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Press Briefing Transcript

Vital Signs: Preventing C Difficile Infections

Tuesday, March 6, 2012 at 1PM ET

Operator: Welcome and thank you for standing by.  At this time, all participants are in a listen–only mode.  During the question and answer session of today's call, you may press star 1 to ask a question.  Today's conference is being recorded and Mr. Llelwyn Grant, you may begin. 

Llelwyn Grant:  Thank you, Shirley.  Good afternoon, everyone.  My name is Llelwyn Grant, and I am the branch chief for CDC's News Media Branch.  I wish to thank you all for joining us for CDC’s vital signs report on Clostridium Difficile, also known as C. Difficile.  Today's report represents a series of Vital Signs reports that illustrate CDC’s commitment to saving lives, protecting people, and saving money through prevention.  Here to discuss the C. Difficile study is CDC’s ATSDR's Principle Deputy Director, Ileana, I–l–e–a–n–a, Arias, a–r–I–a–s, and Dr. Clifford, standard spelling, c–l–I–f–f–o–r–d, McDonald, standard spelling, m, small c, d–o–n–a–l–d, who is a medical epidemiologist with CDC’s Division of Health Care Quality Promotion and lead author of the study.  Following their brief remarks, we will open the line up for questions.  At this time, I would like to turn it over to Dr. Arias. 

Ileana Arias: Thank you for joining us to discuss today's Vital Signs report.  Vital signs are a special MMWR publication that highlights critical public health issues facing our nation.  This month, Vital Signs is focused on health care–associated infections caused by a bacteria called C. Difficile.  It's a deadly infection that poses a significant threat to U.S. health care patients.  Our country has seen rates of other health care associated infections, such as bloodstream infections decline in recent years.  But C. Difficile has climbed, and continues at historically high and unacceptable levels.  Today's report serves as a national call to action for our health care system to make C. Difficile prevention appropriately a high priority.  This call to action includes the federal government, state and local health departments, health care facility administrators, individual doctors, nurses, technicians and cleaning staff.  Everyone with a hand in patient care has a role in preventing this deadly infection.  C. Difficile is causing many Americans to suffer and die.  These infections are linked to at least 14,000 American deaths every year.  This is a high number, but the failure is more difficult to accept, because these are treatable, often preventable deaths.  We know they don't have to happen.  We know what can be done to do a better job of protecting our patients.  Traditionally, C. Difficile infections were thought to be a problem mostly for hospitals.  But today's report shows these infections are a patient safety concern in nursing homes and outpatient care settings, as well.  From a single clinician prescribing unnecessary antibiotics to a nurse or a doctor who doesn't recognize C. Difficile symptoms and doesn't order a test or hospital aide forgetting to wear gloves to medical teams that don't alert each other to C. Difficile infections during patient transfers, we all have a role to play in stopping C. Difficile.  Fortunately, today's vital signs report also highlights that prevention is possible, and how it can be accomplished.  There are key steps both health care providers and patients can take to stop this deadly disease.  To talk more about these prevention steps and new data being released today, I am pleased to introduce and turn the discussion over to Dr. Clifford McDonald. 

Cliff McDonald: Thank you, Dr. Arias.  And thanks, everyone, again, for joining us today.  As has been mentioned, C. Difficile is a formidable opponent that is causing many Americans to suffer or die.  Even as we see rates of other health care–associated infections decline.  People most at risk from this deadly diarrheal infection are those who take antibiotics and also receive medical care in any setting.  This could include a nursing home, hospital, doctor's office or outpatient surgery center.  Why is that?  C. Difficile infection most often requires a one–two punch of antibiotics plus medical care.  Antibiotics destroy good bacteria that typically protect us from infection, leaving the door open for C. Difficile to take over.  If a person swallows C. Difficile spores during this time of vulnerability, they can become infected.  This usually happens in health care facilities, after a patient picks up invisible C. Difficile spores from contaminated surfaces or if a health care provider directly spreads the spores to a patient and then the patient touches his or her face.  There is an excellent graphic simply displaying a potential chain of infection in the fact sheet where on the website accompanying today's MMWR report.  C. Difficile infection risk generally increases with age.  Children are at lower risk, and older adults are at higher risk.  Almost half of C. Difficile infections occur in people younger than 65, yet 90% of deaths related to C. Difficile occur in people 65 and older. 

