Clostridium difficile Colitis: A Retrospective Study of Incidence and Severity Before and After Institution of an Alcohol Hand Rub Policy

Purpose: To determine whether the institution of a hospital wide, alcohol based hand rub (ABHR) policy was associated with an increase in the incidence and/or severity of C. difficile infections. Methods: Retrospective chart review analysis conducted at a 795-bed, community teaching hospital between January 1, 2001 to June 30, 2008 compared incidence rates of C. difficile associated diarrhea (CDAD) before and after implementation of an ABHR policy. We also compared rates of death, sepsis, and colectomy in patients with CDAD before and after ABHR policy implementation as a marker for severity. Results: A total of 766 patients with CDAD were identified. The incidence rate of CDAD was calculated as the number of patients with a positive C. difficile toxin assay per 100,000 patient days both before and after implementation of the ABHR policy on May 1, 2003. The incident rate of CDAD prior to ABHR policy implementation was 49.6 per 100,000 patient days compared to the post implementation rate of 39.8 per 100,000 patient days (p=0.0036). As surrogate measures of CDAD severity we calculated the rates of death, sepsis, and colectomy in the pre and post ABHR policy periods. The crude mortality rate in patients diagnosed with CDAD prior to ABHR policy implementation was 13.3% compared to 10.7% post implementation (p=0.275). The sepsis rate in patients diagnosed with CDAD prior to ABHR policy implementation was 5.2% compared to the post implementation rate of 19.6% (p<0.0001). The rate of colectomy in patients diagnosed with CDAD prior to ABHR policy implementation was 4.8% compared to the post implementation rate of 3.8% (p=0.515). Conclusion: The results showed a significant decrease in CDAD rates after policy implementation. Even though alcohol based rubs do not eradicate C. difficile spores there are several potential explanations for the findings including improved compliance with prevention strategies, increased awareness of hand hygiene importance, and the effectiveness of hand rubbing in reducing spore transmission. Despite a higher rate of sepsis, the colectomy and mortality rates trended down after implementation of ABHR policy, although the results were not significant. These findings suggest a growing trend in management based on more aggressive diagnosis and treatment of the disease. The severity of CDAD increased as evidenced by higher sepsis rates in patients. This is potentially due to more severe forms of CDAD recently identified in major outbreaks in the U.S. and Canada.