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                   References: C. difficile and Hand Hygiene
1. Infect Control Hosp Epidemiol. 2006 May;27(5):479-83.

Lack of association between the increased incidence of Clostridium difficile-
associated disease and the increasing use of alcohol-based hand rubs
Boyce JM, Ligi C, Kohan C, Dumigan D, Havill NL.

OBJECTIVE: To determine whether there is an association between the increasing use of
alcohol-based hand rubs (ABHRs) and the increased incidence of Clostridium difficile-
associated disease (CDAD).

SETTING: A 500-bed university-affiliated community teaching hospital.

METHODS: Use of ABHRs during the period 2000-2003 was expressed as the number of liters
of ABHR used per 1000 patient-days. The proportion of hand hygiene episodes performed by
using an ABHR was determined by periodic observational surveys. CDAD was defined as a
physician-ordered stool assay positive for C. difficile toxin A or A/B. The incidence of CDAD
was expressed as the number of unique patients who had 1 or more positive CDAD test results
per 1,000 patient-days.

RESULTS: During 2000-2003, the use of ABHR increased 10- fold, from 3 to greater than 30
L/1,000 patient-days (P<.001). The proportion of hand hygiene episodes performed using an
ABHR increased from 10% to 85% (P<.001). The incidence of CDAD in 2000, 2001, 2002, and
2003 was 1.74, 2.33, 1.14, and 1.18 cases/1,000 patient-days, respectively.

CONCLUSION: Despite a significant and progressive increase in the use of ABHRs in our
facility during a 3- year period, there was no evidence that the incidence of CDAD increased.
These findings suggest that factors other than the increased use of ABHRs are responsible for t he
increasing incidence of CDAD noted since 2000 in other facilities.

2. Clin Infect Dis. 2007 Jul 15;45(2):222-7. (See full article- Free from

The challenges posed by reemerging Clostridium difficile infection

Blossom DB, McDonald LC.
There have been recent, marked increases in the incide nce and severity of Clostridium difficile-
associated disease (CDAD). These may be attributable to the emergence of a hypervirulent strain
of C. difficile that produces increased levels of toxins A and B, as well as an extra toxin known
as "binary toxin." This previously uncommon strain has become epidemic, coincident with its
development of increased resistance to fluoroquinolones, the use of which is increasingly
associated with CDAD outbreaks. Although not necessarily related to this epidemic strain,
unusually severe CDAD has been reported in populations that had previously been thought to be
at low risk, including peripartum women and healthy persons living in the community.
Challenges posed by the changing epidemiology of CDAD are compounded by current
limitations in diagnostic testing, treatment, and infection control. Overcoming these challenges
and limitations will require a concerted effort from a variety of sources, including an ongoing
partnership between infectious disease clinicians and public hea lth professionals.

3. Infect Control Hosp Epidemiol 2007;28:116–122.

Clostridium difficile-associated disease in Oregon: increasing incidence and
hospital-level risk factors
Chandler RE, Hedberg K, Cieslak PR.

BACKGROUND: The incidence of Clostridium difficile-associated disease (CDAD) appears to
be increasing. Population-based estimates of disease have been limited, and analyses of hospital-
level risk factors for CDAD are lacking. We sought to determine the incidence and trends of
CDAD in Oregon and to identify hospital- level factors associated with increases in disease.

METHODS: We analyzed hospital discharge data to calculate the incidence and to describe
trends of CDAD in Oregon from 1995 through 2002. We administered questionnaires to hospital
laboratory directors, infection control practitioners, and pharmacists to determine the status of
laboratory, infection control, and pharmacy policies over time.

RESULTS: The overall incidence of CDAD in Oregon was 3.5 case patients per 10,000
residents in 2002. Incidence increased from 1.4 to 3.3 cases per 1,000 hospital discharges from
1995 to 2002. Rates of disease increased most in hospitals with licensed bed capacity of more
than 250 beds and more than 5 intensive care unit beds. Few laboratories, infection control
practitioners, and pharmacists were able to identify changes in specific policies over the study

CONCLUSIONS: This is the first study to determine a statewide population-based incidence of
CDAD. Incidence of CDAD in Oregon has more than doubled over the past decade; larger
hospitals experienced the greatest increase in disease rates. We did not identify hospital- level
policies that could explain the increase. A stud y of patients with CDAD at the hospitals with the
largest increases is underway to further identify risk factors.

