What are the latest recommendations for prevention of C. difficile?

Dynamed references Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).  Infect Control & Hosp Epidemiology. 2010; 31(5): 421-455.
Recommendations for prevention of infection during a hospital outbreak include (definitions of ratings are in Table 1, p. 434):
•    Healthcare workers and visitors must use gloves (A-I) and gowns (B-III) on entry to a room of a patient with CDI.
•    Emphasize compliance with the practice of hand hygiene (A-II).
•    In a setting in which there is an outbreak or an increased CDI rate, instruct visitors and healthcare workers to wash hands with soap (or antimicrobial soap) and water after caring for or contacting patients with CDI (B-III).
•    Accommodate patients with CDI in a private room with contact precautions (B-III).   If single rooms are not available, cohort patients, providing a dedicated commode for each patient (C-III).
•    Maintain contact precautions for the duration of diarrhea (C-III).
•    Routine identification of asymptomatic carriers (patients or healthcare workers) for infection control purposesis not recommended (A-III) and treatment of such identified patients is not effective (B-I).
•    Identification and removal of environmental sources of C. difficile, including replacement of electronic rectal thermometers with disposables, can reduce the incidence of CDI (B-II).
•    Use chlorine-containing cleaning agents or other sporicidal agents to address environmental contamination in areas associated with increased rates of CDI (B-II).
•    Routine environmental screening for C. difficile is not recommended (C-III).

Reviewed JKN 4/14

What is the prevalence of C. difficile infection in hospitals in the United States?

DynaMed references CDC report on prevalence of C. diff. diagnoses in hospital discharges
Emerg Infect Dis. 2006 Mar;12(3):409-15.
Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003.  McDonald LC, et al.
Study of annual rate of hospital discharges with listed diagnosis of C. difficile-associated diarrhea in National Hospital Discharge Survey.  31 per 100,000 population in 1996; increasing from 2000 to 2003 reaching 61 per 100,000 population in 2003

Emerg Infect Dis. 2008 Jun;14(6):929-31.
Increase in adult Clostridium difficile-related hospitalizations and case-fatality rate, United States, 2000-2005.  Zilberberg MD, et al.
Reports incidence of C. difficile diagnosis in hospital discharge.  Table displays incidence by age group

Reviewed JKN 4/14

Does the use of a thoracic impedance device during resuscitation improve patient outcomes compared to resuscitations without use of such a device?

There is some evidence that use of an impedance threshold device added to active compression-decompression device  may result in small improvement in survival but impedance device added to standard cardiopulmonary resuscitation (CPR) does not improve survival.

Aufderheide TP, et al. Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomised trial. Lancet. 2011 Jan 22;377(9762):301-11. RESQ Trial
1,653 adult patients with out-of-hospital cardiac arrest randomized to resuscitation with compression-decompression device plus impedance threshold device compared to standard CPR. RESULTS:  Survival to discharge without neurologic impairment was similar for both groups.

Aufderheide TP, et al. A trial of an impedance threshold device in out-of-hospital cardiac arrest. N Engl J Med. 2011 Sep 1;365(9):798-806. ROC PRIMED Trial
9,220 patients with out-of-hospital cardiac arrest randomized to standard CPR with active impedance threshold device (ITD) compared to standard CPR with sham ITD. RESULTS:  Survival to hospital discharge with normal Rankin score was 6% for the sham ITD group compared to 5.8% for the active ITD group.  Rates for return of spontaneous circulation and survival to hospital admission were also similar for both groups.

Also see Cardiac Arrest (Treatment>Other Management>Prehospital care>Improving chest compressions).  In:  DynaMed

Cabrini L, et al. Impact of impedance threshold devices on cardiopulmonary resuscitation: a systematic review and meta-analysis of randomized controlled studies. Crit Care Med. 2008 May;36(5):1625-32.
Systematic review of older, RCTs

Reviewed JKN 4/14

Does pre-warming patients prior to surgery affect post-surgical core temperatures?

Inadvertent Perioperative Hypothermia.  In: Joanna Briggs JBI+Connect, Feb 17, 2011.
Evidence summary on effectiveness of various interventions for preventing hypothermia in patients undergoing surgery. Cites evidence-based guideline (National Collaborating Centre for Nursing and Supportive Care. Clinical practice guideline: the management of inadvertent perioperative hypothermia in adults. April 2008) for evidence that suggests warming patients in the preoperative period may reduce risk for inadvertent perioperative hypothermia. See guideline for specific evidence; Fig. 9 (p. 149) summarizes evidence from two observational studies documenting effect of preoperative temperature on incidence of hypothermia.

