Introduction - Clostridium difficile (CD) is the most common cause of health-care-associated infectious diarrhea and incidence and severity have increased in recent years. The main cause of hospital’s acquired cross infections can be attributed to incorrect hand hygiene. We described the epidemiology of CD infection (CDI) in a teaching hospital in Southern Italy during a two years surveillance period and evaluated the health-care workers compliance to hand hygiene.
Methods - CDI Incidence rates were calculated as the number of patients with positive C. difficile toxin assay per 10,000 patient-days. Compliance with hand hygiene was the ratio of the number of performed actions to the number of opportunities observed. Approximately 400 Hand Hygiene (HH) opportunities/year /ward were observed.
We finally checked out if any correlation could be found.
Results - From January 2015 to December 2016 a total number of 854 CD determinations were performed in patients with clinical symptoms of diarrhea. The search for toxins A and B was positive in 175 cases (21,2 %), confirming the diagnosis of CDI.
Compliance to hand hygiene was significantly inversely associated with the number of CDIs: the lower the compliance of health-care workers with hand hygiene the higher was the number of cases of CDIs (p=0.003).
Conclusion - According to our results proper handwashing of health-care workers appears to be a key intervention in interrupting CD cross infections regardless of age and type of department in which the patient is admitted.
Lessa FC, Mu Y, Bamberg WM, Beldavs ZG, Dumyati GK, Dunn JR, Farley MM, Holzbauer SM, Meek JI, Phipps EC, Wilson LE, Winston LG, Cohen JA, Limbago BM, Fridkin SK, Gerding DN, McDonald LC.
Burden of Clostridium difficile infection in the United States
N Engl J Med. 2015 Feb 26; 372 (9):825-34. doi: 10.1056/NEJMoa1408913.
Heinlen L, Ballard JD.
Clostridium difficile Infection.
The American journal of the medical sciences. 2010; 340(3):247-252. doi:10.1097/MAJ.0b013e3181e939d8.
Zhao S, Ghose-Paul C, Zhang K, Tzipori S, Sun X.
Immune-based treatment and prevention of Clostridium difficile infection.
Hum Vaccin Immunother. 2014; 10(12):3522-30. doi: 10.4161/21645515.2014.980193.
Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, Pepin J, Wilcox MH; Society for Healthcare Epidemiology of America; Infectious Diseases Society of America.
Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA).
Infect Control Hosp Epidemiol. 2010 May; 31(5): 431-55. doi: 10.1086/651706.
Depestel DD, Aronoff DM.
Epidemiology of Clostridium difficile infection.
J Pharm Pract, 26(5).2013; 464-475. doi: 10.1177/0897190013499521
Poutanen SM, Simor AE.
Clostridium difficile-associated diarrhea in adults.
CMAJ : Canadian Medical Association Journal. 2004;171(1):51-58. doi:10.1503/cmaj.1031189.
Clinical spectrum & pathogenesis of Clostridium difficile associated diseases.
Indian J Med Res. 2010; 131, 487-499.
Patel UC, Wieczorkiewicz JT, Tuazon J.
Evaluation of advanced age as a risk factor for severe Clostridium difficile infection.
Journal of Clinical Gerontology and Geriatrics. 2016; 7(1), 12-16. doi.org/10.1016/j.jcgg.2015.06.003
Renewed interest in a difficult disease: Clostridium difficile infections--epidemiology and current treatment strategies.
Curr Opin Gastroenterol. 2009; 25(1), 24-35. doi: 10.1097/MOG.0b013e32831da7c4
Hu MY, Katchar K, Kyne L, Maroo S, Tummala S, Dreisbach V, Kelly CP.
Prospective derivation and validation of a clinical prediction rule for recurrent Clostridium difficile infection.
Gastroenterology. 2009; 136(4), 1206-1214. doi: 10.1053/j.gastro.2008.12.038
Na X, Martin A J, Sethi S, Kyne L, Garey KW, Flores SW, Hu M, Shah DN, Shields K, Leffler DA and Kelly C P.
