Preventing the Spread of CDI in the Healthcare Setting

Stuart Johnson, MD: Finally, measures to prevent and control the spread of Clostridioides difficile infection [CDI] are equally as important as treating it. How can we prevent the spread of CDI in health care settings? It’s another big topic, but just briefly, how good are we at doing this, and what are some important things to know about prevention of CDI spread in hospitals?

Andrew Skinner, MD: One of the big things for preventing the spread of CDI within the hospital is focusing on that horizontal transmission, so that’s one of the first things that we can help providers with. The ways that we do that in the hospital are going to be the contact precautions, making sure that providers, nurses, and everyone are going into these rooms with the appropriate gowns and gloves, and monitoring the surfaces at that point as well. Once they’re wearing that, it’s about making sure they remove it while they’re within the room when they’re leaving. Also, using soap and water to wash your hands afterward, not an alcohol-based hand wash at that point.

Stuart Johnson, MD: That’s in regard to the spore nature.

Andrew Skinner, MD: The spore nature, so you’re not walking into one room, picking up a spore and then all of a sudden walking over to the next room of a patient who is immunocompromised or who has ulcerative colitis, and setting them up for a subsequent C diff infection as well. That’s one of the things, but we also need to focus on the…terminal room cleaning that we do as well. So it is making sure that we are washing these rooms down with bleach or hydrogen peroxide solutions. Also, UV light or radiation tends to be another method that has been utilized as well to clean these rooms after a patient with C diff has been admitted to them.

Stuart Johnson, MD: What about the role of antimicrobial stewardship in preventing CDI, any thoughts on that?

Joseph Reilly, BS, PharmD, BCGP: I have thoughts about that every day at work, every day.

Stuart Johnson, MD: Well, that’s good.

Joseph Reilly, BS, PharmD, BCGP: We track and trend our C diff rates, and the indiscriminate use of antibiotics is certainly a problem. Patients will come in with community-acquired pneumonia and oftentimes will receive 3 different antibiotics from different classes initially before they’re put on whatever they receive, which is often combination therapy. It’s difficult to get providers to adopt the mindset that not everything is a bacterial infection, that viruses cause a lot of upper respiratory tract infections. They want to be safe sometimes and just say, let me throw antibiotics at this patient…. They leave them on it, nobody wants to stop it. Antimicrobial stewardship is required; it’s essential to decrease the rates of C diff and something that all hospitals need to address.

Stuart Johnson, MD: When I think about antibiotic stewardship obviously the concern is overuse of antibiotics and developing resistance, and it cuts across many different areas. Sometimes antimicrobial stewardship for preventing C diff infection is a bit different, and sometimes it’s across purposes, if you will, with other antimicrobial stewardship practices. Is there anything specific your hospital does for C diff prevention with antibiotic stewardship?

Joseph Reilly, BS, PharmD, BCGP: I can tell you that specifically for C diff, now we’re calling it antibiotic stewardship. We take a look at antibiotics that we think are more likely to cause C diff. We try to crack down on our use of clindamycin. We have patients on vancomycin and piperacillin and tazobactam, and you’ll see clindamycin was added because they fear aspiration pneumonia. We try to decrease the use of broad-spectrum antibiotics unnecessarily. We restrict those antibiotics, definitely clindamycin and also the quinolones. We try not to use quinolones in the first line. It also helps us that we have higher resistance rates with the quinolones, especially for Escherichia coli, the indications that they want to use them. So restricting the use of those antibiotics, educating our providers about the development of C diff, is a targeted action we’ve taken over the last few years.

Stuart Johnson, MD: Thanks, any other comments about antimicrobial stewardship?

Andrew Skinner, MD: Within the hospital we’ve covered most of that to where it’s making sure that when someone is on antibiotics, it’s always for the appropriate reason at that point. To make sure that we’re not overreaching, which, as infectious disease providers, it’s something that we see on a regular basis—we’ll get called and they’re on carbapenem plus vancomycin. And we have to guide people back down to maybe cephalosporin or sometimes maybe not even needing antibiotics. It’s as if they have got them on them for the sake of it. But one of the more interesting things is not only providing the education to hospital providers, but also providing that to outpatient providers. That is going to be a big thing and a bit of a challenge going forward with antibiotic stewardship. Because a lot of the times that we see these individuals with C diff in our clinic, as you noted earlier, it’s that you have a dentist who gave clindamycin for the sake of giving clindamycin, or amoxicillin-clavulanic acid for the sake of giving amoxicillin-clavulanic acid, even though there is not a good indication for the use of it in that manner. So we have seen, over the past couple of years, this change in the clinical epidemiology of C diff, where we’re noticing more community-associated infections and a decrease in the hospital-associated infections. That’s going to be one of the frontiers that we need to start addressing from that stewardship standpoint going forward.

Transcript edited for clarity