Preventing Clostridium difficile Infections in Long-Term Care 

Introduction
Long-term care homes are essential institutions that support aging individuals who require assistance with their daily living activities, which prevent them from living independently. However, residents are at a greater risk of being infected by pathogenic organisms such as Clostridium difficile (C. difficile) due to factors such as physiological changes, co-morbidities, and increased use of medical and assistive devices (Pereira et al., 2020). This blog post will present a general multi-faceted strategy to prevent C. difficile infections (CDI) in long-term care homes. 

Burden of Illness
Clostridium difficile (C. difficile) is an opportunistic, gram-positive bacterium found in the intestinal tract of humans, and in addition to being a leading healthcare-associated infection, it is also one of the leading infectious causes of morbidity and mortality in Canada (Pereira et al., 2020). C. difficile is primarily spread through the fecal-oral route, and the main risk factors remain prolonged hospitalization periods, immunosuppression, improper or overuse of antibiotics and old age (Comparacini et al., 2023). From a strictly economic perspective, a recent study in Ontario sought to determine the economic burden of C. difficile infections and found that in long-term care, each resident with CDI levied a median cost of $1051 in additional healthcare costs, not considering the intangible costs including pain and suffering (Pereira et al., 2020; Fautrel et al., 2020).  

The Importance of Education 
To combat C. difficile infections and reduce healthcare costs, it is essential to provide staff and residents with comprehensive education and training on C. difficile transmission, preventive measures, and proper hand hygiene practices. A recent study conducted among nurses and nursing assistants in a long-term care wing by Comparcini and Colleagues (2023) found that a relatively low level of participation in regular training courses correlated to knowledge gaps around what personal protective equipment was needed to be worn and what the correct handwashing method was before and after providing direct care to a resident with CDI to prevent transmission (Comparcini et al., 2023). IPAC Consulting offers comprehensive annual in-person and online training courses for staff in long-term care so that they are empowered with the knowledge to make evidence-informed decisions and take proactive steps to reduce infection risks, protecting themselves and the residents under their care from severe diseases like C. difficile.  

Rigorous Hand Hygiene Practices 
The importance of hand hygiene in preventing outbreaks can not be overstated. Countless studies have found a critical link between hand hygiene practices and outbreaks (Lee et al., 2020). An epidemiological review study of change agents in the prevalence of healthcare-associated infections in the United States by Magill and Colleagues (2018) found that rigorous hand hygiene practices are more important than terminal cleaning in reducing the incidence of such infections (Magill et al., 2018). As such, it is crucial to inform and educate visitors, residents and staff on the most rigorous, evidence-based hand hygiene practices based on the causative agent for the outbreak. Hand hygiene could include the frequent use of alcohol-based hand rubs or frequent handwashing with soap and water, as is the case with C. difficile. C. difficile differs in makeup from other common infectious agents such as influenza or COVID-19, as it spreads through spores at very low inoculum levels, which do not break down in the presence of isopropyl alcohol. As such, the most effective method of hand hygiene during a CDI outbreak is to facilitate and enforce frequent hand washing with medical grade, antibacterial soap and water.  

Strict Environmental Cleaning and Disinfection Protocols 
Implementing rigorous cleaning and disinfection protocols to maintain a clean and safe environment is another critical aspect of preventing outbreaks. Using effective disinfectants that are proven to be effective against C. difficile’s highly resistant spores, paying particular attention to high-touch surfaces like doorknobs, handrails, and bathroom fixtures. Regularly sanitize resident rooms, common areas, and shared equipment to minimize the risk of cross-contamination. A recent study by Carling, Perry and Olmstead (2023) found that accelerated hydrogen peroxide and peroxyacetic acid had just as robust of a sporicidal effect as bleach at 5000ppm, which was previously the gold standard for chemical disinfection when C. difficile was suspected. Accelerated hydrogen peroxide (AHP) has also been effective in inactivating Candida aureus and coronaviruses (Bandara et al., 2022). However, selecting a chemical disinfectant is only one aspect of a rigorous environmental cleaning protocol. Monitoring and evaluation of cleaning and disinfection practices, particularly the thoroughness of the practices, as this will vary over time, is essential to track and retain to compare with outbreak data so that the best disinfection practices can be standardized and communicated to the multidisciplinary infection prevention team (Parry et al., 2022).  

The Role of Laundering Practices 
One area often overlooked regarding an infection control strategy is laundering practices. C. difficile exospores attached to soiled cotton linens, such as bedding, are heat and chemo-tolerant and can often survive detergents and industrial laundering temperatures (Tarrant et al., 2022). As such, it is important to base textile handling and laundering practices for patients with CDI on the body of the best evidence available. The study from Tarrant and Colleagues (2022) found that washing linens at 90 C for 20 minutes inactivated exposures, and the sporicidal efficacy improved when a bleach additive was used in conjunction with industrial detergent (Tarrant et al., 2022).  

Antibiotic Stewardship 
In a recent study, antibiotic stewardship intervention was found to be the most essential and effective control measure for preventing colonizing residents with C. difficile (Stevenson et al., 2020).  Implementing a robust antibiotic stewardship program, complete with an antibiogram, will help ensure the appropriate and judicious use of antibiotics. For more information on antibiotic stewardship, IPAC Consulting has fantastic training resources that will equip registered staff with the knowledge and tools to track antibiotic use and use that data to make the best decisions for and in the best interest of the residents under care.  

Diet and Nutrition 
An evolving and promising area of study for preventing CDI among residents in long-term care involves malnutrition and the gut microbiome (Haran et al., 2021). It is well known that the use of broad-spectrum antibiotics causes what is known as the “dysbiosis” of the intestinal flora in the gut. Essentially, it wipes out all the symbiotic and beneficial gut bacteria, along with those antagonistic or harmful. Counteracting this dysbiosis following antibiotic treatment could be a target for reducing the incidence rates of CDI among residents in long-term care homes, particularly resident colonization. The study by Haran and Colleagues found that introducing a short course of an acid-reducing pharmacological agent, such as a proton pump inhibitor, following antibiotic treatment had a profound protective effect against C. difficile for colonizing the gut of the residents under study. An early systematic review and meta-analysis by Trifan and Colleagues (2017) found a similar protective effect with therapeutic proton pump inhibitors and C. difficile infections (Trifan et al., 2017). From a dietary intervention perspective, a study by Esch and Colleagues (2015) found that increasing the amount of protein in a resident diet, measured based on baseline and post-intervention prealbumin levels, had a profound effect on containing C. difficile outbreaks and reducing the severity and duration of symptoms (Esch et al., 2015).  

Conclusion 
Preventing C. difficile infections in long-term care homes requires a multi-faceted approach involving education, strict hygiene practices, enhanced cleaning protocols, antibiotic stewardship, and implementing therapeutic and nutritional interventions. Although the intervention discussed in this blog represents the best, most recent evidence, like everything in infection, prevention and control, nothing is one-size-fits-all. By partnering with IPAC Consulting, long-term care administrators and management can implement the best interventions and strategies to fit their residents’ needs, reducing the likelihood of C. difficile and other outbreaks and creating a safer environment for residents, staff, and visitors.

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