A Multi-Center Prospective Derivation and Validation of a Clinical Prediction Tool for Severe Clostridium difficile Infection.
PLoS ONE. 2015; 10(4), e0123405. doi.org/10.1371/journal.pone.0123405
Eze P, Balsells E, Kyaw MH, Nair H.
Risk factors for Clostridium difficile infections – an overview of the evidence base and challenges in data synthesis.
Journal of Global Health. 2017; 7(1):010417. doi:10.7189/jogh.07.010417.
Squeri R, Genovese C, Palamara MA, Trimarchi G, La Fauci V.
"Clean care is safer care": correct handwashing in the prevention of healthcare associated infections.
Ann Ig. 2016 Nov-Dec;28(6):409-415. doi: 10.7416/ai.2016.2123.
Alicino C, Giacobbe DR, Durando P, Bellina D, DI Bella AM, Paganino C, Del Bono V, Viscoli C, Icardi G, Orsi A.
Increasing incidence of Clostridium difficile infections: results from a 5-year retrospective study in a large teaching hospital in the Italian region with the oldest population.
Epidemiol Infect. 2016 Sep; 144(12):2517-26. doi: 10.1017/S0950268816000935.
European Centre for Disease Prevention and Control.
European surveillance of Clostridium difficle infections. Surveillance protocol version 2.3
Stockholm: ECDC, 2017. Available at: https://ecdc.europa.eu/en/publications-data/european-surveillance-clostridium-difficile-infections-surveillance-protocol-1
Bauer MP, Kuijper EJ, Van Dissel JT, European Society of Clinical, M., & Infectious, D.
European Society of Clinical Microbiology and Infectious Diseases (ESCMID): treatment guidance document for Clostridium difficile infection (CDI).
Clin Microbiol Infect. 2009; 15(12), 1067-1079. doi: 10.1111/j.1469-0691.2009.03099
World Health Organization.
Hand Hygiene Technical Reference Manual.
Geneva: WHO; 2009.
Chen Y, Glass K, Liu B, Korda RJ, Riley TV, Kirk MD.
Burden of Clostridium difficile infection: Associated hospitalization in a cohort of middle-aged and older adults.
Am J Infect Control. 2017; doi: 10.1016/j.ajic.2016.12.006
Bauer MP, Notermans DW, Van Benthem BH, Brazier JS, Wilcox MH, Rupnik M, Monnet DL, Van Dissel JT, Kuijper EJ, ECDIS Study Group.
Clostridium difficile infection in Europe: a hospital-based survey.
Lancet. 2011 Jan 1; 377 (9759):63-73. doi: 10.1016/S0140-6736(10)61266-4.
Cioni G, Viale P, Frasson S, Cipollini F, Menichetti F, Petrosillo N, Brunati S, Spigaglia P, Vismara C, Bielli A, Barbanti F, Landini G, Panigada G, Gussoni G, Bonizzoni E, Gesu GP; Epidemiology and outcome of Clostridium difficile infections in patients hospitalized in Internal Medicine: findings from the nationwide FADOI-PRACTICE study.
BMC Infect Dis. 2016 Nov 8; 16(1):656. doi.org/10.1186/s12879-016-1961-9
Visconti V, Brunetti G, Cuomo MR, Giordano A, Raponi G.
Nosocomial-acquired and community-onset Clostridium difficile infection at an academic hospital in Italy: Epidemiology, recurrences and toxin genes distribution.
J Infect Chemother. 2017 Nov; 23(11):763-768. doi: 10.1016/j.jiac.2017.08.002.
Mamic P, Heidenreich PA, Hedlin H, TennakoonL, Staudenmayer KL.
Hospitalized Patients with Heart Failure and Common Bacterial Infections: A Nationwide Analysis of Concomitant Clostridium Difficile Infection Rates and In-Hospital Mortality
Journal of Cardiac Failure 2016, Volume 22 , Issue 11 , 891 – 900. doi: 10.1016/j.cardfail.2016.06.005
Rea MC, O'Sullivan O, Shanahan F, O'Toole PW, Stanton C, Ross RP and Hill C.
