The C. diff dilemma: handling an increasingly powerful menace.

In September 2006, a roundtable of infection control (IC) experts from all over the country convened in San Francisco. Their goal was to discuss the prevention, diagnosis, and treatment of Clostridium difficile infection, better known as C. diff--one of the most pressing IC concerns in the healthcare sector.

"I think there are two messages here," said Dale N. Gerding, MD, of research service at Hines (IL) VA Hospital and the Loyola University Chicago Stritch School of Medicine in Maywood, IL. "One is that there is definitely a new epidemic--disease rates are far higher than they've been in the past. Second, the severity of the illness is also markedly higher."

The number of C. diff infections in long-term care environments is increasing, explained Clifford L. McDonald, MD, of the epidemiology and laboratory branch of the Centers for Disease Control and Prevention (CDC) in Atlanta. Since 2005, when a new strain was identified, C. diff has become widespread, with reported outbreaks in 24 states, McDonald said.

"A significant portion of all cases appear to occur in long-term care facilities," he noted. "It's probably about one-third overall."

Gerding, who moderated the September roundtable, didn't cite anything in particular that long-term care facilities--or any other facilities--are necessarily doing wrong. For now, C. diff remains something to be battled, and heightened awareness plus some key IC tips are the ways to fight it.

The state of Ohio, for example, where C. diff cases have been especially prevalent, mandated a reporting of all 2006 C. diff occurrences in both acute and long-term care settings.

"It depends on what type of long-term care facility it is--there will, of course, be different levels of hygiene for different levels of service," said Gerding. "But hand hygiene is the single most important thing. [These infections] are spread by spores of the organism, and they're very hard to eliminate from the environment. For patients who have C. diff, you must put in contact precautions, wear gloves, and wash your hands. Patient contact is the biggest source of spreading."

Keeping C. diff spores contained means being vigilant about all the ways it can spread. By recognizing the following truths about IC, facilities are better able to contain C. diff, according to Robin Griffin, RN, BSN, CIC, director of performance improvement at Radius Technologies in Plymouth, MA:

1. Isolating C. diff residents is a lot easier said than done

Ideally, Griffin said, you should isolate someone with C. diff in his or her own room, with an individual toilet to use to limit the transmission of bacteria around the facility.

Unfortunately, single rooms and toilets just aren't an option for most facilities, and neither is expecting a constantly cleaned communal bathroom--especially with housekeepers coming in only once every 24 hours.

Really, McDonald said, it's a question of whether you can isolate the C. diff resident, and, if not, determining who is the safest resident to put into a room with him or her.

"You have to think about it with future days in mind. If there's another C. diff patient, get them in with them," McDonald advised. "Keep a roommate who is on antibiotics or recent antibiotics out of that room entirely."

But such mixing and matching of resident rooms is rarely easy.

"It would be nice to say, 'Hmm, I have two people with the C. diff diarrhea, so I can put them in the same room,'" Griffin said. "But in long term-care you need to have permission within 48 hours of a move to switch the resident's room. And you can't just move people around like you do in a hospital--long-term care facilities have specialized units. You can't just move somebody from rehab to dementia."

2. Evacuation elicits no easy answer

The problem of how to contain a C. diff resident who needs to evacuate is one experts say is up for debate: Do you allow a C. diff-afflicted resident to use the communal bathroom, or are you better off using a bedside commode?

"I think it's easier if the person who has the diarrhea can go to the bathroom and eliminate the bowel movement, rather than use a bedside commode," Griffin said. "The commode has to be taken down the hall all the way to the utility room, which means lots of potential places to dean and disinfect. It's awkward, but I prefer to have them use the bathroom."

Although a commode is often unwieldy, it does keep contact individualized, said Dianne Connolly, RN, MEd, BSN, IC practitioner at VA Boston Healthcare System.

"Emptying a commode is probably better. At least you're not exposing other residents, and you're in a dirty utility room anyway rather than a shared bathroom," Connolly said. "But you have the other staff members to worry about, as well."

"A bedside commode is better," McDonald agreed. "It's a direct surface, and though it's not pleasant having that, there's no good way to clean [a toilet] after use."

