Clean Hands, Hospitals Prove Best Combination to Reduce C. Diff, Economic Analysis Shows

David Brain, PhD, MPH, Queensland University of Technology

David Brain, PhD, MPH

Better hand washing bundled with improved hospital cleanliness provided the best combination of health benefits and cost-savings for reducing Clostridium difficile infection (CDI), an economic evaluation from Australia suggests.

“Combining efforts to improve hand hygiene compliance at the same time as improving environmental cleaning practices results in a larger decrease in Clostridium difficile cases than delivering those interventions on their own,” lead author David Brain, PhD, MPH, told MD Magazine.

CDI causes an estimated 15—25% of antibiotic-associated diarrhea, presenting a major challenge for healthcare providers. The cost of primary infection ranges from $3,400-$16,300 per case, while treating recurrent infection costs between $13,700–$18,000.

“The most effective approach to reducing Clostridium difficile transmission is to implement interventions in a bundled manner,’’ said Brain, a research fellow at the Australian Centre for Health Services Innovation, Queensland University of Technology, in Brisbane.

At the same time, deaths attributable to CDI have increased from pre-2000 estimates of 1.5% mortality to 4.5%—5.7% mortality in recent years, according to the paper published in PLOS ONE by Brain and a team from Australia and the UK.

“The clinical aspects of the infection have been well described across many different settings globally, but there is very little information from an economic perspective,’’ Brain said.

That is beginning to change.

“Interest in cost-effectiveness analyses, such as this, has spiked in recent years as healthcare decision-makers try to manage increased demand for services with a limited, and often reducing health care budget,” Brain said.

To assess the costs and benefits of various CDI-fighting strategies, Brain and his team considered data from Australian hospitals, the natural history of the disease, and literature on the efficacy of various methods.

"Most hospitals employ a mixed approach that combines antimicrobial stewardship, hand hygiene, environmental cleaning and fecal bacteriotherapy,” the authors wrote.

However, the team found a lack of economic evidence to support current practice.

“The majority of guidelines are built solely on clinical evidence, with no consideration of the costs and health returns from alternative strategies of infection control,’’ they said.

To find the most effective approach to reducing CDI, the authors’ model examined both health outcomes and costs.

To assess health, they considered the effectiveness of an intervention and its subsequent impact on a patient’s quality of life.

They categorized costs as intervention-related, such as staff and equipment expenses, and infection-related, which included the price of diagnosis, treatment and hospital stays.

The most successful approach of the 10 the team assessed combined better hand hygiene with improved environmental cleaning — a bundle the researchers called "hygiene improvement.’’ This strategy decreased disease incidence to 1.1 per 1000 bed days from 3.2 per 1000 bed days.

“Hygiene improvement achieved the greatest health benefits, with 127 quality-adjusted life years (QALYs) gained and the lowest costs, with over $2 million saved,” they found.

However, coupling hygiene improvement with another intervention, such as antimicrobial stewardship (AMS), yielded little additional benefit.

In fact, AMS on its own resulted in only a small reduction in Clostridium difficile incidence to 2.3 per 1000 bed days from 2.8 per 1000 bed days.

“Antimicrobial stewardship programs, which are a common intervention that is designed to reduce the number of C. difficile infections, were not always successful in achieving a reduction,” Brain said.

Fecal transplant also was an ineffective control tool, the team found. On its own, the procedure reduced CDI incidence to just 2.4 per 1000 bed days from 2.5 per 1000 bed days. The technique also appeared to have little impact when combined with other transmission-reduction strategies.

Such analyses can lead to improved decision-making, Brain said. For instance, infectious disease physicians, ward managers and others might divert limited resources from an approach such as AMS to a bundle of hand hygiene and environmental cleaning to achieve better clinical outcomes.

How might such findings inform CDI control in US hospitals?

“The 2 health systems (Australia and US) are quite different from a funding perspective, so I think that the approach to costing would be quite different,” Brain said.

Instead of using a health care perspective, as the current study did, the US might look at the cost to insurers or users’ out of pocket costs, he said.

“There may also be other interventions that would be more locally appropriate to include in the model,’’ Brain said, noting that economic modeling is useful because it can be updated when new data become available.

“I do think that the clinical outcomes are quite transferable, though, especially if there is little information currently available from US-based studies,” he said.

Brain said his team is now focusing on quantifying the economic burden of Clostridium difficile in the Australian hospital setting.

At this point, the extra length of stay attributable to CDI has been difficult to pin down because of irregularities in the way information is collected, he said.

“We hope that the methods will be transferable to other settings, like the US and UK, so that we can contribute to the international evidence base,” Brain said.