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Improving hygiene and limiting antibiotic use are keys to curbing C. difficile intestinal infections, which appear to be up to 20 times more common than previously thought, according to a survey of U.S. hospitals.
By JoNel Aleccia Health writer
updated 11/11/2008 8:46:16 AM ET 2008-11-11T13:46:16

A virulent, drug-resistant gut infection that causes potentially deadly diarrhea, especially among the old and sick, is up to 20 times more common than previously thought, a large survey of U.S. hospitals and health care centers finds.

Thirteen in every 1,000 patients were infected or colonized with Clostridium difficile, known as C. diff, according to surveys by nearly 650 U.S. acute care and other centers, the Association for Professionals in Infection Control and Epidemiology, or APIC, reported Tuesday.

That’s between 6.5 and 20 times higher than previous estimates of the nasty bacterial infection tied to overuse of antibiotics and improperly cleaned hospital rooms, said Dr. William R. Jarvis, the study’s lead author.

“Hopefully this will be a wake-up call about the importance of preventing this organism,” said Jarvis, a private consultant who was formerly in charge of fighting hospital infections at the federal Centers for Disease Control and Prevention.

On average, there may be more than 7,000 infections and 300 deaths in U.S. hospitals on any single day from C. diff., which can cause problems ranging from severe diarrhea and colitis to blood-poisoning and death, the study indicated.

EpidemiologistDr. L. Clifford McDonald, the CDC’s C. diff expert, said previous analyses have estimated about 520,000 infections and up to 30,000 deaths a year, far lower than the APIC figures suggest.

The APIC study was the largest, most comprehensive review of its kind, Jarvis said. Other studies have been limited to a single hospital or a single state, or they used health care discharge data that overcounted some patients and left out others, he noted.

What no one questions, McDonald said, is the idea that C. diff is increasing.

“It’s important data that confirms that there’s an awful lot of this, that’s the bottom line,” McDonald said.

In recent years, McDonald and other infection control experts increasingly have been worried by the spread of C. diff, particularly the virulent NAP1 strain that produces roughly 20 times the toxins of a common, more benign variety.

The toxic strain is becoming resistant to all but the most powerful antibiotics, putting it the same category as methicillin-resistant Staphylococcus aureus, or MRSA, the so-called superbug that riveted the nation's attention last year.

C.diff second only to MRSA
An APIC prevalence study in 2007 found that MRSA was present in 46 patients in 1,000, a rate about 10 times higher than previous estimates.

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“C. diff is a lot less than MRSA, but, having said that, it is still the No. 2 multi-drug-resistant organism,” Jarvis said.

The new APIC survey asked the agency’s 12,000 infection preventionists to count the number of patients with C. diff on any single day between May and August to provide the first-ever snapshot of the extent of the bug’s reach.

Of some 110,550 patients in hospitals and health care centers in 47 states, C. diff was detected in 1,443 patients, with more than 94 percent infected rather than simply colonized with the germ.

Nearly 70 percent of those patients were older than 60, with many far older than that, Jarvis said. Nearly 70 percent had underlying diseases, such as kidney failure, diabetes or heart failure that made them more susceptible to infection.

More than a quarter of the patients had to be admitted to intensive care units, nearly 20 percent developed shock and more than 16 percent required aggressive treatment to combat plummeting blood pressure, the study showed.

C. diff infections typically lead to higher costs and longer hospital stays. If infections reported in the survey were extrapolated to all U.S. hospitals on a single day, patients would rack up an average of more than $32 million in costs and 40,000 extra days in the hospital.

The APIC survey confirms what many infection control professionals already believe: that the infection is sparked by antibiotic use that disturbs the normal flora in the gut. About 80 percent of the patients with C. diff in the APIC study had recently received antibiotics.

“We’ve long been encouraging the public not to demand antibiotics as a solution to all of their problems,” McDonald said. “This brings it home to roost, doesn’t it?”

The study also confirms suspicions that most cases of C. diff are contracted in health care settings. More than 72 percent of the infections in the APIC study were considered to be hospital-acquired, and more than 54 percent were acquired less than 48 hours after admission, the survey showed.

That means people are picking up the bug in the environment, mostly likely from inadequately cleaned surfaces. C. diff produces hard-to-kill spores that are transmitted through feces. People become infected when they ingest the spores, usually by touching surfaces and then touching their mouths, or by eating contaminated food.

Most common hospital cleaners don't eradicate C. diff, which is best cleaned with a strong bleach solution.

Antibiotic use, hospital hygiene are key
There are several keys to preventing C. diff infection, said Dr. Brian Koll, chief of infection control at Beth Israel Medical Center in New York.

Making environmental hygiene a priority that involves staff at all levels is vital, he said. So is emphasizing efforts such as proper hand hygiene for staff, patients and visitors; wiping down equipment between uses; and ensuring that staff members use bleach to kill the C. diff bugs.

“In many respects, our rooms are inspected with as much rigor, if not more, as the kitchen is,” said Koll, whose hospitals have lowered C. diff infection rates to 4 of per 1,000 patients.

Patients also have to take steps to protect themselves, Koll said. Limit antibiotic use whenever possible, insist on proper hand hygiene and speak up about any cleaning concerns.

“Patients and their family members should know they can ask whether or not a piece of equipment has been cleaned or hands washed from any and every health care worker,” he said. 

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