Becker's Clinical Quality & Infection Control

17 Executive Briefing Safeguarding the Healthcare Environment Against Clostridium difficile: Products, Protocols and Planning for the Future By Sarah C. Bell-West, PhD, Senior Scientist, Clorox Healthcare C lostridium difficile is a spore-forming bacterium capable of causing gastrointestinal conditions ranging from diar- rhea to colitis. Twenty years ago, C. diff infections (CDI) were primarily limited to patients who were receiving long-term antibiotic therapy. Today, C. diff is one of the most prevalent causes of healthcare-associated infections in the United States and is considered a top priority of 76 percent of hospital leaders recently surveyed. 1 C. diff-associated diarrhea (CDAD) places financial stress on U.S. hospitals. A study of 170,000 discharges from 477 hospitals from 2009-2011 calculated that a CDAD case can increase a hospital stay by 4.7 days and add $7,286 to hospital costs. 2 And, starting in fiscal year 2017, the Hospital-Acquired Condition Reduction Program, mandated by the Affordable Care Act of 2010, will in- clude financial penalties for "preventable" HAIs including CDI. 3 Preventing CDI has become a formidable challenge, even for healthcare facilities with the most robust infection control pro- tocols. A recent CDC-funded study reported that of the 453,000 CDI cases reported annually in the U.S., almost 30,000 die with- in 30 days of diagnosis. 4 Sixty-six percent of CDI cases were healthcare-associated, with 37 percent of those CDI cases be- ing hospital-onset (as opposed to healthcare-associated com- munity-onset or nursing-home-onset). 4 Community-onset CDI is also increasing, with a recent study of 154 U.S. hospitals from 2008-2015 finding that these rates increased at a much higher rate than hospital-onset CDI rates. 5 In light of these findings, many facilities are re-evaluating their CDI prevention strategies. This article will focus on sporicidal disinfectant selection and compliant cleaning and disinfection of environmental surfaces and medical equipment, critical first lines of defense against C. diff and important components of a robust CDI-prevention plan. Selecting Sporicidal Solutions C.diff and other spore-forming bacteria such as Bacillus subti- lis are among the most difficult microorganisms to kill on en- vironmental surfaces due to their resilience to many chemical disinfectants. Studies have shown that viable C. diff spores can persist in the healthcare environment for months if surfaces are not properly cleaned and disinfected. 6 Most CDI prevention guidelines recommend the use of an Envi- ronmental Protection Agency (EPA)-registered disinfectant with sporicidal claims on environmental surfaces and medical equip- ment in areas housing CDI patients. 7 In 2014, the EPA updated its guidance related to C. diff testing standards to include using a clinically relevant C. diff strain (ATCC 43598) and measuring disinfection efficacy in the presence of a three-part organic soil load which forms a protective layer around spores making dis- infectant penetration more difficult. 8 The new standards raise the bar for efficacy evaluation and may represent more realistic conditions, given that many studies reveal some surfaces are frequently missed during the cleaning step required by the EPA before disinfection against C. diff spores. As of June 2016, 48 surface disinfectants in the U.S. were EPA-registered to kill C. diff spores on hard nonporous surfaces. The new EPA standards are currently only required for new reg- istrations. But some disinfectant manufacturers have proactively tested their disinfectants using the new standards. In reviewing their facility's CDI prevention program, healthcare professionals should review the label of their EPA-registered sporicidal disin- fectant and other technical information to determine whether the new testing standards were applied. They should also fa- miliarize themselves with the product chemistry, directions for use and safety information to determine the suitability of the product for their infection prevention strategy. Integrating Sporicidal Solutions Into Infection Control Protocols Once sporicidal disinfectant solutions are selected, properly integrating them into cleaning and disinfection protocols is es- sential. Many protocols recommend sporicidal disinfectants for high-touch areas in CDI patient rooms and bathrooms for both daily and discharge cleaning, and a recent survey of over 1,000 infection preventionists revealed that 67 percent of facilities were using sporicidal disinfectants in these situations. 9 Sponsored by: Today, C. diff is one of the most prevalent causes of healthcare- associated infections in the United States and is considered a top priority of 76 percent of hospital leaders recently surveyed. 1

• Cover