Lack of Association Between the Increased Incidence of<i>Clostridium difficile</i>–Associated Disease and the Increasing Use of Alcohol-Based Hand Rubs

Boyce, John M.; Ligi, Cathy; Kohan, C.M.; Dumigan, Diane G.; Havill, MT Nancy L.

doi:10.1086/504362

Cited by 117 publications

(59 citation statements)

References 18 publications

(9 reference statements)

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“…Control of this toxin-variant strain was achieved through infection control measures other than curtailing the use of fluoroquinolones and cephalosporins. The hand-hygiene policy was changed in 2002, when alcohol-based hand rub was introduced, and was not associated with an increase in the incidence of C. difficile infection, which is similar to findings reported by Boyce et al 17 and Gordin et al 18 Although the hand-hygiene policy was not altered with regard to the use of alcohol hand rub, heightened awareness and enforcement of this policy is likely to have contributed to control of this outbreak.…”

Section: Discussionsupporting

confidence: 75%

Emergence and Control of Fluoroquinolone-Resistant, Toxin A–Negative, Toxin B–PositiveClostridium difficile

Drudy

Harnedy²,

Fanning³

et al. 2007

Infect. Control Hosp. Epidemiol.

115

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Background.Clostridium difficileis a major cause of infectious diarrhea in hospitalized patients. Between August 2003 and January 2004, we experienced an increase in the incidence ofC. difficile–associated disease. We describe the investigation into and management of the outbreak in this article.Methods.A total of 73 consecutive patients with nosocomialC. difficile–associated diarrhea were identified.C. difficileisolates were characterized using toxin-specific enzyme immunoassays, a tissue-culture fibroblast cytotoxicity assay, polymerase chain reaction (PCR), and antimicrobial susceptibility tests. Rates of recurrence and ofC. difficilecolitis were recorded. Changes in antibiotic use and infection control policies were documented.Results.The incidence ofC. difficile–associated diarrhea peaked at 21 cases per 1,000 patient admissions. Of theC. difficileisolates recovered, 85 (95%) were identical toxin A–negative and toxin B-positive strains, corresponding to toxinotype VIII and PCR ribotype 017. All clonal isolates were resistant to multiple antibiotics, including ofloxacin, ciprofloxacin, levofloxacin, moxifloxacin, and gatifloxacin (minimum inhibitory concentrations [MICs] of greater than 32μg/mL) and erythromycin, clarithromycin, and clindamycin (MICs of greater than 256μg/mL). RecurrentC. difficile–associated disease occurred in 26 (36%) of the patients. At least 10 (14%) of the patients developedC. difficilecolitis. Additional infection control measures introduced included the use of ward memos, a hand-hygiene awareness campaign, increased environmental cleaning, attention to prescribing practices for antibiotics, increased awareness of diarrheal illness, and early isolation of affected patients. Total use of fluoroquinolones did not change throughout the study period. Despite persistence of this toxin-variant strain, the incidence ofC. difficile–associated disease in our institution decreased to fewer than 5 cases per 1,000 admissions.Conclusions.We report on the emergence of a fluoroquinolone- and clindamycin-resistant, toxin A–negative, and toxin B–positive strain ofC. difficileassociated with an outbreak ofC. difficile–associated disease in our institution during a 6-month period. We found that careful attention to improvement of infection control interventions was the most important means of controlling this nosocomial pathogen.

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Section: Discussionsupporting

confidence: 75%

Emergence and Control of Fluoroquinolone-Resistant, Toxin A–Negative, Toxin B–PositiveClostridium difficile

Drudy

Harnedy²,

Fanning³

et al. 2007

Infect. Control Hosp. Epidemiol.

115

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“…Alcohol-based hand sanitizers are thought to be ineffective in controlling CD infection transmission, because they have poor activity against CD spores [30]. This would not explain the spread of CD infection in our hospital, because use of alcohol-based hand sanitizers was not implemented at our facility until after the onset of the CD infection outbreak.…”

Section: Discussionmentioning

confidence: 97%

Control of an Outbreak of Infection with the Hypervirulent Clostridium difficile BI Strain in a University Hospital Using a Comprehensive "Bundle" Approach