Other major data points from today's report show us that 94% of C. Difficile infections occur in people who recently received medical care.  This includes people who are hospitalized when diagnosed, or perhaps in a nursing home.  This also includes people who recently visited a doctor's office, had outpatient surgery, or received other care.  In the past, a lot of C. Difficile infections were considered to happen just generally in the community.  But this report shows that most of these so–called community infections actually occur in people with recent exposure to medical facilities.  Today's vital signs report tells us that C. Difficile should no longer be considered just a hospital problem.  These infections are now a patient safety concern everywhere medical care is given.  About 25% of C. Difficile infections first show symptoms among patients in hospitals; 75% first show symptoms among patients in nursing homes or in patients recently cared for in doctor's offices or clinics.  Although a minority of all infections first show symptoms in hospital patients, hospitals still play a central role in C. Difficile prevention.  This is because many of the most potent antibiotics are prescribed in hospitals today and many infections first show symptoms soon after discharge from hospitals. 

Today's report also shows that 50% of cases diagnosed in hospitals come in the front door with patients who are transferred or recently discharged from other facilities.  In other words, these infections are present on administration.  The other half of infections diagnosed in hospitals are a result of care in that particular facility.  What this means is that hospitals and likely other medical facilities as well are partly at the mercy of surrounding facilities, because patients so often transfer back and forth between facilities or are seen by so many providers.  And an infection issue in one place can easily become a problem in another practice or facility too.  This speaks to the need for strict adherence to infection prevention and control recommendations across all facility types, and the need for greater care coordination.  When CDC recommendations are followed well, we know C. Difficile can be prevented.  In fact, this report highlights three prevention projects that drop C. Difficile rates by an average of 20% by doing just this.  This type of success is possible to achieve nationally.  Specifically for clinicians, CDC recommends six steps to prevention.  First, prescribe and use antibiotics carefully.  About 50% of all antibiotics given are not needed, unnecessarily raising the risk of C. Difficile infections.  Second, test for C. Difficile when patients have diarrhea while on antibiotics or within several months after taking them.  Third, isolate patients with C. Difficile immediately.  Fourth, wear gloves and gowns when treating patients with C. Difficile, even during short visits.  Hand sanitizer does not kill C. Difficile and hand–washing may not be sufficient.  It is important to note that once C. Difficile germs are on a health care provider's hands, they are hard to get off.  It is much better to avoid getting them on your hands in the first place.  Fifth, clean room surfaces with bleach or another EPA–approved spore–killing disinfectant after a patient with C. Difficile has been treated there.  And finally, when patients transfer, notify the new facility of C. Difficile infections.  For patients, we recommend the following.  Antibiotics can be life–saving medications.  But take them only as prescribed by your doctor.  Tell your doctor if you have been on antibiotics or get diarrhea within a few months.  Wash your hands after using the bathroom.  And try to use a separate bathroom if you have diarrhea, or be sure the bathroom is cleaned well if someone who has diarrhea has used it.  As you can see, C. Difficile is a formidable opponent, but one that we can stop.  With that, I’ll turn it back over to you, Dr. Arias. 

Ileana Arias: Thank you, Dr. McDonald.  I'd like to close our remarks with three key points from today's report.  One, C. Difficile is causing deadly diarrhea serious enough to sicken or kill many Americans.  Two, C. Difficile is not just a hospital problem.  It's a patient safety concern in every type of medical patient care facility.  And three, C. Difficile can be prevented.  As has just been described, medical leadership, clinicians and cleaning staff can prevent these infections by following CDC recommendations and patients even can help catch C. Difficile early by telling doctors if they have diarrhea within several months of taking antibiotics.  We thank you all for joining us, and helping us shine a spotlight on this important health topic and what can be done to improve.  And we're now more than happy to take questions you may have. 

