Important Measures in Barrier Precautions for C. Difficile
JUNE 12, 2018
MD Magazine Staff
Peter Salgo, MD: We haven’t even talked about preventing Clostridium difficile [C. diff]. We’ve been talking about treating it. I was always taught that the best thing to do is to keep this darn thing from happening in the first place, and that’s not with antibiotics, at all. We’re talking about barrier precautions, washing your hands, and things like that. Why don’t we do more of it?
Yoav Golan, MD: What do you need to have in order to develop C. diff? There are 2 things that you need to have. You need to be exposed to the reservoir, because most people who are walking in the streets are not colonized for C. diff. It’s not like staph infection, or strep, or other things…
Peter Salgo, MD: Sometimes it seems as though they are, however.
Yoav Golan, MD: That’s right. But you need to be exposed to the reservoir of C. diff. For that, we use infection control. And you need to decrease the load of antibiotic use. For that, we use antibiotic stewardship. So, these are the 2 main interventions for decreasing C. diff. Don’t use antibiotics. If you do, shorten the course and choose the right antibiotics that are associated with a low risk for C. diff. And use infection control.
If you look at infection control, we talked earlier about hand hygiene compliance. We’ve been working on hand hygiene compliance for a long time. If you had to plot compliance with hand hygiene compliance over the past 15 years, it has increased tremendously. Maybe this is because it’s very easy to use the dispenser rather than wash your hands? Maybe it’s because of sneaking into hospitals to look at your compliance and education? If you had to plot C. diff over the past 15 to 20 years, it also looked like that. And if you were a statistician, you would say, “Better hand hygiene compliance.” This, of course, is not the conclusion. The conclusion is that hand hygiene compliance is not enough, particularly when you use alcohol dispensers. So, first of all, if you see a patient with C. diff, will you put that patient on precautions? Most hospitals will put patients on precautions when they actually suspect it—when they send a test. It may only take a very short period of time, within 2 to 3 hours, to get the test results. But you put them on contact precautions, which means that everyone who’s going to approach them is going to clean their hands and then use gloves and gowns.
Peter Salgo, MD: Or theoretically, anyway.
Yoav Golan, MD: Well, they should. There are some data that say that the gloves are effective. Data about gowns are more controversial. The most important thing is that when you remove your gloves, you don’t contaminate your hands. If you contaminate your hands, then the purpose of wearing the gloves is gone. When you remove the gloves, you have to be careful to not touch the outside surface. From a C. diff perspective, if you then use the alcohol dispenser and go from one patient to the other, then you didn’t really clean your hands. So, the best advice is to always use the alcohol dispenser before and after any patient care, regardless of whether they have C. diff or not. After you see a patient with C. diff, particularly a patient who’s highly infectious, someone who has soiled, and/or someone who has severe diarrhea, consider washing your hands as well. You have to wash your hands with water and soap for 30 seconds. This may not be consistent with working in a very busy ICU [intensive care unit], sometimes, but from a C. diff perspective, it is really important.
Peter Salgo, MD: First of all, it has to be, right? I don’t care how busy you are, you’ve got 30 seconds to wash your hands. What’s shocking to me is that when you do these Secret Santa investigations and you look at the percentage of people who are washing their hands, whether they’re using the alcohol-based compounds or soap, it’s ridiculously low. By low, I don’t mean 50%. I think 90% is ridiculously low. I mean, why can’t it be 100%? Have we learned nothing since Lister? Have we learned nothing about the germ theory of disease? What’s in the way here?
Dale N. Gerding, MD: This is human behavior, I think. There’s a multitude of reasons why people aren’t compliant with hand hygiene. We surveyed this in a recent nursing home study. I think the highest we got was 80%. The lowest was probably 40% or 50%.
Yoav Golan, MD: I think there are probably systematic factors in that. So, we have to make it easy for people to wash their hands.
Peter Salgo, MD: OK.
Yoav Golan, MD: If you have to leave a patient’s room and go to the other end of the hallway to find a sink, you’re maybe not going to go. Where I work, they have alcohol dispensers in every patient’s room—right at the door. So, as you’re walking out, you take a squirt. There are multiple ones found down the hallway, and there are sinks at intervals.
Peter Salgo, MD: Right. As we’ve already discussed, just having the alcohol dispensers in every room doesn’t work with C. diff. The spores are resistant to alcohol.
Darrell S. Pardi, MD: That’s true in the petri dish. Clinically, there’s some evidence that demonstrates that when institutions switched to alcohol-based handwashing, they did not see an increase in C. diff infection rate. So, the actual physical act of wiping your hands may have something to do with it.
Peter Salgo, MD: OK. Hospitals have switched to these alcohol-based dispensers. The compliance, at least with alcohol-based handwashing, has gone up. You say that the curve for C. diff seems to parallel that. Is this a case of coincidence or is there some effect from these alcohol-based hand washers?
Yoav Golan, MD: When did we switch? We switched to alcohol dispensers about 10 years ago, right?
Peter Salgo, MD: Right.
Yoav Golan, MD: And if you look at the C. diff occurrence, at least in the United States, taking caveat that C. diff has not been a reportable infection, the estimates may not be reliable estimates. But if you look at the estimates during this period of time, it went up. Only recently has it kind of plateaued. It’s really hard to say what the reason is. There are many contributing reasons. It could be that people were not very likely to wash their hands at all before and now they use the alcohol dispensers. If this is the case, then alcohol dispensers are not going to make any difference.
I think it is really important to use the alcohol dispensers. We have to stress that, in people who have risk factors for C. diff and who have C. diff. These are the same risk factors in people who have other viscous types of bacteria, resistant bacteria. And those are cleanable with the alcohol dispensers. We have to use the alcohol dispensers.
Peter Salgo, MD: So, use the alcohol dispensers, but not necessarily for the C. diff alone. Use them for all of the other comorbidities and the other…
Dale N. Gerding, MD: That’s the reasoning behind it. The guideline for hospitals that don’t have an outbreak or a high endemic rate suggests that you can either clean your hands after you take your gloves off with alcohol or handwashing. They don’t specifically require you to go to handwashing. However, if you have a high rate or you’re in an academic situation, then the handwashing is recommended. The very reason behind that was because the alcohol benefit for other pathogens is so high. Even though it may not affect the spores or C. diff, the chance of having a huge contamination of your hands, if you’ve been wearing you gloves and take them off properly, is fairly low. And so, we haven’t hammered on handwashing in that setting.
A more difficult question is, what to do about all of these asymptomatic C. diff carriers who are in the hospital that you don’t know about? We debated that, as well, and finally came up with no recommendation as to what to do with them. There are studies that are starting to show that maybe they are the source of transmission, but we didn’t think the data were compelling enough for us to start screening these patients for asymptomatic carriage.
Transcript edited for clarity.