3. If it's a surface, it'll become infected

"I have my housekeepers do all rooms--and not just precaution rooms, because it's difficult to know who has what infection," Griffin explained. "It's a one-to-100 bleach solution, and I usually have them start with the bathrooms and spray and then go back later and do the more mechanical cleansing."

But housekeepers generally come through only once per day, so it's up to staff to be aware of all potentially infected surfaces, especially horizontal surfaces.

"It's the overbed tables, the side rails--any surface that peoples' hands touch," she added. "We spend [use] a lot of disinfectant wipes on the floor."

It's also the things you don't immediately think of, Connolly said. "Your equipment, your glucometer, your thermometer, your stethoscope, your side boards--everything."

Easy-access disinfectant is a useful method, Connolly and Griffin agreed.

"When you have a lot of residents, it's a good idea to keep hand wipes in the dining room and provide them along with meals" Griffin urged. "We also make sure all nurses are carrying hand wipes in their pockets." If residents would like, you can even give them some kind of wipe that's safe for hand use to carry around, added Connolly.

4. Alcohol will not prevent the spread of C. diff

Despite its general effectiveness as a sterilizing agent, alcohol will not kill C. diff spores, advised Gerding. Handwashing requires soap, although disinfectant wipes are still a good defense for surfaces.

"You are not killing the spores, but you are mechanically removing them," said Connolly. "You are killing the vegetative cells."

5. Visitors will keep coming to the facility regardless of whether residents are sick

One of the more difficult variables of IC, experts agree, is outside visitors. Keeping them out of the facility entirely is just not an option, but keeping them clean and not contributing to the spread of infection is.

"Politically, it's really not easy to do," Connolly said of trying to keep visitors to a minimum during high infection periods. "But most people do put signs on the door of units with high infections."

Some notices to include on signs are the following:

* "Please refrain from visiting."

* "At this time, we are experiencing an increase in [name of disease] infection."

* "Please wash your hands."

At times of especially high infection rates--such as infuenza outbreaks--Griffin said her social workers will call family members to let them know about the situation in advance.

"If there are so many people in there who are ill, we will do our very best to dissuade people from coming in," she explained. "Chances are, they'll just be talking to their resident," Connolly added. "All you can do is encourage handwashing and make sure they're fully aware of the situation."

The most common concern from visitors is whether their relative is sharing a room with an infected resident. Visitors will want to know why the infected resident is in the room if he or she has C. diff diarrhea, Griffin said. Explain the situation in an up-front manner, give the visitors as many take-home information sheets about the infection as possible, and assure them that you're doing everything you can to safeguard their one.

6. The earlier you identify the presence of C. diff, the easier it will be to contain

"Once you have an outbreak of C. diff, that's tough, because these spores hang around," Connolly stressed. "The earlier you identify C. diff, the better. Be proactive and get a specimen as soon as you suspect C. diff might be the case."

You need to recognize C. diff early on, McDonald agreed, but also be able to escalate treatment when residents have more severe cases. "Older people are always at a much higher risk for C. diff and also at a much higher risk for having a severe outcome related to C. diff, such as losing their colon," he added. "It's entire environments that have the diarrhea. The answer is not to start bleach-cleaning every hallway in the facility, but to be focused on specific environments--actual rooms and bathrooms."

As an extra precaution, you can always call the CDC or your state agency to see about extra IC training for staff.

"Nursing homes are getting more IC-specific positions, but that person ends up wearing many hats, such as quality manager or employee health person" Connolly said. "You can enforce handwashing, but there are also people out there who are willing to come to the facility and lecture."

Other IC problems

C. diff and C. difficile--associated disease mark just one area of the CDC's IC focus.

The CDC is at work on new isolation guidelines for methicillin-resistant Staphylococcus aureus (MRSA), for example. MRSA, C. diff, and norovirus are the three pathogen infections on which the CDC is most keenly focused. Urinary tract infections remain an additional source of consternation, as does the flu.

"We won't be quite so focused on the acute-care setting as we were in previous guidelines," McDonald said. "We're going to try to talk more about the constraints you have in long-term care and be a lot more inclusive."