Assessing control bundles for Clostridium difficile: a review and mathematical model

Figures & data

Figure 1 Flow chart of selection process to identify relevant studies assessing the efficacy of C. difficile control bundles.

Figure 2 Compartmental design of the stochastic, event-driven mathematical model of C. difficile transmission within a simulated 1000-bed acute care hospital.

Table 1 Epidemiological model symbology and parameterization

Symbol	Definition	Value (,vulnerable)	Control range	Reference
η	Develop into asymptomatic infectious (day^−1)	0.2,0.2		34
1−ε	Colonization clearance in non-vulnerable (prop.)	0.8		30
θ	Develop symptomatic CDI (day^−1)	0.04,0.2		30
ζ	CDI self-resolve (proportion of cases)	0.33		37
τ	CDI self-resolve rate (day^−1)	0.5		38
ρ	CDI treatment (day^−1)	0.1		40
σ	Treatment failure (proportion)	0.2		41
ξ	Hospital admission (proportion)	0.75,0.25		31,32
μ	Mortality rate (day^−1)	0.0012		30
Simulated control
λ	Recovery of gut flora (day^−1)	0.011	0.011–0.1	34
α	Antimicrobial treatment (day^−1)	0.1	0–0.1	31,32
β	Transmission coefficient (day^−1)	0.5	0–1
κ	Hospital discharge (day^−1)	0.17	0.17–0.34	33

Table 2 Summary of the clinical studies examining the efficacy of control bundles in mitigating Clostridium difficile infection

Study	C. difficile strain	Study population (n)	Control bundle details	Effect size
Bishop et al., 2013^Citation53	Endemic strain unreported	Surgical inpatients (17, 145)	Resident rounding; hand hygiene; maintaining gastric acidity; antimicrobial stewardship	From 2.8/1000 to 1.8/1000 pd^a
Koll et al., 2013^Citation52	Endemic strain unreported	Acute care inpatients >18 years across 35 hospitals (14, 591 CDI cases)	Contact precaution; hand hygiene; isolation; environmental cleaning	From ∼12/10 000 to ∼8/10 000 (hosp bed days)
Abbett et al., 2009^Citation50	Endemic strain unreported	Acute care inpatients >18 years (881 CDI cases)	Contact precaution; hand hygiene; environmental cleaning; vancomycin	From 1.1/1000 to 0.66/1000 pd
Salgado et al., 2009^Citation51	Epidemic strain unreported	Tertiary care inpatients >18 years (610 beds, 6 years)	Contact precaution; environmental cleaning; hand hygiene	From 1.8/1000 immediately post-epidemic to 1.2/1000 pd, 3 years thereafter
Weiss et al., 2009^Citation49	Epidemic (NAP1/027)	Acute care inpatients (554 beds, 5 years)	Environmental cleaning; contact isolation; antimicrobial stewardship	From 37.3/1000 to 14.5/1000 (admissions)
Muto et al., 2007^Citation48	Epidemic (NAP1/027)	Tertiary care inpatients (834 beds, 8 years)	Environmental cleaning; hand hygiene; contact isolation; antimicrobial stewardship	From 7.2/1000 to 3.0/1000 (hospital discharges)

^apd, patient days.

Figure 3 The effect of control combinations on the ratio of patients discharged relative to those admitted with asymptomatic C. difficile colonization. Controls include: λ, rate of gut microbiota recovery which is expedited by probiotics or intestinal microbiota transplantation; α, rate of antimicrobial prescription which is reduced through stricter stewardship; β, the rate of transmission which is reduced through improvements to hygiene and sanitation; κ, the rate of patient discharge (inverse of average length of stay), which is increased to minimize patient exposure window.

Figure 4 The effect of control combinations on C. difficile symptomatic disease incidence per 1000 hospital bed days. Controls include: λ, rate of gut microbiota recovery which is expedited by probiotics or intestinal microbiota transplantation; α, rate of antimicrobial prescription which is reduced through stricter stewardship; β, the rate of transmission which is reduced through improvements to hygiene and sanitation; κ, the rate of patient discharge (inverse of average length of stay) which is increased to minimize patient exposure window.

Bishop J, Parry MF, Hall T. Decreasing Clostridium difficile infections in surgery: impact of a practice bundle incorporating a resident rounding protocol. Conn Med2013; 77: 69–75.

 PubMedGoogle Scholar

Koll BS, Ruiz RE, Calfee DP et al. Prevention of hospital-onset Clostridium difficile infection in the New York Metropolitan Region using a collaborative intervention model. J Health Qual2014; 36: 35–45.

 PubMed Web of Science ®Google Scholar

Abbett SK, Yokoe DS, Lipsitz SR et al. Original article: proposed checklist of hospital interventions to decrease the incidence of healthcare-associated Clostridium difficile infection. Infect Control Hosp Epidemiol2009; 30: 1062–1069.

 PubMed Web of Science ®Google Scholar

Salgado CD, Mauldin PD, Fogle PJ, Bosso JA. Analysis of an outbreak of Clostridium difficile infection controlled with enhanced infection control measures. Am J Infect Control2009; 37: 458–464.

 PubMed Web of Science ®Google Scholar

Weiss K, Boisvert A, Chagnon M et al. Multipronged intervention strategy to control an outbreak of Clostridium difficile infection (CDI) and its impact on the rates of CDI from 2002 to 2007. Infect Control Hosp Epidemiol2009; 30: 156–162.

 PubMed Web of Science ®Google Scholar

Muto CA, Blank MK, Marsh JW et al. Control of an outbreak of infection with the hypervirulent Clostridium difficile BI strain in a university hospital using a comprehensive “bundle” approach. Clin Infect Dis2007; 45: 1266–1273.

 PubMed Web of Science ®Google Scholar