Muto

Blank²,

Marsh³

et al. 2007

Clinical Infectious Diseases

224

150

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Background. In June 2000, the hospital-acquired Clostridium difficile (CD) infection rate in our hospital (University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, PA) increased to 10.4 infections per 1000 hospital discharges (HDs); the annual rate increased from 2.7 infections per 1000 HDs to 7.2 infections per 1000 HDs and was accompanied by an increase in the frequency of severe outcomes. Forty-seven (51%) of 92 HA CD isolates in 2001 were identified as the "epidemic BI strain." A comprehensive CD infection control "bundle" was implemented to control the outbreak of CD infection.Methods. The CD infection control bundle consisted of education, increased and early case finding, expanded infection-control measures, development of a CD infection management team, and antimicrobial management.Process measures, antimicrobial usage, and hospital-acquired CD infection rates were analyzed, and CD isolates were typed.Results. The rates of compliance with hand hygiene and isolation were 75% and 68%, respectively. The CD management team evaluated a mean of 31 patients per month (11% were evaluated for moderate or severe disease). Use of antimicrobial therapy associated with increased CD infection risk decreased by 41% during the period 2003-2005 (). The aggregate rate of CD infection during the period 2001-2006 decreased to 4.8 infections per 1000 P ! .001 HDs (odds ratio, 2.2; 95% confidence interval, 1.4-3.1;) and by 2006, was 3.0 infections per 1000 HDs, a P ! .001 rate reduction of 71% (odds ratio, 3.5; 95% confidence interval, 2.3-5.4;). During the period 2000-2001, P ! .001 the proportion of severe CD cases peaked at 9.4% (37 of 393 CD infections were severe); the rate decreased to 3.1% in 2002 and further decreased to 1.0% in 2006-a 78% overall reduction (odds ratio, 20.3; 95% confidence interval, 2.8-148.2; ). In 2005, 13% of CD isolates were type BI (20% were hospital acquired), which represented a P ! .001 significant reduction from 2001 ( ). P ! .001 Conclusions. The outbreak of CD infection with the BI strain in our hospital was controlled after implementing a CD infection control "bundle." Early identification, coupled with appropriate control measures, reduces the rate of CD infection and the frequency of adverse events.

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“…Interestingly, the C. difficile incidence increased following ABHR implementation (five new cases compared to zero cases in the preceding 12 months), but that study was limited to one small ward in a single institution and, therefore, was insufficiently powered to allow firm conclusions. Several more recent and larger in vivo studies evaluating CDI incidence following ABHR implementation have been performed (26,94,170,200,184,199 (185). The procurement of soap and ABHR and hospital bed occupancy data were monitored in relation to quarterly mandatory reports of methicillin-resistant Staphylococcus aureus (MRSA)/methicillin-sensitive S. aureus (MSSA) bacteremia and CDI.…”

Section: Alcohol-based Hand Hygiene and Risk Of CDImentioning

confidence: 99%

The Changing Epidemiology of Clostridium difficile Infections

et al. 2010

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SUMMARY The epidemiology of Clostridium difficile infection (CDI) has changed dramatically during this millennium. Infection rates have increased markedly in most countries with detailed surveillance data. There have been clear changes in the clinical presentation, response to treatment, and outcome of CDI. These changes have been driven to a major degree by the emergence and epidemic spread of a novel strain, known as PCR ribotype 027 (sometimes referred to as BI/NAP1/027). We review the evidence for the changing epidemiology, clinical virulence and outcome of treatment of CDI, and the similarities and differences between data from various countries and continents. Community-acquired CDI has also emerged, although the evidence for this as a distinct new entity is less clear. There are new data on the etiology of and potential risk factors for CDI; controversial issues include specific antimicrobial agents, gastric acid suppressants, potential animal and food sources of C. difficile, and the effect of the use of alcohol-based hand hygiene agents.

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Lack of Association Between the Increased Incidence ofClostridium difficile–Associated Disease and the Increasing Use of Alcohol-Based Hand Rubs

Cited by 117 publications

References 18 publications

Emergence and Control of Fluoroquinolone-Resistant, Toxin A–Negative, Toxin B–PositiveClostridium difficile

Emergence and Control of Fluoroquinolone-Resistant, Toxin A–Negative, Toxin B–PositiveClostridium difficile

Control of an Outbreak of Infection with the Hypervirulent Clostridium difficile BI Strain in a University Hospital Using a Comprehensive "Bundle" Approach

The Changing Epidemiology of Clostridium difficile Infections

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