Operator: Thank you.  We will now begin the question and answer session.  If you would like to ask a question, please press star 1.  You will be prompted to record your name.  To withdraw your request, you may press star 2.  Again, press star 1 to ask a question.  And one moment for our first question.  Our first question comes from Daniel DeNoon with WebMD.  You may ask your question. 

Dan DeNoon: Thank you for taking my question.  I have two questions that are not related.  My first one is, can you talk a bit about the hyper viral and resistance strain of c–diff that seems to be a problem and how that is treated.  I know the cartoon you show shows people becoming cured quickly after it's diagnosed and treated.  But I wonder if you can talk about this more resistant strain and the problem it poses.  Let me ask that question first, please. 

Cliff McDonald: Sure.  The strain you're referring to is known as the North American pulsed–field type 1 strain.  We at CDC and colleagues first described this back in 2004.  It continues to be a prevalent strain in U.S. health care facilities.  This strain has been called hyper virulent, because for various reasons, including the production of increased amount of toxin.  You mentioned its resistance.  I would just clarify, this is not resistant to the main antibiotics used to treat the infection, but resistance to other commonly used antibiotics that have given this strain a leg up on other strains and advantage for other strains.  You asked about the treatment of this strain and C. Difficile in general.  Usually, C. Difficile infections are treated with an antibiotic.  The FDA–approved antibiotic for C. Difficile includes antibiotics oral vancomycin and fidaxomicin.  Another commonly used is metronidazole.  And these are generally used for ten days. 

Dan DeNoon: Thank you very much.  And an unrelated question, is the requirement of reporting by hospitals that will be coming up in the next year or so, can you talk more about these new reporting rules that will begin in 2014? 

Cliff McDonald: You’re referring to the center for Medicare and Medicaid services. 

Dan DeNoon: Yes, I am. 

Cliff McDonald: Requirement for hospitals to report for their annual payment update.  Now commonly referred to as pay for reporting.  This requirement, according to the common rule that we heard about last summer, will begin in 2013.  All hospitals reimbursed under that system will likely begin reporting through the national health care safety network, the CDC–run surveillance network.  Those infections will be reported using the same mechanism that we talk about in this report under NHSN.  They'll be reporting through 2013, and then in 2014, posting on the hospital compare website. 

Llelwyn Grant: Next question, Shirley. 

Operator: It comes from Mike Stobbe.  You may ask your question.

Mike Stobbe: Thanks for taking my call.  I wanted to make sure I understood the phrase call to action.  You said this is a call to action.  I just want to make sure I understand.  What does that mean?  Is it sort of a general description of we're trying to draw the public and the medical world's attention to this, or is there a certain level of activity that means you guys are spending x amount on an awareness campaign?  I'm just wondering what that means, exactly. 

Cliff McDonald:  I think it is a focused, concerted action.  It's bringing this infection –– educating the public about this infection.  When the public is informed, patients are informed.  Everyone is better off.  The medical community is better off.  And the entire system responds better.  We're also, of course, looking at –– as the previous question suggested, a period in the very near future where we'll have increased transparency and accountability about this infection. 

Llelwyn Grant: Next question? 

Operator: Our next question comes from Miriam Falco with CNN Medical News.  You may ask your question. 

Miriam Falco: Hi, thanks for taking our questions.  You mentioned that other infectious diseases are going down, the hospital–acquired ones.  But this one has been going up.  And the question in my mind is, why are we still talking about educating hospitals about how to properly clean rooms, properly handle patients who have an infectious disease?  Is it because they don't know the patient has c–diff, or why is it so difficult to do these basic things that would prevent these hospital–acquired or transmitted infectious diseases? 

