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Inpatient rates of Clostridioides difficile (or C. difficile), a common healthcare-associated infection, reached an all-time low at UNC Hospitals earlier this year as COVID-19 moved into North Carolina. Collaboration between Infection Prevention and the Carolina Antimicrobial Stewardship Program seeks to sustain it.

In April, only two C. difficile infections (CDI) were reported, and the fiscal year ending June 30 showed a 16% reduction compared to the 2018 baseline.

The recent dramatic reductions are likely positive spillover effects from fastidious COVID-related infection prevention practices such as environmental cleaning and handwashing. Also, hospital beds were intentionally left empty in preparation for a surge in COVID-19 hospitalizations, keeping the hospitals’ patient census lower than average, and no visitors (who may unintentionally contribute to spreading germs) were permitted for several months.

Lower CDI rates are a silver lining to the upheaval caused by COVID, and hospital staff are eager to find ways to sustain the very low rates of this infection that sickens an estimated 462,000 people in the US, leading to some 15,000 deaths each year.

C. difficile can be especially dangerous for older persons or those who are hospitalized for other conditions. They may have weakened immune systems or be using antibiotics, which can pave the way for the pathogen to multiply rapidly in the intestines. Part of the problem with controlling C. difficile is that it forms spores, which are resistant to alcohol-based cleaners. Washing hands with soap and water is critical for prevention of C. difficile.

“C. difficile infection is a major problem, both because it can make people very sick, but also because it can be recurrent,” said Nikolaos Mavrogiorgos, medical director of the Carolina Antimicrobial Stewardship Program (CASP) at UNC Medical Center. “There are patients who have C.difficile present in their gut but have no symptoms. These asymptomatic carriers could potentially spread the infection in hospital settings and sometimes end up developing symptomatic infection down the road, too.”

In addition to the human toll, hospitals are also at risk of losing millions of dollars in reimbursements from the Centers for Medicare and Medicaid Services if their healthcare-associated infection rates – to which CDIs contribute – pass a certain threshold. In 2016, UNC Medical Center set a goal of reducing CDI among its inpatients by 10%. Just over one year later, they achieved astonishing results: a 42% reduction in its CDI rate, far exceeding the initial goal.

The implementing team wrote about the evidence-based, multidisciplinary approach they took. The group used a bundle of proven interventions: hand hygiene; diagnostic stewardship to prevent inappropriate testing; education for clinicians on the hospital policy regarding C. difficile testing; enhanced isolation precautions for patients with known or suspected CDI; improved environmental cleaning and disinfection of the rooms of patients with CDI; and antimicrobial stewardship and pharmacy interventions, for example, to reduce the use of drugs associated with increased risk of CDI.

“Clindamycin, fluoroquinolones, and third- and fourth-generation cephalosporins are among the antibiotics linked with increased rates of CDI, but in reality any broad-spectrum antibiotic can predispose to CDI, especially the longer patients are on them,” explained Mavrogiorgos. “One main role of antimicrobial stewardship is to ensure that antibiotics are used prudently and that the shortest effective duration of therapy is chosen,” he said.

C. difficile workgroup started in 2016 under the leadership of the department of Infection Prevention. The workgroup and CASP forged a close collaboration to sustain low infection rates in partnership with the Nursing Department’s Spread of Innovation initiative in 2020, which will continue into the next year. Three new interventions have been added to the existing bundle implemented in 2016. First, the Information Services Division enacted changes in the electronic medical record system to more efficiently document and display patients’ bowel movements and laxative use so that the clinician ordering a CDI test has all the information in one place. Second, Environmental Services operationalized a detailed cleaning protocol to ensure all high-touch surfaces are cleaned each shift. Third, Nutrition and Food Services provides all patients with an opportunity to clean their hands before meals.

Implementing these changes during the pandemic is not without challenges. However, the multidisciplinary, collaborative approach that worked so well to reduce CDI in 2016 is expected to be the linchpin of efforts this newest round of interventions. “We count on our colleagues in antimicrobial stewardship and Pharmacy, Nursing and Providers, Environmental Services, Nutrition and Food Services, Information Services, the Microbiology lab, and the whole patient care team to help keep infection rates low,” Shelley Summerlin-Long, a Senior Quality Improvement Leader in Infection Prevention said. “We’re all in this together.”