Pa Patient Saf Advis 2016 Jun;13(2):74-76.
Data Snapshot: Clostridium difficile Infections in Long-Term Care Facilities
Gerontology; Infectious Diseases
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Author

JoAnn Adkins, RN, BSN, CIC
Infection Prevention Analyst
Pennsylvania Patient Safety Authority

Data Snapshot

* Correction (Pa Patient Saf Advis 2016 Sep;13[3]:123.)

Clostridium difficile (C. diff) infection is a difficult-to-treat disease that may affect patients in healthcare facilities and can cause severe diarrhea and even death. C. difficile infection (CDI) can be devastating to anyone, but it is especially worrisome in the elderly because older people are more susceptible to developing CDIs and have a higher mortality rate.1 In the United States, more than 80% of the deaths associated with CDI occur in people age 65 or older. C. diff causes almost half a million infections yearly, with more than 100,000 occurring among residents in long-term care, making it one of the most serious healthcare complications for residents.1,2 Inappropriate or unnecessary antibiotic use and inadequate infection-prevention practices may increase the transmission of C. diff in a facility and from one facility to another when infected patients are transferred.1,2 Although the incidence of CDI is decreasing in Pennsylvania long-term care facilities, diligence remains important because of the high incidence of CDI nationally and the significant mortality of CDI in elderly people.

Between January 2010 and December 2015, Pennsylvania long-term care facilities (LTCFs) reported 13,100 CDIs to the Pennsylvania Patient Safety Authority. The CDI rate in Pennsylvania LTCFs in that period shows modest yearly decreases with an overall decrease of 16% (Figure 1).

 Figure 1. CDI Rates in Pennsylvania Long-Term Care Facilities, as Reported to the Pennsylvania Patient Safety Authority, 2010 through 2015

Figure 1. CDI Rates in Pennsylvania Long-Term Care Facilities, as Reported to the Pennsylvania Patient Safety Authority

CDI, Clostridium difficile infection.

The Southcentral and Southwest regions had higher rates of CDI than the other regions of the state for the period January 1, 2010, through December 31, 2015. The Table lists CDI rate by region.

Table 1. Clostridium difficile Infections Reported to the Pennsylvania Patient Safety Authority, by Region, January 2009 through December 2015 ​

Region
Clostridium difficile Infection Rate per 1,000 Resident Days
Region 1 – Northeast1.34 (n = 66,708)
Region 2 – Southeast2.95 (n = 395,266)
Region 3 – Northcentral0.52 (n = 11,316)
Region 4 – Southcentral1.74 (n = 85,159)
Region 5 – Northwest0.91 (n = 31,845)
Region 6 – Southwest4.54 (n = 334,744)

 

The Northeast region had an increase in CDI from baseline year of 2010 compared with 2015; however, it has had consistently low rates. The other five regions had decreases in CDI, with the Southcentral and Northwest regions having the most significant decreases (Figure 2).

 

Figure 2. Changes in CDI Rates in Pennsylvania Long-Term Care Facilities, as Reported to the Pennsylvania Patient Safety Authority, 2010 through 2015

Figure 2. Changes in CDI Rates in Pennsylvania Long-Term Care Facilities, as Reported to the Patient Safety Authority

CDI, Clostridium difficile infection.

Strategies to reduce and prevent CDI in LTCFs include a combination of antimicrobial stewardship and infection-prevention practices. Prudent use of antibiotics is necessary because antibiotic exposure is a major risk factor for the acquisition of C. diff. This includes avoiding antibiotic therapy when it is not indicated, such as for asymptomatic bacteruria, and selecting narrow-spectrum antibiotics that are associated with a lower CDI risk.3-5 Tools to help facilities develop antibiotic stewardship programs are provided in the Pennsylvania Patient Safety Advisory articles “Antibiotic Stewardship in Hospitals and Long-Term Care Facilities: Building an Effective Program4 and “Strategies to Turn the Tide against Inappropriate Antibiotic Utilization.”5 Infection-prevention practices are important to reduce transmission. C. diff forms spores that are resistant to many commonly used disinfectants and to the bactericidal effects of alcohol.

Effective infection prevention practices include:

  • Hand hygiene
  • Immediate implementation of full barrier contact precautions for patients with CDI
  • Environmental cleaning with sodium hypochlorite (bleach) or a sporicidal disinfectant approved by the Environmental Protection Agency (EPA)
  • Identification and testing of residents with diarrhea for CDI, especially if they have had recent antibiotic therapy
  • Communication with transferring facilities if a resident has a CDI
  • Education of staff, residents, and visitors1-3,6-9

CDI is a serious disease that can cause significant morbidity and mortality, especially in the elderly. Using appropriate antibiotics and implementing effective infection-prevention practices along with active surveillance for potential CDI cases can help facilities prevent transmission of C. diff.

Notes

  1. Centers for Disease Control and Prevention (CDC). Vital signs. Making health care safer - stopping C. difficile infections [online]. 2012 March [cited 2015 Dec 15]. http://www.cdc.gov/vitalsigns/HAI/StoppingCdifficile/index.html
  2. Stone N. Dying from C. diff: who is most vulnerable? [online]. Medscape 2015 June 2 [cited 2016 Jan 11]. http://www.medscape.com/viewarticle/845534
  3. Chopra T, Goldstein E. Clostridium difficile infection in long-term care facilities: a call to action for antimicrobial stewardship. Clin Infect Dis 2015 May 15;60 Suppl 2:S72-6.
  4. Bradley S. Antibiotic stewardship in hospitals and long-term care facilities: building an effective program. Pa Patient Saf Advis 2015 Jun [cited 2016 Jan 11]. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2015/Jun;12(2)/Pages/71.aspx
  5. Adkins J, Bradley S, Finley E. Strategies to turn the tide against inappropriate antibiotic utilization. Pa Patient Saf Advis 2015 Dec [cited 2016 Jan 11]. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2015/Dec;12(4)/Pages/149.aspx
  6. Dubberke E, Carling P, Carrico R, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014 Sep;35 Suppl 2:S48-65. 
  7. Goudarzi M, Seyedjavadi S, Hossein Goudarzi H, et al. Clostridium difficile infection: epidemiology, pathogenesis, risk factors and therapeutic options. Scientifica (Cairo) 2014;2014:916826. http://www.hindawi.com/journals/scientifica/2014/916826/
  8. Gould C, McDonald LC. Bench-to-bedside review: Clostridium difficile colitis [online]. Crit Care 2008;12(1):203 [cited 2016 Jan 11]. http://ccforum.com/content/12/1/203
  9. Stokowski L, McDonald LC. Refining our approach to Clostridium difficile prevention [online]. Medscape 2012 Mar 21 [cited 2016 Jan 11]. http://www.medscape.com/viewarticle/760505
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