IDSA: Cleaning Protocol Dramatically Reduces Nosocomial C. difficile diarrhea

SAN DIEGO, Oct. 10 -- A universal bleach-based cleaning protocol reduced the rate of nosocomial Clostridium difficile infection by two-thirds at a New Orleans hospital, according to a report presented here.

However, the favorable effect on C. difficile-associated diarrhea did not translate into reduced antibiotic usage or rates of other nosocomial infections, Julio Figueroa, M.D., of Louisiana State University Health Sciences Center in New Orleans told attendees at the Infectious Diseases Society of America meeting.

The lack of impact on methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) led to speculation that those infections arise from different mechanisms than C. difficile.

"We speculate that MRSA and VRE transmission occurs mostly while the colonized patient is in the environment," said Dr. Figueroa. "Therefore, active surveillance and contact isolation should work better.

"C. difficile transmission occurs to a significant degree through a contaminated environment left behind by unidentified patients," he added. "Therefore, universal bleaching might be an important strategy to reduce nosocomial transmission in areas of high endemicity."

Nosocomial C. difficile-associated diarrhea adds almost ,700 to the cost of the average hospital stay, and the total attributable annual cost is estimated at .1 billion, said Dr. Figueroa.

Current efforts to prevent nosocomial infection include aggressive hand washing protocols, proactive identification of patients with C. difficile diarrhea, contact prevention for cases, and bleach-based cleaning protocols.

Nosocomial C. difficile diarrhea was defined as onset more than 72 hours after hospital admission.

Despite adherence to recommended procedures to prevent nosocomial transmission, an outbreak of C. difficile diarrhea occurred in an inpatient neurological rehabilitation unit at Touro Infirmary, a community, not-for-profit hospital in New Orleans.

Encouraged by results of a pilot study to combat that outbreak, Dr. Figueroa and colleagues implemented a hospital-wide universal cleaning protocol that consisted of

1) contact isolation for all patients with C. difficile diarrhea, terminal;

2) cleaning with a bleach-based cleaning protocol following patient;

3) discharge or upon transfer from the ICU;

The protocol used a commercial bleach-based cleaning solution and that the encompassed every surface area in a patient room.

After six months, the rate of nosocomial C. difficile diarrhea decreased by 68%, from 10.0 cases/10,000 patient days to 3.4 cases/10,000 patient days. The protocol also was associated with a 50% reduction in early cases (onset less than 72 hours after admission) from 6.2 to 3.1 cases/10,000 patient days.

Rates of VRE and MRSA were unaffected by the cleaning protocol. The MRSA rate vacillated between 6 and 9 cases/10,000 patient days during the six-month protocol evaluation, and the VRE rate remained stable at about 4 to 5 cases/10,000 patient days.

Use of quinolone antibiotics, third-generation cephalosporins, and clindamycin did not change during the protocol evaluation. Use of penicillins increased slightly.