Lesser-known C-diff a bigger hospital threat than MRSA?

Updated 3/22/2010, By Elizabeth Weise, USA TODAY

There's good and bad news on the "superbug" front. In community hospitals in the Southeast, an easily spread bacterium appears to have overtaken the widely feared MRSA as the most common hospital-acquired infection. But a pilot project in Ohio found that pushing hard on simple things such as hand washing and thorough cleaning can lower rates of that bug significantly.

Known as Clostridium difficile, or "C. diff," the bacterium resides in the gut, is spread by contact and can cause painful intestinal infections and in some cases death. It's primarily seen in those over 65, and relapses occur in a fourth of patients, despite treatment.

More than 90% of cases happen after antibiotic use, when the healthy flora of the gut are destroyed and C. diff can take up residence.

C. difficile was 25% more common than MRSA in a study of 28 hospitals in the Southeast, says Becky Miller, an infectious-disease researcher at Duke University Medical Center in Durham, N.C. The proportions nationwide aren't known.

MRSA "was the big bad pathogen in hospitals," but C. diff has overtaken it, Miller says. She worked the study by looking at C. difficile rates at community hospitals in the Duke Infection Control Outreach Network. The data were presented over the weekend at the Fifth Decennial International Conference on Healthcare-Associated Infections conference in Atlanta.

Rates of MRSA, or methicillin-resistant Staphylococcus aureus, have been falling nationwide as hospitals increased infection control work, says Jose Cadena, a professor of infectious disease at the University of Texas Health Science Center at San Antonio. MRSA causes serious skin and soft tissue infections. C. diff rates doubled between 1996 and 2003, research has shown.

Each year in the USA, more than 28,000 people die of C. diff, according to the Centers for Disease Control and Prevention. The breakdown is:

• Hospital-acquired, hospital-onset cases: 165,000 patients, $1.3 billion in excess costs, and 9,000 deaths

• Hospital-acquired, post-discharge (up to 4 weeks), 50,000 patients, $0.3 billion in excess costs, and 3,000 deaths.

• Nursing home-onset cases, 263,000 patients, $2.2 billion in excess costs, and 16,500 deaths.

That is why work in Ohio is so promising. A carefully monitored study of a quarter of the state's hospitals showed that following strict guidelines on hand washing, contact isolation and cleaning caused the number of cases to fall from 7.7 per 10,000 patient days in the hospital to 6.7 between the first and last half of 2009, says Julie Mangino, a professor of internal medicine at Ohio State University Medical Center in Columbus, Ohio.

"One of the units which was very vigilant had no new cases," she says.

The procedures aren't rocket science: "hand washing before and after room entry, compliance with gown and glove rules and meticulous cleaning," she says. But the researchers actually set up observers, to make sure they were happening. That made the difference.

While prevention may seem a no-brainer, it's anything but.

C. diff is hugely expensive to treat. Each case of hospital-acquired C. diff is estimated to cost between $4,000 and $9,000 to treat, she says.

Many other states also are targeting C. diff prevention, using federal stimulus funds. Ohio and New York were first, but there are about a dozen coming, says the CDC's Nicole Coffin.

C. difficile is especially difficult to stop because in addition to being a bacterium, it can exist in a dormant spore form, which can survive for weeks or months on hard surfaces, then begin multiplying when ingested. The alcohol-based hand foams that have become ubiquitous in hospitals don't kill it. It doesn't even appear that soap and water kill the bacteria when it's in spore form. "But some people think just the physical process of washing gets it off your hands," says Neil Fishman, president of the Society for Healthcare Epidemiology in America.

Hospitalization is a double whammy, both because the bacteria can become resident in a given facility and contaminate others and because people in hospitals are already sick and have lower resistance.

Judicious antibiotic use is another key factor in lowering rates, says Coffin. "Good" bacteria in the gut can keep C. diff in check. But antibiotics can wipe out those good bacteria, allowing C. diff to flourish.

In general, it's hard to convince individuals that they should not take antibiotics unnecessarily, because the threat is a general one — it might in the future render that antibiotic less effective against disease. But in the case of C. diff, it's very immediate. "If you're being treated with antibiotics for something else, you're at higher risk for C diff. It's a big reminder to clinicians that they need to make sure that you're using antibiotics appropriately and judiciously."