The five selected collaborative wards saw a 73% reduction in HA-CDI cases per 1,000 patient bed days after 3 months, and the rest of the hospital saw a 56% reduction in CDI cases per 1,000 patient bed days after 6 months. Key findings about multicomponent interventions • Multicomponent interventions to prevent CDI were associated with decreases in CDI rates. • The most common component was environmental cleaning, followed by hand hygiene and patient isolation practices; antimicrobial stewardship and contact precautions; and CDI testing and surveillance. • No single CDI prevention resource was used across studies. • Information was limited on staff compliance andfinancial costs of interventions. • Collaborations and teamwork were reported to be facilitators of implementation of multicomponent interventions. • Additional facilitators of staff compliance included adequate supplies (e.g., gowns, soap), communication, signage, and institutional support. Barriers included time it takes to perform prevention practices (e.g., wash hands, put on gowns), inadequate staff education, inconsistency in testing criteria and unclear roles for ordering CDI tests, visitors notpracticing contact precautions, and lack of isolation rooms. • Real-world studies on the implications of different practice combinations, as well as studies on regional prevention efforts and nonhospital settings, will help improve understanding. Conclusions about interventions to prevent C. difficile infections Antimicrobial Stewardship: ASPs are associated with decreases in CDI. Individual study outcomes were mixed, showing statistically significant decreases and statistically nonsignificant decreases/no change in facility- or ward-level CDI. Interventions included formulary restrictions, prescriber education, and audit and feedback/case review practices. Significant reductions in CDI were associated with higher baseline CDI rates/outbreaks, ASPs developed specifically to reduce CDI (as opposed to ASPs focused on other clinical and microbiological outcomes), and ASPs that included restrictions to high-risk antimicrobials or a preauthorization component. Prescriber buy-in and staffing and technical resources were factors that impacted implementation. Hand Hygiene: In laboratory testing, washing with soap and water outperforms ABHRs for removal of C. difficile spores from hands; ABHRs are not effective in killing C. difficile spores. It is the mechanical action of washing that removes the organism; therefore, proper handwashing technique is important. Hand hygiene is frequently framed as an HCW compliance issue, with studies
measuring the impact of sink location and education on hand hygiene compliance. Patient hand hygiene initiatives show promise for helping prevent the spread of CDI. Environmental cleaning and decontami- nation for C. difficile is associated with significant decreases in facility-level CDI rates in most stud- ies. Practices with positive outcomes include daily and terminal cleaning of CDI patients’ rooms with bleach solutions (typically 5,000 ppm), and termi- nal bleach cleaning plus the use of no-touch de- contamination methods such as hydrogen peroxide or UVD. The UVD process takes less time than the hydrogen peroxide method. Both methods require the room or area be vacant, which is an implemen- tation challenge. Studies suggest that standardized cleaning protocols and training and observation of environmental cleaning services staff help improve cleaning and decontamination for C. difficile . For CDI surveillance, using standardized and accurate case definitions is an important practice. Research using new technologies for C. difficile genotyping and ribotyping has helped identify outbreaks. Despite the role CDI surveillance plays in understanding epidemiology and informing prevention practices, CDI surveillance implementation is not well studied. Testing. Rapid and accurate identification of CDI is important in order to initiate treatment and discontinue antimicrobials (if appropriate) for CDI patients. If test results cannot be obtained on the same day, patients with suspected CDI should be placed on preemptive contact precautions pending test results. The evidence indicates that NAATs and multistep test combinations show best results. CDI risk- prediction tools show promise for preemptive intervention. There are different perspectives on whether to test for (and subsequently isolate) asymptomatic carriers; However, some studies show this practice is resource intensive. Multicomponent CDI prevention interven- tions included environmental cleaning, hand hy- giene, patient isolation, antimicrobial stewardship, testing, and surveillance, as well as other PSPs and cross-cutting strategies. Studies consistently show associations between multicomponent interventions and statistically significant reductions in CDI. Factors that facilitated implementation of multicomponent interventions included the use of checklists and assigned roles, staff education, and collaboration and teamwork. Minimizing exposure to invasive devices and reducing device-associated risks An invasive device is any medical device that is introduced into the body, either through a break in the skin or an opening in the body. Invasive devices include catheters, such as urinary catheters or central venous catheters, and endotracheal tubes used for mechanical ventilation. Medical catheters are tubes that serve purposes such as administering fluids, blood products, medications, and nutritional solutions; providing hemodynamic monitoring; and
collecting urine and measuring urinary output. Endotracheal tubes are inserted into a patient’s trachea to provide an unobstructed passageway for oxygen and other gases (e.g., anesthesia) while a patient is mechanically ventilated. The use of invasive devices in patients, while often medically necessary, has been associated with increased risk of invasive infections (e.g., bloodstream infections) and overall mortality. From 2011 to 2014, catheter-associated urinary tract infections (CAUTIs), central-line associated blood stream infections (CLABSIs), and ventilator- associated pneumonias (VAPs) accounted for 38%, 24%, and 2% of all healthcare-associated infections, respectively. 75 The treatment of these infections is often complicated by resistance to commonly used antibiotics. Within these three categories of infections (i.e., CAUTIs, CLABSIs, and VAPs), the percentage of pathogens that exhibited drug resistance varied depending on species and antibiotic, but an estimated 14% percent were caused by an antibiotic-resistant pathogen. Catheters To reduce the harms associated with catheter use (intravascular or urinary catheters), interventions can target several stages of their use: • Avoiding unnecessary and inappropriate catheter use • Ensuring aseptic placement of catheters • Maintaining awareness and proper care of catheters in place • Promptly removing unnecessary catheters A systematic review by Patel et al. (2018) reviewed 102 studies with interventions aiming to reduce CAUTIs and CLABSIs. 76 The review determined that the most successful interventions targeted multiple stages. For both CAUTIs and CLABSIs, successful interventions included protocols to remove by default based on certain criteria (e.g., time). various recommendations for reducing harm throughout the phases of the patient’s care, including: 77 • Timing of catheter placement • Selection of the appropriate catheter device • Use of hand hygiene • Aseptic technique strategies • Barrier precautions during device placement and care • Use of systemic antibiotics (not recommended) and antibiotic lock solutions Published guidelines have Urinary Catheters Specific to urinary catheters, Mody et al (2017) conducted a large-scale before-and- after intervention study of 404 nursing homes that implemented a multicomponent strategy that included targeting multiple stages of device use. 78
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