Clostridium difficile (CD) One step closer to lower CD hospital-acquired infection (HAI) rates

Background: CD requires effective management of the environment through a collaborative effort of environmental services, nursing personnel, and infection preventionists. CD is a fastidious anaerobe and in its vegetative form would generally die within 24 hrs outside of the colon. When conditions become unfavorable, CD is able to survive for up to 5 mths in spore form and is resistant to heat, radiation, drying, and chemicals including typical hospital disinfectants. Use of an Environmental Protection Agency (EPA) registered hypochlorite-based disinfectant (bleach) has been identified as the preferred disinfectant to reduce the rates of CDI and transmission. In Q3 2008, our hospital experienced an increase in CD HAI rates accompanied by a lab confirmed re-emergence of the BI strain. BI is associated with hypersporulation and increased virulence and therefore can contribute to the hospital spread and severe  outcomes. Cleaning was accomplished with a quaternary ammonium (QA) disinfectant for all patient care areas and a 2 step cleaning process for known CD rooms (QA disinfectant plus bleach)  Undiagnosed and/or asymptomatic patients not known to be colonized/infected, contaminated common areas, and miscommunication in identifying CD + patient room may be an important sources of CD spread. On average, there are ~28 patients in CD precautions/day. Despite anticipated increased time to complete a 2 step process, allocated time/room (7 to 10 minutes) was not increased. This too could contribute to missed opportunities for effective cleaning. A multidisciplinary group, supported by leadership, proposed a switch to a simplified one-step bleach cleaning procedure.  
Objective: To increase efficiency and efficacy in removal of CD spores and other pathogens and decrease hospital-acquired CD rates.
Methods: In June, 2009 a one-step cleaning product which contained both a cleaning agent and bleach (Clorox^® Germicidal Wipes) was implemented for use in all patient care areas and for shared patient care equipment. HA CDI tradition (T) and expanded (E) rates (1,000 pt-days) pre-intervention were compared to post-intervention rates as was negative environmental outcomes.
Results:

	Pre-intervention										Post-intervention				% reduction	P value
	9/08	10/08	11/08	12/08	1/09	2/09	3/09	4/09	5/09	6/09	7/09	8/09	9/09	10/09
HA-CDI T Rate	1.23	0.89	1.45	1.47	0.71	0.65	0.71	0.96	0.66	0.67	0.44	0.70	0.94	0.55	35	<1 X 10-7
	0.77										0.50
HA-CDI E Rate	0.96	0.68	1.1	1.24	0.49	0.59	0.49	0.68	0.66	0.56	0.33	0.65	0.65	0.39	31	0.027
	0.97										0.67
Adverse Events	0	0	0	0	0	0	0	0	0	0	0	0	0	0	NC	-

Conclusions:
· Re-emergence of the BI CD strain was associated with an increase in HA CDI rates.
· Implementing a universal one-step bleach cleaning process was associated with better use of cleaning time,   less risk of missed cleaning opportunities and was associated with a significant reduction of HA CDI rates
· Proactive simplified approaches to infection control measures can assist in reducing HAIs.