C. diff Prevention "Tour de Force"

In the current issue of Clinical Infectious Disease Daniel Caroff and colleagues published an elegant article on the epidemiology and prevention of Clostridium difficile colitis. Many of the points that they make need to be emphasized in terms of how we operationalize C diff prevention efforts.

The most important points made in the paper are the following:

1) 10% of patients admitted to the hospital have asymptomatic C. diff colonization. This percentage is even higher in the following groups of patients:

a. Patients with recent hospitalizations

b. Patients who have received recent antibiotics

c. Patients who have recently had C. diff

2) Up to 30% of hospital -acquired C diff is likely acquired from those who are asymptomatically colonized and shedding C diff.

Based upon these 2 fundamental observations from the literature shouldn't we consider re-tooling our preventative efforts in the following ways?

1) Screening all admissions for asymptomatic C diff colonization or at least the "high risk group" as indicated above. This would be a major effort in terms of work flow and likely cost however this group of patients is a set-up for infection and should constitute a "protected group".

If we are not going to do this then we need to consider the following:

2) "Soap and water" hand washing for all healthcare workers or use of gloves for all patient contacts. We know from an elegant study by Donskey and colleagues that the alcohol hand sanitizer has no effect on C diff on the hands. It is quite likely then that healthcare workers are spreading C diff from asymptomatic patients despite using the alcohol based hand gel.

3) Disinfection of all inpatient room with Sporocidal agents. This would entail once daily cleaning of all patient rooms with bleach, hydrogen peroxide or UV lights/robots

3) Cleaning stethoscopes with sporocidal wipes

4) Eschewing the white coat and long sleeves for Healthcare workers. Since we are likely dragging C diff from asymptomatically colonized patients from the sleeves of these garments why not go "Bare Below the Elbows" with short sleeves and wipe able vests to carry our stuff? "Bare Below the Elbows" is the law of the land in Great Britain.

5) Strict PPI stewardship. Proton pump inhibitors have been identified in numerous studies as an independent risk factor for the development of C. diff. We see a ubiquitous use of proton pump inhibitors in the population. The "little purple pill” marketing campaign has been an unbridled success. PPIs were never meant to be lifelong therapies. Many patients interviewed have no idea why they are on these medications. PPIs use should really be scrutinized and be restricted to those with complicated GERD, on H. pylori treatment or those at high risk or with recent or active GI bleeding.

6) Use of "Lower Risk" Antibiotics. No antibiotic is "no risk" when it comes to C diff but some are more risky than others. High risk agents include Fluoroquinolones ( Ciprofloxacin, Levofloxacin, and Moxifloxacin), 3rd and 4th Generation Cephalosporins ( Ceftriaxone, Ceftazidime, Cefepime), Clindamycin and Amoxicillin- Clavulanate. Agents that have a lower risk of C. diff include Piperacillin -Tazobactam, Bactrim,Tetracyclines and Tigecycline. The use of Piperacillin- Tazobactam was associated with a lower development of asymptomatic C. diff colonization compared with other agents. A three day course of aminoglycoside use for UTIs was found to be " gut sparing" in terms of its effect on the intestinal microbiota.

7) Strict application of Antibiotic duration guidelines. It is well known that we have been treating infections for far too long. Data continues to be published showing juts how short we can go for common indications:

a) CAP- 5-7 days

b) HAP and VAP- 7 days

c) skin/soft tissue infections- 5 days

d) cystitis- 3 days

e) Complicated UTI/Pyelonephritis- 7 days

f) Intra-abdominal infection- 4 days after achieving "source control" of infection

g) COPD/AECB- 5 days

8) Implementation of "Antibiotic Timeout". At 72 hours into empiric antimicrobial therapy we really should be re-assessing our antimicrobial therapy to see if our antibiotic choice can be stopped or narrowed. We really should consider useful technology to this end including:

a. Procalcitonin and CRP . Normal levels or normalization  of these biomarkers has been used to shorten the duration of antimicrobial therapy

b) BioFire Filmarray identification panels for Meningitis/Encephalitis, GI and Respiratory pathogens. Avoidance of antibiotic use when a viral pathogen is identified rapidly can be achieved.

c) Rapid ID and antimicrobial susceptibility data of blood culture isolates. The Accelerate Phenosense assay can ratchet back the determination of proper antibiotic choice in bacteremia by days

9) Probiotic Prophylaxis . The use of  probiotics in patients on antibiotic is associated with a 58% relative risk reduction of 58% with a number needed to treat (NNT) of 43 to prevent 1 case of C diff. The relative risk reduction rose to 68% if probiotics were initiated within 2 days of starting antimicrobial therapy. This treatment effect was statistically significant when a lactobacillus-containing formulation was used. One formulation, BIO K+, had a NNT  of 16.

10) Urine Culture Stewardship. It is quite common for UA and urine cultures to be sent on patients presenting to the ED or HCP with change in mental status or change in color of odor of the urine. It turns out that these findings are often present in asymptomatic bacteriuria and will respond to hydration without any antimicrobial therapy. The revised McGeer criteria are quite useful in deciding who to send a urine sample on and thus prevent unnecessary antibiotics for positive cultures. In patients without a urinary catheter these criteria require fever or leukocytosis and 1 symptom referable to the GU tract such as CVA or suprapubic pain, gross hematuria or new or worsening incontinence, urgency or frequency. A patient without fever or leukocytosis should have 2 additional symptoms before a UA is sent. For a catheterized patient, a change in mental status must be accompanied by leukocytosis and no other explanation. Similarly fevers, rigors or hypotension must have no other explanation. Local symptoms referable to the GUC tract including purulent discharge around the catheter, new suprapubic or CVA pain or pain or swelling in the testes, epididymis or prostate would also suffice.

11) Oral Vancomycin Prophylaxis (OVP) in patients with a history of C. diff. A small retrospective study demonstrated that pre-emptive use of oral vancomycin in patients with a history of prior C diff who were on systemic antibiotics was associated with a statistically significant odds ratio of 0.12.

I am happy to share an educational PPT presentation with all the strategies described above. Please note that I have no financial conflict of interest with respect to any of these strategies.