4. Clin Infect Dis. 2007 Nov 15;45(10):1266-73.
Control of an outbreak of infection with the hypervirulent Clostridium
difficile BI strain in a university hospital using a comprehensive "bundle"
Muto CA, Blank MK, Marsh JW, Vergis EN, O'Leary MM, Shutt KA, Pasculle AW, Pokrywka
M, Garcia JG, Posey K, Roberts TL, Potoski BA, Blank GE, Simmons RL, Veldkamp P,
Harrison LH, Paterson DL.

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 (P<.001). The aggregate rate of
CD infection during the period 2001-2006 decreased to 4.8 infections per 1000 HDs (odds ratio,
2.2; 95% confidence interval, 1.4-3.1; P<.001) and by 2006, was 3.0 infections per 1000 HDs, a
rate reduction of 71% (odds ratio, 3.5; 95% confidence interval, 2.3-5.4; P<.001). During the
period 2000-2001, 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; P<.001). In 2005, 13% of
CD isolates were type BI (20% were hospital acquired), which represented a 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

5. Am J Med. 1990 Feb;88(2):137-40.

Prospective, controlled study of vinyl glove use to interrupt Clostridium
difficile nosocomial transmission
Johnson S, Gerding DN, Olson MM, Weiler MD, Hughes RA, Clabots CR, Peterson LR.
PURPOSE: Despite recognition that Clostridium difficile diarrhea/colitis is a nosocomial
infection, the manner in which this organism is transmitted is still not clear. Hands of health care
workers have been shown to be contaminated with C. difficile and suggested as a vehicle of
transmission. Therefore, we conducted a controlled trial of the use of disposable vinyl gloves by
hospital personnel for all body substance contact (prior to the institution of universal body
substance precautions) to study its effect on the incidence of C. difficile disease.

PATIENTS AND METHODS: The incidence of nosocomial C. difficile diarrhea was
monitored by active surveillance for six months before and after an intensive education program
regarding glove use on two hospital wards. The interventions included initial and periodic in-
services, posters, and placement of boxes of gloves at every patient's bedside. Two comparable
wards where no special intervention was instituted served as controls.

RESULTS: A decrease in the incidence of C. difficile diarrhea from 7.7 cases/1,000 patient
discharges during the six months before intervention to 1.5/1,000 during the six months of
intervention on the glove wards was observed (p = 0.015). No significant change in incidence
was observed on the two control wards during the same period (5.7/1,000 versus 4.2/1,000).
Point prevalence of asymptomatic C. difficile carriage was also reduced significantly on the
glove wards but not on the control wards after the intervention period (glove wards, 10 of 37 to
four of 43, p = 0.029; control wards, five of 30 to five of 49, p = 0.19). The cost of 61,500 gloves
(4,505 gloves/100 patients) used was $2,768 on the glove wards, compared with $1,895 (42,100
gloves; 3,532 gloves/100 patients) on the control wards.

CONCLUSIONS: Vinyl glove use was associated with a reduced incidence of C. difficile
diarrhea and is indirect evidence for hand carriage as a means of nosocomial C. difficile spread.

6.Infect Control Hosp Epidemiol. 2008 Jan;29(1):8-15.

Prospective, controlled, cross-over trial of alcohol-based hand gel in critical
care units
Rupp ME, Fitzgerald T, Puumala S, Anderson JR, Craig R, Iwen PC, Jourdan D, Keuchel J,
Marion N, Peterson D, Sholtz L, Smith V.

BACKGROUND: There are limited data from prospective studies to indicate whether
improvement in hand hygiene associated with the use of alcohol-based hand hygiene products
results in improved patient outcomes.

DESIGN: A 2- year, prospective, controlled, cross-over trial of alcohol-based hand gel.

SETTING: The study was conducted in 2 medical-surgical ICUs for adults, each with 12 beds,
from August 2001 to September 2003 at a university-associated, tertiary care teaching hospital.

METHODS: An alcohol-based hand gel was provided in one critical care unit and not provided
in the other. After 1 year, the assignment was reversed. The hand hygiene adherence rate and the
incidence of nosocomial infection were monitored. Samples for culture were obtained from
nurses' hands every 2 months.