Clostridium difficile carriage in elderly subjects and associated changes in the intestinal microbiota.
J Clin Microbiol. 2012; 50(3), 867-875. doi: 10.1128/JCM.05176-11
Kulaylat AN, Rocourt DV, Podany AB, Engbrecht BW, Twilley M, Santos MC, Cilley RE, Hollenbeak CS, Dillon PW.
Costs of Clostridium difficile infection in pediatric operations: A propensity score-matching analysis.
Surgery. 2017 May; 161(5):1376-1386. doi: 10.1016/j.surg.2016.10.020.
Tamma PD, Sandora TJ.
Clostridium difficile Infection in Children: Current State and Unanswered Questions.
Journal of the Pediatric Infectious Diseases Society. 2012;1(3):230-243. doi:10.1093/jpids/pis071.
Piccolo F, Tai AS, Ee H, Mulrennan S, Bell S, Ryan G.
Clostridium difficile infection in cystic fibrosis: an uncommon but life‐threatening complication.
Respirology Case Reports. 2017 ; 5(1):e00204. doi:10.1002/rcr2.204.
Com G, Cetin N,O'Brien C.E.
Complicated Clostridium difficile colitis in children with cystic fibrosis: Association with gastric acid suppression?
Journal of Cystic Fibrosis 13 (2014) 37–42. doi.org/10.1016/j.jcf.2013.08.005
Roncarati G, Dallolio L, Leoni E, Panico M, Zanni A, Farruggia P.
Surveillance of Clostridium difficile Infections: Results from a Six-Year Retrospective Study in Nine Hospitals of a North Italian Local Health Authority.
Int J Environ Res Public Health. 2017 Jan 10;14(1). pii: E61. doi: 10.3390/ijerph14010061.
Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, Perneger TV. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme.
Lancet. 2000; 356(9238), 1307-1312. PMID: 11073019
Sickbert-Bennett EE, DiBiase LM, Willis TM, Wolak ES, Weber DJ, Rutala WA.
Reduction of Healthcare-Associated Infections by Exceeding High Compliance with Hand Hygiene Practices.
Emerg Infect Dis. 2016; 22(9), 1628-1630. doi: 10.3201/eid2209.151440
Horn K, Otter JA.
Hydrogen peroxide vapor room disinfection and hand hygiene improvements reduce Clostridium difficile infection, methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and extended-spectrum beta-lactamase.
Am J Infect Control. 2015; 43(12), 1354-1356. doi: 10.1016/j.ajic.2015.06.029
Ragusa R, Lombardo A, Bruno A, Sciacca A and Lupo L.
Environmental Biodecontamination: When a Procedure Performed by the Nursing Staff has an Economic Impact in ICU Rooms.
J Nurs Care. 2016; 5:355 doi: 10.4172/2167-1168.1000355
S. Castaldi, R. Ragusa
HTA applicato all’Igiene ospedaliera.
In book: Health Technology Assessment and Public Health Chapter: 13 Publisher: Journal of Preventive Medicine and Hygiene 2017; 58,3 (Suppl. 1): E71-E78 EID: 2-s2.0-85033578796
Wiegand PN, Nathwani D, Wilcox MH, Stephens J, Shelbaya A, Haider S.
Clinical and economic burden of Clostridium difficile infection in Europe: a systematic review of healthcare-facility-acquired infection.
J Hosp Infect. 2012; 81(1), 1-14. doi: 10.1016/j.jhin.2012.02.004.
Desai K, Gupta SB, Dubberke ER, Prabhu VS, Browne C, Mast TC.
Epidemiological and economic burden of Clostridium difficile in the United States: estimates from a modeling approach.
BMC Infect Dis. 2016; 16, 303. doi: 10.1186/s12879-016-1610-3.
Jones AM, Kuijper EJ, Wilcox MH.
Clostridium difficile: a European perspective.
J Infect. 2013; 66(2), 115-128. doi: 10.1016/j.jinf.2012.10.019.