key: cord-0899567-pq3g68o3
authors: Bentivegna, Enrico; Alessio, Giuliano; Spuntarelli, Valerio; Luciani, Michelangelo; Santino, Iolanda; Simmaco, Maurizio; Martelletti, Paolo
title: Impact of COVID-19 prevention measures on risk of health care-associated Clostridium difficile infection
date: 2020-10-05
journal: Am J Infect Control
DOI: 10.1016/j.ajic.2020.09.010
sha: 5afa1933234c2496e6ad97263b00d826a6682a5c
doc_id: 899567
cord_uid: pq3g68o3

Clostridium difficile is the most common pathogen between health care-associated infections and its incidence has increased during the last years. lack of enough evidence about effective hygiene interventions to prevent this disease. Due to the coronavirus disease 2019 (COVID‑19) pandemic, several strategies to reduce microorganism spread were adopted in hospital setting. The objective of this study was to establish whether such strategies can reduce healthcare associated Clostridium difficile infection (HA-CDI) incidence. We found that, during the pandemic (2020) HA-CDI incidence was significantly lower with respect to the previous years. This work demonstrates that maintaining this level of attention regarding control activities related to prevention of microorganism transmission significantly reduce HA-CDI and related expenses in terms of health costs and human lives.

control activities related to prevention of microorganism transmission significantly reduce HA-CDI and related expenses in terms of health costs and human lives.

Clostridium difficile (CD) is the most common pathogen among health care-associated infections [1, 2] . An important obstacle in prevention of Clostridium difficile infection (CDI) is the lack of enough evidence about effective hygiene interventions to prevent this disease. Although preventive contact precautions are recommended, there are no sufficient data on their effectiveness for its prevention [3, 4] . Due to the coronavirus disease 2019 (COVID-19) pandemic, several strategies to reduce microorganism spread were adopted in hospital setting [5] . The objective of this study was to establish whether such strategies can reduce healthcare associated Clostridium difficile infection (HA-CDI) incidence. The primary task was to identify differences on HA-CDI incidence in medical wards before and during the COVID-19 pandemic. The secondary task was to evaluate if severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection could influence the incidence of CDI.

We conducted a retrospective analysis on medical wards' discharges (n. 1617) in S. Andrea Hospital (Rome) from March 1 st to June 30 th comparing data before (2017, 2018 and 2019) and during (2020) the COVID-19 pandemic. Intensive care units and paediatric wards were excluded. CDI diagnosis was confirmed by clinical suspicious (presence of diarrhoea defined as ≥3 unformed stools in 24 hours) plus stool tests positive for CD. HA-CDI incidence were depicted as CDI diagnosed ≥72 h after admission per 100 total discharges. Data was collected using Excel Office, and Chi-square test was performed to detect differences in HA-CDI incidence between different groups. Value of p < 0.05 was considered as significant.

The number of discharges and HA-CDI diagnosis for each medical ward is reported in table 1. No statistically significative difference of HA-CDI incidence between years 2017, 2018 and 2019 was observed.

Conversely, during the pandemic (2020) HA-CDI incidence was significantly lower with respect to 2017 (odds ratio [OR] = 2,98; P = .002), 2018 (OD = 2.27; P = .023) and 2019 (OD = 2,07; P = .047) (see Tab. 1 and Fig. 1) . Interestingly, during 2020, COVID-19 departments showed higher HA-CDI incidence respect to Covid-19 free wards (not significative). This data suggests SARS-Cov2 infection as a possible risk factor for CDI in agreement with recent evidences that report altered gut microbiota in COVID-19 patients [5] .

Furthers studies are needed to confirm this hypothesis.

CDI incidence has increased from 4.5/1000 adult discharge in 2001 to 8.2/1000 discharge in 2010 [7] with annual healthcare costs that exceed $1.5 billion in the U.S [8] . Several studies have been carried out to identify CDI prevention strategies in hospital setting. Although contact precautions, PPE employments and healthcare workers hygiene education are strongly recommended, as of today, evidence for their effectiveness in CDI prevention is still weak [3, 4] . Although within a limited period of observation, this work provides evidences for such strategies' effectiveness in reducing HA-CDI incidence. From the beginning of the pandemic, personal protective equipment (PPE) (surgical masks, latex gloves and disposable medical coats) were employed by healthcare workers and a greater attention has been paid to frequent hand washing and surfaces disinfection. Relatives' visits to patients were limited to only one family member at a time and were reduced from two to one time per day. Each visitor had to wear PPE described above and adopt the social distancing measures recommended by the World Health Organization (WHO). We report a significative reduction of HA-CDI incidence while using these precautions. Our study does not tell which ones of the prevention measures adopted during emergency played a major role in this modification. Previous studies demonstrated that intensified hand-hygiene practices alone were not effective in preventing CDI [4] . We can therefore speculate that all practices described above adopted in their complex along with greater attention payed by health personnel have led to lower CD spread.

Healthcare associated infections frequency is an indicator of the healthcare quality. Previous studies demonstrated how health workers hygiene errors are at the base of microorganism spread in hospital setting: in particular, protocol deviations during PPE donning and doffing are common and cause selfcontamination [9] . The COVID-19 emergency has led to extraordinary levels of attention by all healthcare personnel regarding control activities related to prevention of microorganism transmission. This study demonstrates that maintaining this level of preventive measure over time would significantly reduce HA-CDI and related expenses in terms of health costs and human lives.

Guidance document for prevention of Clostridium difficile infection in acute healthcare settings

Clostridium Difficile Infection in Acute Care Hospitals: Systematic Review and Best Practices for Prevention

Principles of Disinfectant Use and Safety Operation in Medical Facilities During Coronavirus Disease 2019 (COVID-19) Outbreak. SN Compr

Alterations in Gut Microbiota of Patients With COVID-19 During Time of Hospitalization

The rise in Clostridium difficile infection incidence among hospitalized adults in the United States: 2001-2010

Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system

Assessment of Healthcare Worker Protocol Deviations and Self-Contamination During Personal Protective Equipment Donning and Doffing

During 2020 Covid-19-free departments shown lower incidence of HA-CDI compared to the previously years (* = P < .05). Covid-19 departments shown higher HA-CDI incidence than Covid-19-free departments of the same year