Saying that half of hospitalized patients treated for Clostridium difficile illness came through the door already infected, the Centers for Disease Control and Prevention Tuesday called on all providers, from nursing homes to private physician practices, to take more aggressive steps to inform each other to stop the deadly bacteria.
"What this means is that hospitals... are partly at the mercy of surrounding facilities because patients so often transfer back and forth between facilities or are seen by so many providers," Ileana Arias, the CDC's principal deputy director, said during a news briefing. "An infection in one place can easily become a problem in another practice or facility too."
Healthcare providers used to think many C. difficile infections occurred randomly in the community, added Clifford McDonald, MD, CDC epidemiologist and lead author of a new CDC report on the topic from 2010.
But the CDC's report "shows that most of these so-called community infections actually occur in people with recent exposure to medical facilities such as outpatient surgery or [who have] just visited their doctor's office. In fact, "everywhere medical care is given."
A staggering 94% of these infections occured in people who recently received medical care in any of a wide range of facilities. While one-fourth of patients first showed symptoms while they were being treated in a hospital, 75% first showed symptoms while in nursing homes or after being cared for in a doctor's office or clinic, McDonald said.
C. difficile infections, mortality, and medical care costs "have reached historic highs," says the CDC's report, published in Tuesday's Vital Signs, Morbidity and Mortality Weekly Report. The agency says these outbreaks, marked by symptoms of excessive diarrhea and sepsis are linked to 14,000 deaths in the U.S. each year.
From 2000 to 2009, the number of hospitalized patients with a C. difficile discharge diagnosis more than doubled, form approximately 139,000 to 336,000, and the number with a primary diagnosis more than tripled from 33,000 to 111,000, the CDC report said.
Costs of care are an important element as well. Just one hospital-onset case is estimated to cost between $5,042 to $7,179 in excess medical expenses. Across the nation, treating C. difficile adds $897 million to $1.3 billion to healthcare expenses, the report said. Transmission easily occurs after someone touches an infected surface, and transfers C. difficile spores to the mouth.
A Drug-Resistant Strain
One development that has exacerbated the problem is the emergence in 2004 of a hypervirulent strain of C. difficile called NAP1, which strongly resists treatment with drugs commonly used in community settings to treat the infection.
But C. difficile infections are emerging in importance for another reason. Starting Jan. 1, 2013, hospitals will be guided by a Centers for Medicare & Medicaid Services payment for reporting program for infections, with payment adjustments forthcoming with discharges starting Oct. 1, 2014.
Scores will be posted on CMS' Hospital Compare, and in time, it is expected that higher infection rates may result in Medicare reimbursement reductions. Additionally, CMS may add C. difficile to the list of healthcare-acquired conditions for which it will not pay for additional care required.
"When the public is better informed, patients are informed, and everyone is better off," McDonald said. "In the very near future, we'll have increased transparency and accountability about this infection."
Reducing Infection Rates
But even as the C. difficile problem spreads in healthcare settings, McDonald and Arias said they've learned from experiences of three state-run programs in Illinois, Massachusetts and New York, that cooperation can bring infection rates down.
The program involved 71 hospitals. "The pooled hospital-onset CDI rate across the three prevention programs declined 20%, from 9.3 per 10,000 patient-days during the early comparison period to 7.5 during the later comparison period," the report said. The state programs did this by using many of the strategies outlined in the new CDC recommendations.
The CDC's 6-Point Checklist
The CDC issued its report with a six-point list of lessons from the three-state effort, the most important of which is to prescribe and use antibiotics more carefully, taking care to stop them when they aren't needed.
1. Don't over treat. "About 50% of antibiotics given (to patients) are not needed, but they unnecessarily raise the risk of C. difficile infection," by destroying good bacteria that keep C. difficile in check, he said.
2. All healthcare facilities should inform subsequent providers whenever they transfer or discharge a patient with C. difficile infection, so the downstream caregivers are better prepared. To get that done, McDonald called on state health departments to form hospital collaboratives or even take regulatory steps to make sure facilities communicate.
3. Providers should make sure to test patients for C. difficile when they have diarrhea while on antibiotics or within several months after taking the medication.
4. Providers should immediately place infected patients into isolation upon arrival at their facilities.
5. Providers should wear gloves and gowns when treating patients with the infection, even during short visits. "Hand sanitizer does not kill C. diff. and handwashing may not be sufficient," McDonald said. "It is important to note that once C. difficile germs get on a healthcare provider's hands, they are harder to get off so it is much better to avoid getting them on your hands in the first place."
6. Providers, especially housekeeping staffs, should clean room surfaces with bleach or another spore killing disinfectant approved by the Environmental Protection Agency.
"There needs to be concerted action across different facilities," McDonald said. "And this is something somewhat new. We think the health department especially has a particular role to bring different facilities together."
In a phone interview after the news briefing, McDonald said the CDC is working with state health departments to develop a standard, perhaps one piece of a licensing and certification requirement, that would require healthcare facilities to have a procedure to test for C. difficile infections and notify downstream providers, with penalties, with penalties or licensing issues if they fail.
In an accountable care kind of organization, McDonald continued, insurers and providers, "would be very interested in knowing that their hospitals and other providers would be doing this. But these (policies) are in the early stages (of development)," he said.