One would think that with killer Clostridium difficile infections now at "historically high levels," acute care teams by now would have solid evidence-based knowledge of how to stop this intestinal nightmare from taking hold of their hospitals.
But then, as the saying goes, one would be wrong.
Results from a national survey of infection preventionists provide a rude wake-up jolt, and not just regarding how tough this problem is. Not only does C. difficile kill 14,000 patients a year in the U.S., but providers seem to be all over the map in their methods to attempt to annihilate this aptly named spore.
These practice differences are sure to be more obvious in coming months. As of January 1, the Centers for Medicare & Medicaid Services began requiring hospitals that want to continue receiving federal reimbursement to report their C. diff infection rates (CDIs) to the Centers for Disease Control and Prevention's National Healthcare Safety Network. Presumably, everyone will be watching what everyone else is doing.
In time, these rates will likely be publicly reported by hospital name. Some state laws already require it. And eventually the rates will probably become a measure of pay-for-performance for federal and private payers.
So there's a need to figure out what works and get infection control experts on the same page. But that just isn't happening. And the result is extremely frustrating.
Here's one example from the 26-question APIC survey, 78% of whose participants said they worked in acute care hospitals.
While 70% of those responding said their healthcare facilities had adopted additional interventions to control CDI, 24% had not and 6% didn't know. Of the 24% responding from facilities that had not adopted additional interventions, 55% said there were no plans for their organizations to adopt interventions in the next fiscal year.
In response to a follow-up question about whether interventions and surveillance had resulted in a decline in healthcare facility onset or associated C. diff rates, only 42%% said there had been a decline, but 43% said there had not. And 15% said they didn't know.
That's discouraging.
There are many more examples of strategy variation. But before I go on, you should know that this "Pace of Progress" survey was designed by members of the well-regarded Association for Professionals in Infection Control and Epidemiology, which sent it to its 14,000 members.
To be fair, only 1,087 professionals responded—just under 8%—which isn't that great. APIC officials are quick to acknowledge that this was not a rigorous scientific survey.
But it was a survey, and it was the first one the organization has done on C. diff practicesin three years. During that time, CDIs continued their rampage through healthcare settings.
According to a CDC report, between 2000 to 2009 the number of patients discharged from hospitals with any diagnosis of CDI more than doubled, from 139,000 to 336,000, even though incidence of other healthcare-associated infections had declined in that period.
The CDC estimates healthcare cost of hospital-onset C. diff infections to be $5,042 to $7,179 per case with a national annual estimate of $897 million to $1.3 billion.
Evidence for controlling infections "has been published," the CDC says, but it acknowledges a very real problem: The scientific underpinnings for that evidence are weak.
"The degree to which they can prevent CDIs effectively across a range of hospitals is unknown, as is the relative burden of CDIs in nonhospital and hospital healthcare settings," the CDC said in a "Vital Signs" report a year ago.
So for C. diff, it appears, it's still the wild, wild West.
APIC president-elect Jennie Mayfield, an infection preventionist and epidemiologist at Barnes-Jewish Hospital/Washington University Medical School in St. Louis, MO, says that many of the responses were surprising. "But to me, they all reflect the fact that we don't fully understand the epidemiology of this organism. We just have more basic science to do."
She adds that for her, the take-home message is that there remains a "variety of policies and practices regarding when to initiate isolation, and when to stop." Perhaps most discouraging, she says, is that despite hospitals' additional interventions, "rates have not gone down."
There is no national guideline, "because there are no strong published studies that tell us what to do. Evidence-based research [is needed], and we just don't have that for C. difficile."
And there aren't any studies underway that will yield answers anytime soon, she says. "It boils down to money," Mayfield says. "We're aware that the research budgets for federal agencies, including the CDC, have all been cut."
So today, in any healthcare setting, "people are trying to find their own solutions in their individual facilities." According to the APIC survey:
- One-third of respondents said their current policy on cleaning a room occupied by a patient infected with C. diff does not include the use of sodium hydroclorite (bleach) solution.
- Only 21% of respondents said their organizations had added infection prevention staff in the last three years, while 77% said they had not.
- But 9% of the responders said they always use bleach for all room cleaning and 6% use bleach only during outbreaks or increases in infection rates. Another 5% use other routine hospital disinfectants for all room cleaning and disinfection.
I asked Mayfield why providers might not use bleach.
"Some people don't want to use bleach because it's corrosive. It can damage equipment, furniture, clothing, uniforms, and it may be irritating to patients, and that's why there's reluctance to use it automatically," she explains.
And bleach isn't necessarily the solution. "Sodium hydroclorite is only as good as the person doing the cleaning," she says.
Another survey eye-opener is the wide variation in providers' use of contact precautions for their C. diff patients. One in four respondents said they keep patients on contact precautions until after drug treatment has started and the patient has had no diarrhea for 48 hours.
But 42% activate it for the entire duration of hospitalization or until discharge, 9% until after treatment has started and there has been no diarrhea for 72 hours, and 24% gave several other answers.
There is some hope that a patient cure to C. diff may be found, even if environmental eradication of spores proves more challenging. Mayfield says that fecal transplants so far tried in just a very few patients, have had "remarkable success." But patients are only eligible for that procedure if they have failed other efforts other drug regimens, by which time it may be closer to a last resort.
"There's a lot of interest in the biology of C. diff," Mayfield says. "But I can't say that in five years there will be anything at the patient level, ready to administer and proven efficacious, that does what it's supposed to do without killing people."
So healthcare settings are going to have to step up their diligence, she says. "This infection requires commitment in terms of dollars and personnel to explore new technologies and engineering controls." Newer technologies like UV radiation lights to kill spores or hydrogen peroxide vapor should be tried, but that costs money too, she says.