Crossing the quality chasm for Clostridium difficile infection prevention.

To cite: Safdar N, Perencevich E. BMJ Qual Saf 2015;24:409–411. Clostridium difficile, a spore-forming organism, causes as many as 25% of cases of healthcare-associated diarrhoea. In many developed countries, C. difficile infection (CDI) is now the most important healthcare-associated infection (HAI), suggesting an urgent need of strategies for effective containment. Recent studies on the impact of antimicrobial stewardship initiatives and CDI prevention ‘bundles’ have reported variable reductions in CDI rates. For example, a recent meta-analysis found that implementing an antimicrobial stewardship programme was associated with a 50% reduction in CDI rates, particularly if it utilised restrictive over persuasive policies. Following declines in other types of HAI such as central line (CL)-associated bloodstream infection and catheter-associated urinary tract infection with the use of a checklist of recommended practices and bundled interventions, many healthcare institutions have adopted a similar approach to reducing CDI. This is easier said than done. The complex, incompletely understood pathogenesis of CDI, large reservoirs in the environment and in asymptomatically colonised patients, multiple pathways for spread of the organism, lack of a readily removable ‘device’ to target, uncertain relative roles of antibiotic stewardship versus infection control practices, and a relatively sparse evidence base for prevention all combine to make C. difficile containment extremely challenging in comparison to device-related HAI. Daneman et al report the findings of a survey conducted in 2011 with the goal of determining acute-care hospital prevention practices for C. difficile prevention in Ontario, Canada. Unlike many other descriptive surveys, the authors achieved a 100% response rate and took a welcome step further by correlating hospital-level self-reported prevention practices with patient-level information on risk factors and outcomes of CDI gathered from administrative databases. The authors chose to focus on a few particular CDI prevention practices selected by a hospitalist and an infectious diseases specialist as both being important to CDI prevention and having a high likelihood that respondents would accurately gauge the practice along with sufficient expected variability across sites. Overall, they found patient-level risk factors, particularly comorbid illnesses, were predictive of CDI and that none of the six hospital prevention practices they examined were associated with a statistically significant reduction in the risk of CDI. At first glance, this may seem counter-intuitive. However, several findings from their study merit mention and may explain the conclusions. First, the authors identified low self-reported implementation of most CDI prevention practices, with only 27% of facilities reporting isolation of all patients at onset of diarrhoea, and 16% reporting auditing of antibiotic stewardship practices. Low adherence rates for these two practices in particular are concerning because prompt institution of contact precautions is necessary to reduce nosocomial transmission of C. difficile. And antimicrobial stewardship is at least as important as infection prevention practices, if not more so, for reducing CDI. Moreover, low adherence to evidencebased practices has been shown to adversely affect infection rates for other types of HAIs. For example, in a crosssectional study of 250 National Healthcare Safety Network (NHSN) hospitals, 49% reported having a written CL bundle policy. However, of those that monitored compliance, only 38% reported very high compliance with the bundle. CL-associated EDITORIAL