The survey also showed a variation in how hospitals clean patients’ rooms. C. diff spores live on surfaces like bedrails, bedpans, and doorknobs for several months, and are usually placed on those surfaces by the unwashed hands of caregivers who have handled materials soiled by infected patients. When uninfected patients touch those surfaces, they unknowingly collect spores and can then ingest them, allowing C. diff to germinate in the gut and release bowel-harming toxins. Frequent wipe-downs of highly touched surfaces with bleach, the only common disinfectant that kills C. diff spores, are a surefire way to eradicate the bacteria from patient rooms. But according to the APIC survey, only 67 percent of respondents have a firm daily-bleaching policy in place at their facilities.
Just as crucial as the wipe-downs, says Mayfield, is the integration of objective measures of room cleanliness. “In the past, it’s usually been housekeeping supervisors walking around, eyeballing rooms,” says Mayfield of the way cleanliness has usually been evaluated. “It’s just visual observation, it’s subjective.”
Now, tools are available to check for the presence of organic matter on a given surface. One device uses swabs to check cleaned surfaces for the presence of ATP, the energy storehouse of the cell, an indicator of biological life forms. With another, a fluid that glows under ultraviolet light is dabbed randomly throughout a room. If those dabbed areas glow after cleaning, the surface has not been properly cleaned. But according to the APIC survey, these tools are not being integrated broadly. “What’s surprising to me is that we have an objective way of measuring the effectiveness,” says Mayfield, who notes that 64 percent of respondents are still doing subjective observation of room-cleaning practices.
Cutting down on erroneous use of antibiotics is a confirmed preventive measure. “That, to me, remains the key potential intervention for decreasing C. diff,” says Anderson. Yet again, the APIC survey showed a wide variation in practices. Antibiotics have always been associated with C. diff infections. But whereas the illness used to occur most often in patients taking clindamycin and amoxicillin, this latest strain is associated with some of the most commonly used antibiotics, such as ciprofloxacin and levofloxacin. Yet just 60 percent of survey respondents have instituted antimicrobial stewardship programs to prevent overuse of these medications.
The survey also showed a wide variety in isolation practices, with major differences in when infected patients, who are mostly aged 65 or older and mostly come to hospitals from nursing homes, were put into isolation and the duration of their stay.
As the cost of treating patients with C. diff infections rises and the high death rate continues, health officials are beginning to sound the alarm bells. In January of this year, the Centers for Medicare and Medicaid Services began requiring hospitals to report C. diff events in order to receive reimbursement for care (a C. diff illness raises the cost of care by about $2,400 per patient, according to one study, cited by the Centers for Disease Control and Prevention (CDC) among others). And new C. diff-killing technologies—such as vaporized hydrogen peroxide and ultraviolet light—are being tested to see if they do a better job of eradicating the bacteria compared with standard cleaning practices. At Duke, Anderson is leading a nine-hospital study, funded by the CDC, comparing bleach plus UV light versus bleach alone, with results expected by mid-2014.