URINARY TRACT INFECTION

The Prevalence of Clostridium Difficile Infections

Student Name

Mervyn M. Dymally School of Nursing

Abstract

This paper is a brief analysis of Clostridium difficile infections and how it affects quality patient care. The first section describes this clinical problem and includes the current process. The lax in infection control and the overuse of antibiotics are identified as the leading cause of C. difficile infections. Potential solution involves reinforcement of hand washing with soap and water and more accountability in antibiotic use. In the sensitive indicator section, nosocomial infection and skill mix: percent of total nursing hours supplied is briefly discussed. The secondary indicator discussed is the total nursing care hours provided per patient day as it is related to burnouts and infection control. Goals includes limiting antibiotic use, preventing nurse burnouts, and the constant re-education about hand washing. An economic barrier is discussed. The solution involves better leadership, management and realization that an investment to prevent nosocomial infection will be beneficial in the long run.

Keywords: ariz guzman, nosocomial infection, clostridium difficile infection, c. diff, c.difficile, concepts paper, Charles Drew University

The Prevalence of Clostridium Difficile Infections

Though hospitals are remarkable institutions for reducing illness and facilitating health, they are also a medium for nosocomial infections. These hospital-acquired infections could potentially counteract the hospital’s purpose in providing quality patient care. Thus, nosocomial infection is a clinical topical problem that needs to be addressed. These kinds of infections are considered “the greatest risk that a hospital environment poses to patients” Rothman, 1985() . These infections often come from bacterial organisms that evolved to resist common broad spectrum antibiotics. One such bacteria is the Clostridium difficile (C. difficile or C. diff), an anaerobic gram-positive bacteria that can cause symptoms ranging from diarrhea to life-threatening pseudomembranous colitis, a severe inflammation of the colon associated with eradication of the normal gut flora by the prescribed antibiotics. The Center of Disease and Prevention 2011() suggests that 337,000 cases of C. difficile are reported each year and about 14,000 is linked to 14,000 American deaths. They are found on the surfaces in the hospitals and are mostly transferred from one person to another. Current process to this clinical problem is improved through the successful restriction of the use of antimicrobial agents Gerding, Muto, & Owens, 2008() . Current guideline also includes the continuous acknowledgement and reinforcement of the efficacy of hand washing to prevent contamination. Washing hands with soap and water remains the most effective measure in removing this bacteria and is the preferred method of disinfection over the use of alcohol‐based hand rubs when contact with C. difficile is suspected or likely Oughton, Loo, Dendukuri, Susan Fenn, & Libman, 2009() .

Causes, Related Factors and Potential Solutions

The main mechanism of Clostridium difficile infection exposure to the patient is mediated through the hands of health-care providers. The root cause is related to the failure of infection control. When it comes to C. diff infection, hand washing continues to be the most effective means of reducing hand contamination. Specifically, the use of soap and warm water should be encouraged as alcohol-based hand sanitizers does not often destroy C. diff spores Gerding et al., 2008() . Though hand washing is the primary method of preventing transmission of all bacteria in the hospital, it is not enough. Even the most well-intentioned health care providers clean their hands and glove up, but when they reach and open the privacy curtain to see the next patient, they re-contaminate themselves because it is more than likely that the privacy curtain is not sterile. A solution that should be considered is to have the patient visually see the health care provider wash their hands in front of them with soap and warm water.