Cliff McDonald: That’s a great question.  These are human behaviors we're talking about.  We're talking about changing practices.  And on the surface, they appear very simple, and they are in many ways.  On another aspect, we're talking about large organizations.  And now we're talking also, as highlighted in this report, the fact that there needs to be concerted action across different types of facilities.  This is something somewhat new.  And yet we think the health department, especially, has a particular role to bring different facilities together.  This is highlighted in the report about how –– and I mentioned also in my brief comments about how one facility will be somewhat at the adversity of another facility and that's why they need to work together on this.  The other thing is, within facilities getting simple behavior changes affected can be challenging.  And yet these 71 hospitals and these 3 states did accomplish this, resulting in a 20% reduction in these infections.  How did they do that?  Well, it involved engagement of the hospital leadership.  It involved using these recommended practices, educating on them, and sharing also these hospitals share with one another under these –– we call these collaboratives, these prevention programs, where they share with one another how they implemented them.  And finally, they use data for action.  I mean, I think that there's a real reason for optimism here, especially as data becomes more available, these rates all become more transparent, and plain to people.  And I think that we are going to see –– I’m optimistic we're going to see this turn around. 

Llelwyn Grant: Next question, Shirley. 

Operator: Thank you.  That comes from Delthia Ricks with Newsday.  You may ask your question. 

Delthia Ricks: Thank you very much.  I was hoping one of you could tell me a little bit about the spores.  You mentioned them.  I would like to know how long they survive on surfaces, and do people primarily ingest them, do they rub them in their eyes?  What exactly is the root through which people are infected? 

Cliff McDonald: This organism does form spores.  We mentioned that.  It actually –– when it's not in spore form, it dies very quickly in the presence of oxygen.  But in the spore, it can persist in the environment for even months.  And maybe even longer.  Other spores, we know, can exist even longer.  This spore is the infective form.  This is what we said swallowed, usually on the hands –– hands are contaminated, we touch our face all of the time.  And just that small ingestion, when you're vulnerable.  We emphasize that too.  Many people, this doesn't affect at all unless you've had antibiotics recently.  But the ingestion or swallowing of those few spores are resistant to stomach acid and in the intestine and come back to life and start growing. 

Delthia Ricks: Thank you very much. 

Operator:  Next question comes from Cheryl Clark with health leaders’ media for health care executives.  You may ask your question. 

Cheryl Clark: Thank you very much.  I wanted to ask a little bit more about antibiotic stewardship, and for each –– the hospital, the nursing home, and the physicians' practice.  What do you think should change from current practice today? 

Cliff McDonald: well, we –– stewardship is an area we are actively working with several partners on, including the infectious disease society of America, society of health care epidemiology of America.  We have a program called "get smart."  That has been in existence for a number of years, focused mostly in the community.  And now we also have part of this, which is "get smart for health care."  And it really –– as the name suggests, using antibiotics more wisely.  They are life–saving drugs.  They have allowed modern health care to do the wonderful things that we are achieving in modern health care.  They aren't without risk, though.  That's the point.  So there is education always there of prescribers.  That's always key.  There are several key steps.  One of them is just to take an antibiotic time–out, for example.  Reassess after a patient has been on antibiotics for a day or two, do they still need those antibiotics?  Ordering the appropriate cultures before the antibiotics are started.  And then whenever possible, stopping antibiotics that are no longer needed.  There's a lot of different ways we could talk at length about how to implement all that.  But these things have to happen in hospitals, as we mentioned already.  But as you're alluding to, in nursing homes, doctors' offices, across all of the spectrum. 

