A Quality Improvement Project to Decrease Clostridium Difficile Associated Infection in a Bone Marrow Transplant Unit: A Multidisciplinary Approach

Introduction: Clostridium difficile infection (CDI) is considered the most common cause of acute infectious diarrhea among hospitalized patients and is a major concern in the hematopoietic stem cell transplantation (HSCT) setting. HSCT patients constitute a highly vulnerable population for CDI. This susceptibility can be attributed to long hospitalizations, prolonged exposure to of broad-spectrum antibiotics and chemotherapy-related disruption of enteric mucosal barriers. With the increase of CDI prevalence over the last decade the morbidity, mortality, and medical care costs of CDI have reached historic highs; therefore there is a need for prevention policies that apply to the specific characteristics of this population. An infection prevention surveillance audit at the South Texas Veterans Health Care System Bone Marrow Transplant Unit, during a 3 month period (October-December 2013), revealed an increase in the rate of healthcare associated hospital onset (HAHO) CDI (>72 hours after admission).

Methods: We assembled a multidisciplinary team with the aim to decrease the rate of CDI over a 3 months period (January-March 2014). A team including physicians, nurses, pharmacists and infection preventionist was called in to evaluate the rates of CDI and establish procedures to decrease these rates. Interventions included the following: education of staff and patients about CDI prevention and transmission, hand hygiene awareness, proper use of cleaning products, de-cluttering of nurses' work station, decontamination of common areas, daily chlorhexidine baths, revision and review of the daily cleaning of rooms, environmental service supervisor visual room inspection and feedback after terminal cleaning, use of ultraviolet pulses of light (UVC pulsed technology), restriction of CDI positive patients to their room and contact precautions until 48 hours after resolution of diarrhea stools.

Results: Visual inspection of the room was increased to 100%, as rooms were not released until a sign was placed on the door signed by the environmental service supervisor performing the inspection. Usage of the UVC units increased from 17.5 per month (pre-intervention) on average to 42 per month (post intervention). Hand hygiene was 100% based on peer, unblinded review. The rates of HAHO-CDI decreased from a cumulative of 73 per 10.000 patient-days to a rate of 23.8 per 10.000 patient-days, with no new cases during the last month of surveillance.

Conclusion: A multidisciplinary approach to decrease rates of CDI including: education, enhanced environmental cleaning with review and feedback, and standard use of UVC pulsed technology was effective to reduce the rates of CDI in a bone marrow transplant unit.