A related cause to Clostridium difficile infection is the overuse and misuse of antibiotics. A report done by the Mayo Clinic 2012() for the annual meeting of the American College of Gastroenterology argues how C. difficile infections are more common and more severe in hospitalized children and the elderly due to greater use of antibiotics. This is furthered by a recent study featured in the February issue of Infection Control and Hospital Epidemiology which argues how many patients with C. difficile infection are often prescribed with unnecessary antibiotics, which increases their risk of recurrence of the deadly infection Shaughnessy et al., 2013() . A bacteria’s resistance is the natural out product of us using antibiotics NPR, 2013() . The use of antibiotics kills off the susceptible bacteria, but leaves behind the bacteria that are resistant to the drug. The antibiotics also upsets the natural flora found in the intestinal tract, and the toxins that C. difficile’s spore release is allowed to flourish. These bacteria then replicate and grow, spreading and sharing their resistant genes. The bacteria do what is natural—they survive and then adapt. A potential solution for this is the use of probiotics or live organisms that improve and enhance the microbial balance of the host. A research published through The American Journal of Gastroenterology 2006() suggests using Saccharomyces boulardii as a probiotic to offset the C. difficile infection. Since the use of antibiotics kills off the natural flora allowing C. difficile to grow, probiotic should be implemented as a potential solution. Probiotics is said to modulate the intestinal mucosa “by antagonizing pathogens through the production of antimicrobial compounds and chemicals, thereby reducing the rate of nosocomial infection and recurrence of C. difficile” Rohde, Bartolini, & Jones, 2009() . The overuse of antibiotics must be taken into consideration. The Nobel laureate Joshua Lederberg 2000() recognizes that “the future of humanity and microbes would likely evolve as episodes of our wits versus their genes.” We must accept that bacteria will do what is natural and continue to adapt. No matter how perfect our antibiotic stewardship is, no matter how perfect our infection control is, these bacteria will always adapt ADDIN EN.CITE <EndNote><Cite ExcludeAuth="1" ExcludeYear="1" Hidden="1"><Author>NPR</Author><Year>2010</Year><RecNum>156</RecNum><record><rec-number>156</rec-number><foreign-keys><key app="EN" db-id="fstdtptdnzfr57ew5vcxww2qed2e2svddss5">156</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>NPR</author></authors></contributors><titles><title>Bacterial Infections Defy Treatment.</title></titles><volume>2013</volume><number>March 10</number><dates><year>2010</year></dates><urls><related-urls><url>http://www.npr.org/templates/story/story.php?storyId=126049670</url></related-urls></urls></record></Cite></EndNote>—this is Darwin’s Law of Natural Selection. With this in mind, a solution is accountability of antibiotic use or finding alternatives such as probiotics.

Patient Care Outcome Sensitive Indicators

The American Nurses Association has targeted nosocomial infection, specifically bacteremias such Clostridium difficile as outcomes that affects nursing in acute care settings. This indicator is also defined by the parameters established by the Centers for Disease Control and Prevention 2011() which acknowledges about 14,000 deaths linked to C. difficile infection a year. Research shows that “nearly 2 million nosocomial infections occur annually in the United States, resulting in unnecessary morbidity and mortality” Duffy, 2002() .

A secondary indicator to this addresses the Total Nursing Care Hours Provided per Patient Day ANA, 2013() . The heavy workload of nurses heavily influences the quality of patient care. A Rutgers College of Nursing studies shows how increased hospital infections is linked to nurse burnout Cimiotti, Aiken, Sloane, & Wu, 2012() . The study argues how “cognitive detachment associated with high levels of burnout may result in inadequate hand hygiene practices and lapses in other infection control procedures among registered nurses" Cimiotti et al., 2012() . The healthcare provider’s health and state of mind should be considered and addressed in consolidation with their patients.

ANA (2013) also includes Skill Mix: Percent of total nursing hours supplied as an indicator. An adequate skilled staff is important in providing quality patient care. Understaffing significantly contributes to the spread of nosocomial infections Duffy, 2002() . Units that are busy due to understaffing and/or a high bed-occupancy rate or patient census tends to be poor in the reinforcement of hand hygiene Archibald, Manning, Bell, Banerjee, & Jarvis, 1997() .

