Few people check into a hospital expecting to come down with a severe case of diarrhea while undergoing care for an entirely unrelated problem. And even fewer expect to die of the hospital-acquired intestinal infection that causes the watery stools. Yet for approximately 14,000 Americans each year, that is exactly what happens. The culprit is a strain of a spore-forming bacterium known as Clostridium difficile, or C. diff—in particular, a relatively recent strain that has grown more virulent and resistant to drugs.
The new strain of C. diff, called NAP1, emerged in the mid-2000s, and is at least in part responsible for skyrocketing infection rates in hospitals throughout the U.S. In 1993 fewer than 100,000 hospital stays were associated with C. diff either as a primary diagnosis upon admission or as a secondary diagnosis after admission, according to the Agency for Healthcare Research and Quality. By 2009, that number had climbed to 336,600, with about 9.1 percent of those stays ending in death at the hospital (versus 2.1 percent of all inpatient hospitalizations). NAP1, which produces far more of the illness-causing toxin than other C. diff strains, is also refractory to many once-effective antibiotics; when treatment is stopped, the illness recurs.
Even though deaths from NAP1 are on the rise, many hospitals fail to take simple and inexpensive measures to prevent infection. A recent survey from the Association for Professionals in Infection Control and Epidemiology (APIC) of 1,087 hospitals revealed inadequate implementation of cleaning strategies known to prevent hospital-acquired C. diff infections, such as daily wipe-downs of commonly touched surfaces with bleach, washing hands with soap and water, and limiting antibiotic use. All hospitals surveyed are taking measures to reduce C. diff infections, but their responses vary widely.
Part of the problem is a lack of data about how C. diff spreads, says Jennie Mayfield, clinical epidemiologist at Barnes-Jewish Hospital/Washington University School of Medicine, St. Louis, and president-elect of the 14,000-member APIC. The bacterium somehow eludes the methods of isolating and culturing that have made headway in unraveling the spread of other common hospital pathogens such as MRSA (methicillin-resistant Staphylococcus aureus) and VRE (vancomycin-resistant Enterococcus), rates of which have both gone down in recent years. C. diff is notoriously difficult to isolate (one reason behind its name), making it nearly impossible to track its path through hospitals. “We don’t even know if patients on the same nursing unit are getting infected with the same strains,” says Mayfield. “We can assume it, but we don’t really know.”
The survey, says Mayfield, reflects that uncertainty, beginning with basic hand washing. Alcohol gels and foams don’t remove the spores so are an inadequate defense against spreading the germ. Only soap and water can rinse spores away. “If everybody washed their hands like they’re supposed to, there would be hardly any transmission of this stuff,” says Deverick Anderson, associate professor of medicine and chair of antibiotic stewardship at Duke University. However, only 77 percent of survey respondents had a policy of promoting soap-and-water hand washing when caring for C. diff–infected patients, and only 10 percent had policies requiring sick patients to wash their hands with soap and water.