RESULTS: During 17,994 minutes of observation, which included 3,678 opportunities for hand
hygiene, adherence rates improved dramatically after the introduction of hand gel, increasing
from 37% to 68% in one unit and from 38% to 69% in the other unit (P< .001). Improvement
was observed among all groups of healthcare workers. Hand hygiene rates were better at higher
workloads when hand gel was available in the unit (P= .02). No substantial change in the rates of
device-associated infection, infection due to multidrug-resistant pathogens, or infection due to
Clostridium difficile was observed. Culture of samples from the ha nds of nursing staff revealed
that an increased number of microbes and an increased number of microbe species was
associated with longer fingernails (ie, more than 2 mm long), the wearing of rings, and/or lack of
access to hand gel.

CONCLUSIONS: The introduction of alcohol-based gel resulted in a significant and sustained
improvement in the rate of hand hygiene adherence. Fingernail length greater than 2 mm,
wearing rings, and lack of access to hand gel were associated with increased microbial carriage
on the hands. This improvement in the hand hygiene adherence rate was not associated with
detectable changes in the incidence of healthcare-associated infection.

7. Ann Intern Med. 2007 Jul 3;147(1):69-70. (Letter)
Hand hygiene and Clostridium difficile

Gay TW.

Rapid Responses to:

       John G. Bartlett
       Narrative Review: The New Epidemic of Clostridium difficile–Associated Enteric
       Disease Ann Intern Med 2006; 145: 758-764

In the infection control section of his otherwise excellent review of the epidemic strain of C.
difficile, Dr. Bartlett notes that standard recommendations of the Society for Healthcare
Epidemiology of America (SHEA) include, ". . . soap and water for handwashing rather than
alcohol- based hand hygiene." However, the reference (1) cited is a SHEA position paper from
1995 and does not even address alcohol-based hand hygiene. Indeed, the authors reviewed the
available information on hand decontamination with nondisinfectant soap versus disinfectant
soap and water and conclude, ". . . the emphasis should be on compliance with the use of
handwashing (with either a disinfectant or soap) until more data are available in the clinical
setting to support one handwashing agent over another."

Guideline for Hand Hygiene in Health-Care Settings (2) states, "None of the agents (including
alcohols, chlorhexidine, hexachlorophene, iodophors, PCMX, and triclosan) used in antiseptic
handwash or antiseptic hand-rub preparations are reliably sporocidal against Clostridium spp. or
Bacillus spp." The authors note that soap and water may help to physically remove spores and
that use of these products (cf alcohol-based products) is "prudent" during "outbreaks of C.
difficile-related infections."

As the medical director of infection control in a community hospital that has seen only sporadic
cases of C. difficile, I am more concerned about preventing transmission of multi-drug resistant
organisms on the hands of healthcare workers, and alcohol based products are generally felt to be
superior in this regard and they have led to increased compliance. I feel we are sending our
healthcare workers mixed messages without scientific support when we tell them that alcohol-
based products are inferior when caring for every patient with C. difficile, as Dr. Bartlett

1. Gerding DN, Johnson S, Peterson LR, Mulligan ME, Silva J Jr. Clostridium difficile-
associated diarrhea and colitis. Infect Control hosp Epidemiol. 1995;16:459-77.

2. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care
Settings: Recommendations of the Healthcare Infection Control Advisory Committee and the
HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(No. RR-16:[17]

8. Clin Infect Dis. 2008 Jan 15;46 Suppl 1:S43-9.

Measures to control and prevent Clostridium difficile infection.
Gerding DN, Muto CA, Owens RC Jr.

Hines Veterans Affairs Hospital, Hines, IL 60141, USA.

Control of Clostridium difficile infection (CDI) outbreaks in health care facilities presents
significant challenges to infection control specialists and other health care workers. C. difficile
spores survive routine environmental cleaning with detergents and hand hygiene with alcohol-
based gels. Enhanced cleaning of all potentially contaminated surfaces with 10% sodium
hypochlorite reduces the environmental burden of C. difficile, and use of barrier precautions
reduces C. difficile transmission. Thorough handwashing with chlorhexidine or with soap and
water has been shown to be effective in removing C. difficile spores from hands. Achieving
high- level compliance with these measures is a major challenge for infection control programs.
Good antimicrobial stewardship complements infection control efforts and environmental
interventions to provide a comprehensive strategy to prevent and control outbreaks of CDI. The
efficacy of metronidazole or vancomycin prophylaxis to prevent CDI in patients who are
receiving other antimicrobials is unproven, and treatment with these agents is ineffective against
C. difficile in asymptomatic carriers.