C. difficile review and commentary published in Critical Care

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A new Infection thematic review series, led by Dr Steven Opal (Memorial Hospital of Rhode Island, USA) has just been launched in Critical Care, with the first article published being a timely paper documenting the global spread of Clostridium difficile.

Described as a good reference for clinicians faced with this issue, the authors Carolyn V Gould and L Clifford McDonald, from the Centers for Disease Control, detail the pathogenesis, diagnosis and possible treatment strategies in this most topical of hospital-acquired infections.  The onus is on healthcare professionals to maintain awareness of the changing epidemiology of the disease, as well introducing measures to reduce the risk to patients.  

In a related commentary, Aurora Pop-Vicas and Marguerite Neill (Memorial Hospital of Rhode Island) reiterate the statements made in the review, and conclude that only through following basic standards of hygiene will slow down the spread of transmission, placing the responsibility squarely ‘in our hands’.

Review
Bench-to-bedside review: Clostridium difficile colitis
Carolyn V Gould, L Clifford McDonald
Critical Care 2007, 12:203 (18 January 2008)
[Abstract] [Full text] [PDF]

Commentary
Clostridium difficile: the increasingly difficult pathogen
Aurora Pop-Vicas, Marguerite A Neill
Critical Care 2008, 12:114 (7 February 2008)
[Abstract] [Full text] [PDF]

More authoritative reviews in this exciting new series will be published continuously online in the coming weeks and months. Critical Care’s reviews and commentaries require a subscription for access, but if you do not currently have a subscription to the journal, you can register for a free 30-day trial.

All research articles published in Critical Care are open access.

Surayya Johar
In-house Editor, Critical Care

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3 Comments

phillip huggan

I’ve been a big proponent of gelFAST alcohol rub dispensors, Sprixx’s similiar product, and this $300 hospital bed handwashing reminder prototype:
http://www.cbc.ca/health/story/2008/03/03/handwashing-system.html
…to save health care budgets money via reduced nosocomial infections, to presently mitigate any potential Avian Influenza pandemic, and to mitigate in the future any potential designer pandemic WMD.

Most papers on the subject suggest very cursory results that wearable alcohol rub despensors will lower nosocomial hospital infection rates. But there is one outlier that suggests alcohol rubs decrease virii counts on the hand, but have no effect on nosocomial infection rates:
“Prospective, Controlled, Cross-Over Trial of Alcohol-Based Hand Gel in Critical Care Units”
I’m just 1/2 way through the paper. Previous news blurbs have suggested the paper didn’t measure infection rates long enough to note a decline.
One result I’ve noticed suggesting something “wrong” with the paper, is that CDAD (Clostridium difficile) rates are typically reduced much more by soap and water handwashing, than by alcohol rub hand sanitation. The physical process of alcohol rub handwashing probably removes many CDAD spores, but it is soap that actually kills them. Yet the paper, divided into a control, and a Unit A and Unit B, shows in Unit A alcohol rubs are more effective at killing CDAD on the hand than is soap and water. Unit B shows conventionally expected results.

I’m not sure why Unit A CDAD spores are killed more by alcohol than soap in the paper, but medical science knows the opposite to be true. The papers methodology seems sound; I’m not a statistician, but whatever is causing this false conclusion about CDAD, may also be responsible for diagnosing MRSA and other nosocomial infection rates as not being lessened by the use of wearable alcohol rub dispensors. I’ll post more when I finish the paper and reflect.

phillip huggan

My hurried conclusions above were wrong since I assumed infrequent handwashing kills more CDAD spores than frequent alcohol-rubbing, and the truth isn’t known.
I was focused upon the sample size, but at the moment I don’t really understand hospital clinical trials enough to speculate why CDAD infection rates would spike in opposite directions under identical protocols; how much of an outlier the CDAD stats are here.
I’ll read the half dozen or so other MRSA alcohol rub papers and will post my conclusions here.
There is an article her that says paper methodological errors are far more likely than sample size errors…

phillip huggan

Have reflected and reread some alcohol rub papers. To reiterate, I was worried in the above outlier paper, that having the ability to use alcohol rub dispensors was correlated with an increase in CDAD rates.
IN retrospect, a simple explanation is that medical personnel didn’t behave similarly in the two different hospital units studied. The baseline rates of handwashing observed in Units A and B respectively were 38% and 37%, and the baseline rates of handwashing with strategically placed (not wearable) alcohol rub dispensors were 69% and 68%. But in Unit A the handwashing rate where no dispensors were placed (only soap and water available I assume) was 52% and only 32% in Unit B. This alone is probably enough to explain the lack of a CDAD spike in Unit A when there was rub dispensors, vs a Unit B CDAD spike when there was dispensors. Just speculating, but if nurses knew there was a CDAD outbreak (not that rare of an occurrence in hospitals), they may have consciously chosen to wash their hands at a 52% rate, spoiling the comparison.
Also, I’m not a statistician, but the paper only covered about 13 days worth of minutes, and only observed about 3700 opportunities for hand sanitation. A single virulent CDAD patient, or a single poop-handling nurse with less-than stellar hand sanitation, could probably be enough to skew the results.
I guess all this is covered by the qualifiers mentioned in the authors conclusions. I just had to see for myself. You’d expect the odd study to happen in the midst of an unpredictable hospital disease outbreak, rendering the control baseline infection rate useless.

It would be interesting to study CDAD infection rates for hospitals using stationary strategically-placed alcohol rub dispensors, using gelFAST/Sprixx wearable dispensors, and using just soap and water. I’m not so much worried about MRSA or other non-spore efficacy studies anymore. There is still a question of how effective alcohol rub dispensors are over plumbing-dependant soap and water, but even a small correlation (as seems to be demonstrated by the aggregate of research papers) justifies a $300 handwash sensor investment in all Western world beds, and a $1/hr/nurse cost of gelFAST. I hope health-care product procurers hurry up and buy these two products before boomers get sick en masse.

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