analyzed. RT and MLST were used for homologous analysis. Clinical data of the patients were collected to analyze the isolation rate of Clostridium difficile in different populations. Results Forty-eight strains of Clostridium difficile were isolated from 46 patients with diarrhea and three of them were isolated from the same patient. The incidence of CDI among all patients, outpatients and inpatients were 14.3%(46/321), 12.8%(5/39) and 14.5%(41/282), respectively. Toxin B was detected in all of the strains as indicated by the cytotoxicity test. Strains of sequence type 1(ST1) showed the strongest cytotoxicity of all the isolated Clostridium difficile strains. Ten out of the 48 strains (20.8%) were tcdA(-)/tcdB(+ ) strains, which belonged to either ST37 or ST81. The results of RT and MLST were consistent in assigning the strains into nine types, in which the predominant type was ST1/RT027 accounting for 27.1% (13/48). All of the ST1/RT027 strains presented a toxin gene profile of tcdA(+ )/tcdB(+ ) and cdtA(+ )/cdtB(+ ). Most of the ST1/RT027 strains were isolated from the Traditional Chinese Medicine Department of Respiratory, where smallnosocomial outbreaks of ST1/RT027 strain infection might happen. Conclusion CDI diagnosed in CJFH mainly belongs to nosocomial infection. Most of the isolated strains harbor tcdA(+ )/tcdB(+ ) genes. Surveillance for the outbreaks of CDI caused by ST1/RT027 strains over producing toxins A and B should be strengthened in hospitals. Key words: Clostridium difficile; Standard phenotypic culture method; Cytotoxicity test; Ribotyping; Multilocus sequence typing

Evaluation of fixed and variable hospital costs due to Clostridium difficile infection: institutional incentives and directions for future research

Economic analysis of Clostridium difficile infection (CDI) should consider the incentives facing institutional decision-makers. To avoid overstating the financial benefits of infection prevention, fixed and variable costs should be distinguished. To quantify CDI fixed and variable costs in a tertiary referral hospital during August 2015. A micro-costing analysis estimated CDI costs per patient, including the additional costs of a CDI outbreak. Resource use was quantified after review of patient charts, pharmacy data, administrative resource input, and records of salary and cleaning/decontamination expenditure. The incremental cost of CDI was €75,680 (mean: €5,820 per patient) with key cost drivers being cleaning, pharmaceuticals, and length of stay (LOS). Additional LOS ranged from 1.75 to 22.55 days. For seven patients involved in a CDI outbreak, excluding the value of the 58 lost bed-days (€34,585); costs were 30% higher (€7,589 per patient). Therefore, total spending on CDI was €88,062 (mean: €6,773 across all patients). Potential savings from variable costs were €1,026 (17%) or €1,768 (26%) if outbreak costs were included. Investment in an antimicrobial pharmacist would require 47 CDI cases to be prevented annually. Prevention of 5%, 10% and 20% CDI would reduce attributable costs by €4,403, €8,806 and €17,612. Increasing the incremental LOS attributable to CDI to seven days per patient would have increased costs to €7,478 or €8,431 (if outbreak costs were included). As much CDI costs are fixed, potential savings from infection prevention are limited. Future analysis must consider more effectively this distinction and its impact on institutional decision-making.

Outbreak Column 20: are outbreaks man-made disasters that display intertwined errors of human judgement and behaviour?

Man-made disasters are reported to have five intertwined errors of human judgement and behaviour. As outbreaks are essentially man-made disasters, the cited intertwined errors of engineering overreach, smooth sailing fallacy, insider view, risk-seeking incentives and social-herding were looked for in five notable outbreaks of Clostridium difficile infection. Engineering overreach was found to be the most identifiable error. The purpose of this reflective exercise was to turn hindsight into foresight and determine the intertwined levels of safety behaviour needed to prevent any future pathogen emerging to produce healthcare disasters.

Cost analysis of an outbreak of Clostridium difficile infection ribotype 027 in a Dutch tertiary care centre

The economic impact of Clostridium difficile infection (CDI) on the healthcare system is significant. From May 2013 to May 2014, an outbreak of C.difficile ribotype 027 occurred in a Dutch tertiary care hospital, involving 72 patients. The primary aim of this study was to provide insight into the financial burden that this CDI outbreak brought upon this hospital. A retrospective analysis was performed to estimate the costs of a one-year-long C.difficile ribotype 027 outbreak. Medical charts were reviewed for patient data. In addition, all costs associated with the outbreak control measures were collected. The attributable costs of the whole outbreak were estimated to be €1,222,376. The main contributing factor was missed revenue due to increased length of stay of CDI patients and closure of beds to enable contact isolation of CDI patients (36%). A second important cost component was extra surveillance and activities of the Department of Medical Microbiology and Infection Control (25%). To the authors' knowledge, this is the first study to provide insight into the attributable costs of CDI in an outbreak setting, and to delineate the major cost items. It is clear that the economic consequences of CDI are significant. The high costs associated with a CDI outbreak should help to justify the use of additional resources for CDI prevention and control.