Cheryl Clark: Is there a first line that should –– of antibiotic that should be tried instead of, say, another line?  Or, you know ––

Cliff McDonald: There are some higher–risk and lower–risk antibiotics.  I don't think we can get into that right now.  I want to, though, put that also in the context that the 20% reductions we're seeing in the 71 hospitals reported on here, antibiotic stewardship was some of the focus of one of these programs, one of the states.  But overall, not a lot was done with antibiotic stewardship so far.  And we think there is a lot more that can be done.  But there's other steps that are key to bring out in addition.  Antibiotic stewardship is the first.  It is one of the most important, and that's another reason for optimism, is we do more with stewardship.  But also, diagnosing these infections rapidly.  Getting them diagnosed, getting patients into isolation.  When they're in isolation, using gloves and gowns.  And environmental cleaning.  Cleaning these rooms well, using a sporicidal disinfectant, EPA–registered, and notifying patients as they're being transferred we're highlighting also is key. 

Cheryl Clark: You mean notifying the subsequent ––

Cliff McDonald: Exactly.  Notifying the subsequent facility that this patient either has an active infection or has recovered. 

Llelwyn Grant: Okay, Shirley, we have time for two more calls. 

Operator: Thank you.  Next question comes from Heidi Splete with family practice news.  You may ask your question. 

Heidi Splete: Hi.  Thank you for taking my call.  I'm sort of following up a little bit on these –– on the things that doctors can do.  And I guess as far as testing, if patients have diarrhea while on antibiotics, is that an area where you have any idea of how often that's being done, or is that something that you would try and monitor, say, in an outpatient setting? 

Cliff McDonald:  Yes.  I'll mention a couple things.  First of all, that antibiotic –– antibiotic–associated diarrhea is very common.  Many people when they're on the antibiotic, they might have some loose stools.  C. Difficile turns out to be only a proportion of that.  Maybe one–third of that.  With that said, there are some clues.  More than three unformed stools in a 24–hour period.  Fever, abdominal pain.  Diarrhea that continues once you stop the antibiotic or maybe the diarrhea started only after the patient stopped antibiotic, maybe a week later, and it starts.  These are all clues that C. Difficile.  Basically, though, especially in inpatient care facilities and also in –– also in outpatient care facilities, but especially inpatient care facilities, really leaning forward.  If someone has been on antibiotics and they develop diarrhea, to think about C. Difficile early and get them tested.  And we also mention the importance of more accurate testing.  This is a highlight of a med–scape commentary we have posted.  And I refer you to that. 

Heidi Splete: Thank you. 

Operator: Thank you.  Our final question comes from Maryn McKenna with wired.com.  You may ask your question. 

Maryn McKenna: Thanks.  Several times in discussing what needs to be done, you have mentioned the role of environmental services and cleaning in the hospital.  And I was wondering if you could enlarge on that a bit.  And what I’m particularly interested in is you're talking here about a really important infectious threat being prevented by the actions of some of the least–paid and lowest status people on a facility's staff.  And I’m wondering what your thoughts are about facilities bringing them into decision–making or motivating them or making them understand how important their role is. 

Cliff McDonald: I think that's a great question.  And a very good, important point that we have been working with our partners on.  In fact, some of the state –– some of our state partners in Illinois, in particular.  But I think all three states have focused on environmental services in their work with their hospitals.  It is –– you're alluding to the fact that these individuals may have a high job turnover rate.  There may be language issues sometimes.  Educating them, engaging them, helping them understand how critical they are in patient care, patient safety is very important.  And we are working to do that.  We have also developed some tools, ways of assessing the adequacy of cleaning.  This is something else to point out, that just because something looks clean doesn't mean that it is clean.  And so that's a very key point also. 

Llelwyn Grant:  I wish to thank you all for participating in today's telebriefing.  To obtain a copy of the vital sign report on C. Difficile, please visit www.cdc.gov/vitalsigns, all one word.  For more information about preventing C. Difficile and other health care–associated infections, visit www.cdc.gov/hai.  A transcript will be available later this afternoon.  For follow–up questions, please contact CDC’s main press office at 404–639–3286.  This concludes our media telebriefing, and thanks again for joining us. 

Operator: Thank you.  And this does conclude today's presentation.  We thank you for your participation.  At this time, you may disconnect your lines.  

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