Goals, Action Plans and Steps for Evaluating

One goal to reduce Clostridium difficile infection is the prevention of nurse burnouts. Since studies suggests how burnouts are associated with secondary infections Cimiotti et al., 2012() , lessening work hours for nurses or having more staff on hand could prevent errors due to human fatigue. Nurses working extended work shifts of twelve hours or longer tend to experience burnout, job dissatisfaction which results to patients that are dissatisfied with their care Stimpfel, Sloane, & Aiken, 2012() . The plan is to implement organizational changes that take the stress levels of the health care staff into consideration. The nursing leadership should make necessary adjustments in their staff as “staffing adequacy directly affected emotional exhaustion, and use of a nursing model of care had a direct effect on nurses' personal accomplishment—both directly affected patient safety outcomes” Laschinger & Leiter, 2006() . This plan requires the nursing leadership to be mindful of their staff’s reactions to their workload and to better recognize whether their staff is experiencing burnouts. The plan of action should focus on encouraging a workplace culture that takes care of the needs of the individual health provider in association with the needs and health of their clients. In a unit level, taking care of all of those involved improves quality patient care. A required monthly evaluation or a meeting to discuss overall healthcare provider satisfaction or dissatisfactions should be implemented. The nursing leadership should encourage an atmosphere of openness to encourage their staff to be confident enough to ask for help when their workload becomes too intense.

Another goal that should be considered is the reinforcement of infection control focused on washing hands with soap and warm water as well as thoroughly cleaning surfaces in hospitals. Though many hospitals have procedures in place that encourages the persistent scrubbing of all surface and relentless hand washing, and terminal cleaning, nosocomial infections related to C. difficile still occurs. The plan that should be implemented involves a monthly re-education about infection control, risk factors, routes of transmission, treatment and prevented measures related to C. difficile so that the knowledge and actions that specifically responds to this infection is continuously reinforced and becomes second nature. The extensive education about hand washing given to the nursing and healthcare staff should also be given to the client, patient, and their friends and families who visits them. This allows a partnered approach as the responsibility of hand washing is given to all those involved. A possible necessary step is to have the healthcare staff encourage the patient to ask anyone who is going to touch them to always clean their hands before their interaction. For evaluation, documentation of a formal written consent or agreement for this procedure should be encouraged and considered, if not implemented.

Reducing our dependency on antibiotics is also another important goal. The overuse of antibiotics is attributed to the increased rate of C. difficile infections Gerding et al., 2008() . Monitoring antibiotic use and, when necessary, altering current antimicrobial prescribing practices has been shown to improve patient care Dellit et al., 2007() . A plan to decrease the use of antibiotics is through the use of probiotics. Probiotics should be used by itself or along with antibiotics. This involves putting emphasis on maintaining a healthy immune system so the colonies of C. difficile cannot overtake an area of the body and cause problems. Probiotics is said to lower C. difficile impact McFarland, 2006() and should be considered as an alternative to strictly using antibiotics. Arguably, overcoming infection is done more efficiently when the body’s natural immune system is strengthened. Perhaps by improving the body’s own bacterial immune system instead of directly attacking the infection should be considered as an option McFarland, 2006() . Evaluation for this plan involves close monitoring and perhaps strict regulation of antibiotic use.

Potential Barriers and Solutions

Money or an economic barrier is what usually prevents an easy and attainable solution. The barrier is the initial monetary investment. It takes resources to implement any changes and time for those changes to be actualized. Hospitals have to be selective in investing their limited resources. Even the development of new antibiotics or alternative method to antibiotics requires money and is not cost efficient. Antibiotic research has a poor return on investment for most companies Boucher et al., 2009() . Pharmaceutical companies would rather produce and sell drugs that is taken every day for the rest of your life than a drug that will cure you in about a week. In a macro level, government mediation is a solution, albeit a controversial one. Monetary incentives should be given for antibiotic research. Incentives should be specifically encourage on researching and finding other alternatives to antibiotic use. Monitoring antibiotic use and, when necessary, altering current antimicrobial prescribing practices has been shown to improve patient care Dellit et al., 2007() . The solution to be considered is participation with an Antimicrobial Stewardship Program as it has been shown to “improve appropriateness of antibiotic use and cure rates, decrease failure rates, and reduce healthcare-related costs” Fishman, 2006() .

When it comes preventing nurse burnouts, the hiring of more staff or lessening work hours is a simple solution, albeit an expensive one. Unburdening the bedside provider by taking advantage of new technologies that reduce nosocomial infections is a solution Kollef, 2008() . Though at first glance, investing money on more staff or technology drains hospital resources, it actually does the opposite. An estimated savings of $41 million is seen if the proportion of nurses with high burnout is reduced to 10 percent from the average 30 percent Cimiotti et al., 2012() . The solution therefore is to convince those in charge of hospital finances that their initial investments will beneficial in the long run.