Presentation Number 14 - Summary of PFGE and MMLVA Pattern Analysis for a Facility-Wide Outbreak of Clostridium Difficile Infection (CDI) at a Large Tertiary Care Hospital in Ontario, Canada

BACKGROUND: According to the Centers for Disease Control and Prevention, Clostridium difficile causes 337,000 infections and 14,000 deaths annually. Infection Preventionists can proactively reduce hospital-onset C. difficile infections (HO-CDI) by utilizing a multidisciplinary performance improvement (PI) approach. The formulation of policies along with the support of management, medical staff, nursing and ancillary staff can result in a statistically significant reduction of patient harm. METHODS: Infection Peventionists at a 716 bed safety-net hospital observed a statistically significant increase in HO-CDI between January and July 2014 utilizing statistical process control charts (SPC). C. difficile infections (CDI) were identified using the National Hospital and Safety Network 2014-2015 definition; patients identified as C. difficile toxin positive on or after calendar day four of admissionwere considered to be hospital-onset. Despite efforts, in June 2015, SPC revealed another statistically significant deviation and an outbreak investigation exposed potential evidence of nosocomial spread in a medical-surgical unit. A hospital-wide policy titled “Enhanced Contact Precautions” for CDIwas implemented in July 2015. By clarifying Enhanced Contact Precautions for CDI, patient care providerswere prompted towashhandswith soap and water and clean patient rooms with a bleach product. RESULTS: The increase in HO-CDI spurred the formation of a multidisciplinary PI approach that resulted in a 41% decrease in the HOCDI rate from August 2014 to April 2015. In June of 2015 another CDI outbreakwas identified and the infection rate increased to 13.50/ 10,000 patient days (+3 sigma). Subsequent PI efforts resulted in a decrease in the HO-CDI rate to an average of 3.62/10,000 patient days from July to October 2015. CONCLUSIONS: Multidisciplinary PI, including comprehensive staff education, enhanced terminal cleaning, enhanced contact isolation, changes in the electronic medical record to augment continuity of care and the initiation of a hand hygiene subcommittee resulted in a significant reduction in HO-CDI rates.

Reproducible elimination of Clostridium difficile spores using a clinical area washer disinfector in 3 different health care sites

Following a Clostridium difficile infection outbreak, the Infection Prevention and Control team at our institution queried the risk of transmission via bedpans reprocessed in washer disinfectors (WDs). This study's objective was to determine the effectiveness of the mechanical action, detergent, and temperature on the eradication of C difficile spores in 1 type of WD model. Three types of reusable bedpans/pots were inoculated with sterile human feces that contained 1 × 10(7) CFU/mL C difficile spores. The 0.3 mL fecal-spore suspension was inoculated in sealed cryovials. These items were reprocessed using the longest wash cycle of WDs in 9 clinical units, and then tested for residual C difficile spores. The number of colonies on each replicate organism detection and counting plate was recorded after anaerobic incubation at 35°C for 48 hours, and the log reduction was calculated. All 9 WDs met the manufacturer's operational specifications. Forty-three (96%) of 45 bedpans had no viable spores (>5.9 log10C difficile spore reduction). Two bedpans had 1 to 2 spores remaining. Viable C difficile spores were isolated from all 9 cryovials. Results demonstrated that when operating the WD as stipulated, C difficile spores were satisfactorily eliminated from bedpan surfaces. Temperature alone was insufficient to kill C difficile spores. It also suggested the importance of staff training, machine maintenance, and WD purchase specifications.

Risk Factors Associated with Clostridium difficile Infection in A Pediatric Hematology-Oncology Ward with Analysis of the Infection Control Measures

Introduction: The impact of clostridium difficile infection (CDI) on patients’ health and hospitals’ cost is significant. Currently CDI is recognized as an increasingly important pathogen in children with increasing incidence among pediatric patients. Data is scarce on the incidence and risk factors of CDI in Saudi Arabia, especially in pediatric oncology population. In this study, we report the first outbreak of CDI in pediatric hematology-oncology ward in Saudi Arabia and describe the associated risk factors for CDI. Methods: This is a descriptive, epidemiologic hospital based case-control study of pediatric Patients in hematology-oncology ward who had CDI in an outbreak from January 2012 to June 2013 at a tertiary hospital in Saudi Arabia, matched randomly to a control group who were admitted in the same ward during the study period. The main outcome measure was the adjusted odds ratio estimates of potential risk factors for CDI infection. We also describe the control measures that were implemented to control this outbreak. Results: Risk factors associated with CDI were antibiotic use with cotrimoxazole being the most used one, and length of hospital stay. Controls were found to have been treated more with penicillins and aminoglycosides. Conclusion: Factors associated with CDI infection are often complex and maybe confounded by local variables, antibiotic exposure and lengthy hospital stays are among many risk factors for CDI in high -risk populations. Our study also highlights the importance of infection control measures in controlling and preventing outbreaks of CDI.