Boone N, Eagan J A, Gillern P, Armstrong D, Sepkowitz K A
Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
Am J Infect Control. 1998 Dec;26(6):584-7. doi: 10.1053/ic.1998.v26.a84725.
Diarrhea caused by Clostridium difficile is increasingly recognized as a nosocomial problem. The effectiveness and cost of a new program to decrease nosocomial spread by identifying patients scheduled for readmission who were previously positive for toxin was evaluated.
The Memorial Sloan-Kettering Cancer Center is a 410-bed comprehensive cancer center in New York City. Many patients are readmitted during their course of cancer therapy. In 1995 as a result of concern about the nosocomial spread of C difficile, we implemented a policy that all patients who were positive for C difficile toxin in the previous 6 months with no subsequent toxin-negative stool as an outpatient would be placed into contact isolation on readmission pending evaluation of stool specimens. Patients who were previously positive for C difficile toxin were identified to infection control and admitting office databases via computer. Admitting personnel contacted infection control with all readmissions to determine whether a private room was required.
Between July 1, 1995, and June 30, 1996, 47 patients who were previously positive for C difficile toxin were readmitted. Before their first scheduled readmission, the specimens for 15 (32%) of these patients were negative for C difficile toxin. They were subsequently cleared as outpatients and were readmitted without isolation. Workup of the remaining 32 patients revealed that the specimens for 7 patients were positive for C difficile toxin and 86 isolation days were used. An additional 25 patients used 107 isolation days and were either cleared after a negative specimen was obtained in-house or discharged without having an appropriate specimen sent. Four patients (9%) had reoccurring C difficile after having toxin-negative stools. We estimate (because outpatient specimens were not collected) the cost incurred at $48,500 annually, including the incremental cost of hospital isolation and equipment.
Our policy to control the spread of nosocomial C difficile required interdisciplinary cooperation between infection control and the admitting department. By identifying patients who were positive for toxin through admitting, we were able to place all potentially infected patients into isolation. Our positivity rate of 15% on readmission demonstrates the importance of this policy. The cost of controlling C difficile can be significantly lowered by clearing patients who were previously positive for toxin before hospital readmission.
艰难梭菌引起的腹泻日益被视为一个医院感染问题。我们评估了一项新计划的有效性和成本，该计划旨在通过识别之前毒素检测呈阳性的再次入院患者来减少医院感染的传播。
纪念斯隆凯特琳癌症中心是纽约市一家拥有410张床位的综合性癌症中心。许多患者在癌症治疗过程中会再次入院。1995年，由于担心艰难梭菌的医院感染传播，我们实施了一项政策，即所有在过去6个月内艰难梭菌毒素检测呈阳性且之后门诊大便检测未转为毒素阴性的患者，再次入院时将被置于接触隔离状态，等待大便标本评估。通过计算机在感染控制和入院办公室数据库中识别出之前艰难梭菌毒素检测呈阳性的患者。入院人员在所有患者再次入院时联系感染控制部门，以确定是否需要单人病房。
在1995年7月1日至1996年6月30日期间，47名之前艰难梭菌毒素检测呈阳性的患者再次入院。在他们首次计划再次入院之前，其中15名（32%）患者的标本艰难梭菌毒素检测为阴性。他们随后作为门诊患者被解除隔离，再次入院时未被隔离。对其余32名患者的检查发现，7名患者的标本艰难梭菌毒素检测呈阳性，共使用了86个隔离日。另外25名患者使用了107个隔离日，他们要么在院内获得阴性标本后被解除隔离，要么在未送检适当标本的情况下出院。4名患者（9%）在大便毒素检测呈阴性后艰难梭菌复发。我们估计（由于未收集门诊标本）每年的成本为48,500美元，包括医院隔离和设备的增量成本。
我们控制医院艰难梭菌传播的政策需要感染控制部门和入院部门之间的跨学科合作。通过在入院时识别毒素检测呈阳性的患者，我们能够将所有潜在感染患者置于隔离状态。我们再次入院时15%的阳性率证明了这项政策的重要性。通过在患者再次入院前清除之前毒素检测呈阳性的患者，可以显著降低控制艰难梭菌的成本。