References

http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality/Research-Measurement/The-National-Database/Nursing-Sensitive-Indicators_1/default.aspxANA. (2013). Nursing-Sensitive Indicators. Retrieved March 10, 2013, from

Archibald, L. K., Manning, M. L., Bell, L. M., Banerjee, S., & Jarvis, W. R. (1997). Patient density, nurse-to-patient ratio and nosocomial infection risk in a pediatric cardiac intensive care unit. The Pediatric infectious disease journal, 16(11), 1045-1048.

Boucher, H. W., Talbot, G. H., Bradley, J. S., Edwards, J. E., Gilbert, D., Rice, L. B., . . . Bartlett, J. (2009). Bad bugs, no drugs: no ESKAPE! An update from the Infectious Diseases Society of America. Clinical infectious diseases, 48(1), 1-12.

CDC. (2011). Clostridium dificile Infection - HAI. Retrieved March 10, 2013, from http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html

Cimiotti, J. P., Aiken, L. H., Sloane, D. M., & Wu, E. S. (2012). Nurse staffing, burnout, and health care–associated infection. American journal of infection control, 40(6), 486-490.

Clinic, M. (2012). C. diff infections becoming more common, severe in children and elderly. Retrieved March 10, 2013, from http://www.sciencedaily.com/releases/2012/10/121022081219.htm

Dellit, T. H., Owens, R. C., McGowan, J. E., Gerding, D. N., Weinstein, R. A., Burke, J. P., . . . Carpenter, C. F. (2007). Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clinical infectious diseases, 44(2), 159-177.

Duffy, J. R. (2002). Nosocomial infections: important acute care nursing-sensitive outcomes indicators. AACN Advanced Critical Care, 13(3), 358-366.

Fishman, N. (2006). Antimicrobial stewardship. American journal of infection control, 34(5 Suppl 1), S55.

Gerding, D. N., Muto, C. A., & Owens, R. C. (2008). Measures to control and prevent Clostridium difficile infection. Clinical infectious diseases, 46(Supplement 1), S43-S49.

Kollef, M. (2008). SMART approaches for reducing nosocomial infections in the ICU. CHEST Journal, 134(2), 447-456.

Laschinger, H. K. S., & Leiter, M. P. (2006). The impact of nursing work environments on patient safety outcomes: The mediating role of burnout engagement. Journal of Nursing Administration, 36(5), 259-267.

Lederberg, J. (2000). Infectious history. Science, 288(5464), 287-293.

McFarland, L. V. (2006). Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease. The American journal of gastroenterology, 101(4), 812-822.

NPR. (2010). Bacterial Infections Defy Treatment. Retrieved March 10, 2013, from http://www.npr.org/templates/story/story.php?storyId=126049670

NPR. (2013). 'Nightmare Bacteria' Defy Even Last Ditch Drugs. Retrieved March 10, 2013, from http://www.npr.org/2013/03/08/173821490/nightmare-bacteria-defy-even-last-ditch-drugs

Oughton, M. T., Loo, V. G., Dendukuri, N., Susan Fenn, M., & Libman, M. D. (2009). Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile. Hand, 30(10), 939-944.

Rohde, C. L., Bartolini, V., & Jones, N. (2009). The use of probiotics in the prevention and treatment of antibiotic-associated diarrhea with special interest in Clostridium difficile–associated diarrhea. Nutrition in Clinical Practice, 24(1), 33-40.

Rothman, K. J. (1985). Sleuthing in hospitals. New England Journal of Medicine, 313(4), 258-260.

Shaughnessy, M., Amundson, W., Kuskowski, M., DeCarolis, D., Johnson, J., & Drekonja, D. (2013). Unnecessary antimicrobial use in patients with current or recent Clostridium difficile infection. Infection control and hospital epidemiology: the official journal of the Society of Hospital Epidemiologists of America, 34(2), 109-116.

Stimpfel, A. W., Sloane, D. M., & Aiken, L. H. (2012). The Longer The Shifts For Hospital Nurses, The Higher The Levels Of Burnout And Patient Dissatisfaction. Health Affairs, 31(11), 2501-2509.