Interventions to reduce the incidence of hospital-onset Clostridium difficile infection: An agent-based modeling approach to evaluate clinical effectiveness in adult acute care hospitals

Abstract

Background

Despite intensified efforts to reduce hospital-onset Clostridium difficile infection (C. difficile; HO-CDI), its clinical and economic impacts continue to worsen. Many institutions have adopted bundled interventions that vary considerably in composition, strength of evidence, and effectiveness. Considerable gaps remain in our knowledge of intervention effectiveness and disease transmission, which hinders HO-CDI prevention.

Methods

We developed an agent-based model of C. difficile transmission in a 200-bed adult hospital using studies from the literature, supplemented with primary data collection. The model includes an environmental component and four distinct agent types: patients, visitors, nurses, and physicians. We used the model to evaluate the comparative clinical effectiveness of nine single-interventions and eight multiple-intervention bundles at reducing HO-CDI and asymptomatic C. difficile colonization.

Results

Daily cleaning with sporicidal disinfectant and C. difficile screening at admission were the most effective single-intervention strategies, reducing HO-CDI by 68.9% and 35.7%, respectively (both, p<0.001). Combining these interventions into a two-intervention bundle reduced HO-CDI 82.3% and asymptomatic hospital-onset colonization 90.6% (both, p<0.001). Adding patient hand hygiene to healthcare worker hand hygiene reduced HO-CDI rates an additional 7.9%. Visitor hand hygiene and contact precaution interventions did not reduce HO-CDI, compared to baseline. Excluding those strategies, healthcare worker contact precautions was the least effective intervention at reducing hospital-onset colonization and infection.

Conclusions

Identifying and managing the vast hospital reservoir of asymptomatic C. difficile by screening and daily cleaning with sporicidal disinfectant are high yield strategies. These findings provide much needed data regarding which interventions to prioritize for optimal C. difficile control.