CINAHL search on preoperative and warming and (postoperative temperature OR hypothermia)
Search results include several quasi-experimental studies evaluating change in post-operative rates of hypothermia after implementing preoperative warming including:

  • Preprocedure warming maintains normothermia throughout the perioperative period: a quality improvement project.  Hooven K; Journal of PeriAnesthesia Nursing, 2011 Feb; 26 (1): 9-14S
  • A preoperative forced-air warming protocol to maintain postoperative normothermia… ASPAN National Conference.  Sedei J; Journal of PeriAnesthesia Nursing, 2010 Jun; 25 (3): 198
  • The Effects of Forced Air Warming in Preventing Post-Operative Hypothermia.  Ochampaugh, Barbara U.; Glenning, Carol; Journal of PeriAnesthesia Nursing, 2011 Jun; 26 (3): 201

PubMed search: preoperative AND warming identified
Torossian A. Thermal management during anaesthesia and thermoregulation standards for the prevention of inadvertent perioperative hypothermia. Best Pract Res Clin Anaesthesiol. 2008 Dec;22(4):659-68.
Reviews the literature’s findings on all current methods both passive and active and attempts to institute management guidelines for thermal management.

Reviewed by John Nemeth 4/14

Are there systematic reviews of the evidence about the effect of chlorhexidine on rate of catheter associated urinary tract infections?

Joanna Briggs Institute’s JBI+COnNECT, an evidence summary source, has published this evidence summary:  Urethral Catheter (Indwelling Short-Term):  Urinary Tract Infection Prevention

The Clinical Bottom Line section summarizes evidence on various care regimens, including daily cleaning.  Two relevant statements:
“Daily cleansing of the urethral meatus using soap and water or perineal cleanser has been shown to be effective to reduce CAUTI.3 (Level II)”
“The following interventions are not deemed effective for reducing CAUTI incidence: sterile technique for catheter insertion, use of antiseptic solutions or ointment during routine meatal care, 2-chambered urinary drainage bags, antiseptic filters incorporated into the drainage bag, bladder or catheter irrigation, frequent urinary drainage bag changes and placing an antiseptic solution into the urinary drainage bag.3 (Level I)”

References to other systematic reviews are available through this PubMed search: chlorhexidine AND urinary tract infection AND catheter AND (systematic review OR meta-analysis)

Does perineal cleaning with chlorhexidine prior to inserting a urinary catheter reduce the rate of catheter-acquired urinary tract infections (CAUTI)?

Bottom line:  There is no evidence that cleaning the perineal area with chlorhexidine prior to catheter insertion reduces the rate of CAUTI.

Summary:  Identified documents using JBI+COnNECT (Joanna Briggs Institute)

Review of results led to CDC CAUTI guidelines, 2009.
Page 43 references two studies that found no difference between cleaning with chlorhexidine v. water prior to catheter insertion.  There are also studies referenced in that section that address intermittent care.

A systematic review of the management of short-term indwelling urethral catheters to prevent urinary tract infections
Page 702 – describes 1 RCT of 436 patients admitted to obstetrical unit who were randomized to periurethral cleaning with water v. chlorhexidine prior to insertion of catheter.  No significant difference in rates of CAUTI between the groups.

The RCT of 436 patients is also referenced in this best practice summary: Management of short-term indwelling urethral catheters to prevent urinary tract infections

What are the recidivism rates for hospitalized medical psychiatry or geriatric psychiatry patients?

Readmission to psychiatric units of acute care hospitals
Healthc Q. 2007;10(2):30-2.
Madi N, Zhao H, Li JF.  Hospital readmissions for patients with mental illness in Canada.
In Canada, during the years 2002-2004, 37% of patients discharged with a mental illness diagnosis were readmitted at acute care hospitals within a one year period.

Readmission to psychiatric hospitals
Psychol Rep. 2003 Dec;93(3 Pt 1):816-8.
Feigon S, Hays JR.  Prediction of readmission of psychiatric inpatients.
Prospective study of 943 patients admitted to an urban psychiatric hospital.  Over 5 years of follow up, 33% of the patients (all ages) had at least one readmission.

Aust N Z J Psychiatry. 2011 Jul;45(7):578-85.
Zhang J, et al.  Factors associated with length of stay and the risk of readmission in an acute psychiatric inpatient facility: a retrospective study.
Retrospective study of 286 randomly selected admissions over 12 month period.  Of the 178 patients involved in these admissions, 46% were readmitted during this 12 month period.

Readmission to geriatric psychiatry inpatient unit
J Geriatr Psychiatry Neurol. 2006 Dec;19(4):226-30.
Woo BK, et al.  Factors associated with frequent admissions to an acute geriatric psychiatric inpatient unit.
Study included 424 consecutive admissions to a university-based geriatric psychiatry inpatient unit over a 20-month period. Mean age of patients was 79.4 years.  35.6% were readmissions.