PDI Perspective

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Clostridium difficile: Is there an Infection Prevention Sweet Spot based on Hospital Occupancy?

Posted by Holly Montejano, MS, CIC, CPHQ on Aug 1, 2018 9:15:00 AM

Patients do not go to the hospital with pneumonia, a heart attack, or any other medical emergency, expecting to become sicker with a diarrheal illness!  Being hospitalized is not without its own risks- including being exposed to additional infections.  We know the common variables related to Clostridium difficile infection (CDI) for hospitalized patients—staff, patient and visitor hand hygiene, antibiotic use, and environmental cleaning and disinfection.  A new variable has recently been studied in the CDI risk portfolio—hospital occupancy—and the results are interesting!

Many studies have been published looking at the relationship between nurse staffing and adverse patient outcomes (patients suffer more adverse events due to inadequate nurse staffing)1, 2, but now the question being asked, is there a sweet spot that exists between patient hospital-acquired CDI and inpatient occupancy3.  Researchers at the University of Michigan looked at hospital-acquired CDI and inpatient occupancy to see if a risk relationship exists.

Clostridium difficile infection, caused by a spore-forming bacteria, causes inflammation of the colon (colitis), watery diarrhea, fever, loss of appetite, nausea and abdominal tenderness4.  Elderly patients, those who have received antibiotics and those who have frequent inpatient hospital stays are at greatest risk for developing this infection4.  Abir, et al, looked at retrospective admissions data from acute care hospitals in California during 2008-2012.  The study population included Medicare patients ≥ 65 years of age with an emergency department admission for acute myocardial infarction, pneumonia, or heart failure with a hospital length of stay < 50 days.  Taking a more precise approach to inpatient occupancy, the researchers categorized hospital occupancy during the patient’s admission into four levels: low (0-25 percent), two levels of moderate (26-50 percent and 51-75 percent), and high (76-full capacity).  What they found was not expected. Hospital acquired CDI rates were three times greater when hospital occupancy was in the moderate range, and much lower when the hospital was at a low and high occupancy3.  Ultimately, the sweet spot is not where we would expect.  Per the researchers, these results beckon further review of infection prevention and nursing practices, policy and staffing variations based on hospital occupancy, and call for routine collection of occupancy information when reviewing all infections.  It is important to review what infection prevention processes possibly could be impacted during moderate occupancy that appear to function well at low and high occupancies3.

Per Centers for Disease Control and Prevention (CDC), patients who present with diarrheal illness or are suspected or confirmed with CDI should be placed on contact precautions with appropriate personal protective equipment (PPE) use.  An EPA-approved hospital disinfectant with a sporicidal claim, like Sani-Cloth® Bleach wipes, should be used to clean and disinfect surfaces around the patient.  Hand hygiene for both the patient and the caregiver should consist of soap and water in an outbreak setting.  For patients who are bedbound, or unable to perform soap and water hygiene in a non-outbreak setting5, an alcohol hand wipe, like Sani-Hands® wipes, is an optimal substitute6.  Pokrywka, et al found a significant reduction in healthcare-onset CDI when bedbound patients were provided with a wipe containing at least 65.9% alcohol.  These patients were educated by hospital staff to perform hand hygiene at the appropriate moments (before and after having visitors, after returning from testing or a procedure, before touching dressing incisions, prior to meals, and after toileting).  The researchers in this study concluded “although alcohol is not considered to be an effective agent for killing Clostridium difficile spores, it can be theorized that the alcohol wipes provided mechanical cleaning of the patients’ hands, which removed organic debris and, potentially, spores from the skin surface6”.

Clostridium difficile infection is often due to multiple factors, and many preventive measures can be taken to keep patients safe from hospital-acquired CDI.  A close review of these infections within a facility, along with concurrent occupancy tracking, may provide some insight on best practices which fall to the wayside.  What we do know is that hand hygiene, appropriate antibiotic use, environmental cleaning and disinfection, and PPE use can stop the spread of this dangerous infection—and should be practiced consistently along the entire spectrum of hospital occupancy.




  1. Needleman, J., Buerhaus, P., Pankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. New England Journal of Medicine364(11), 1037-1045.
  2. Robert A. Weinstein, Patricia W. Stone, Monika Pogorzelska, Laureen Kunches, Lisa R. Hirschhorn; Hospital Staffing and Health Care–Associated Infections: A Systematic Review of the Literature, Clinical Infectious Diseases, Volume 47, Issue 7, 1 October 2008, Pages 937–944, https://doi.org/10.1086/591696
  3. Abir, M., Goldstick, J., Malsberger, R., Setodji, C. M., Dev, S., & Wenger, N. (2018). The Association of Inpatient Occupancy with Hospital-Acquired Clostridium difficile Infection. Journal of hospital medicine.
  4. https://www.cdc.gov/hai/organisms/cdiff/cdiff_faqs_hcp.html Accessed July 23, 2018
  5. https://www.shea-online.org/images/patients/CDI-hand-hygiene-Update.pdf Accessed July 23, 2018
  6. Marian Pokrywka MS, CICa,*, Michele Buraczewski BSNb, Debra Frank MSN, BSNc, Heather Dixon MSN, BSNd, Juliet Ferrelli MS, MT(ASCP), CICa, Kathleen Shutt MSe, Mohamed Yassin MD, PhD. Can improving patient hand hygiene impact Clostridium difficile infection events at an academic medical center?  American Journal of Infection Control, Volume 45, Issue 9, 959 – 963.