Clostridium difficile: Is there an Infection Prevention Sweet Spot based on Hospital Occupancy?

Author: Holly Montejano, MS, CIC, CPHQ, VA-BC

Categories: C. difficile August 1, 2018

Patients do not go to the hospital with pneumonia, a heart attack, or any other medical emergency, expecting to become sicker with a diarrheal illness! Being hospitalized is not without its own risks- including being exposed to additional infections. We know the common variables related to Clostridium difficile infection (CDI) for hospitalized patients—staff, patient and visitor hand hygiene, antibiotic use, and environmental cleaning and disinfection. A new variable has recently been studied in the CDI risk portfolio—hospital occupancy—and the results are interesting!

Many studies have been published looking at the relationship between nurse staffing and adverse patient outcomes (patients suffer more adverse events due to inadequate nurse staffing)1, 2, but now the question being asked, is there a sweet spot that exists between patient hospital-acquired CDI and inpatient occupancy3. Researchers at the University of Michigan looked at hospital-acquired CDI and inpatient occupancy to see if a risk relationship exists.

Clostridium difficile infection, caused by a spore-forming bacteria, causes inflammation of the colon (colitis), watery diarrhea, fever, loss of appetite, nausea and abdominal tenderness4. Elderly patients, those who have received antibiotics and those who have frequent inpatient hospital stays are at greatest risk for developing this infection4. Abir, et al, looked at retrospective admissions data from acute care hospitals in California during 2008-2012. The study population included Medicare patients ≥ 65 years of age with an emergency department admission for acute myocardial infarction, pneumonia, or heart failure with a hospital length of stay < 50 days. Taking a more precise approach to inpatient occupancy, the researchers categorized hospital occupancy during the patient’s admission into four levels: low (0-25 percent), two levels of moderate (26-50 percent and 51-75 percent), and high (76-full capacity). What they found was not expected. Hospital acquired CDI rates were three times greater when hospital occupancy was in the moderate range, and much lower when the hospital was at a low and high occupancy3. Ultimately, the sweet spot is not where we would expect. Per the researchers, these results beckon further review of infection prevention and nursing practices, policy and staffing variations based on hospital occupancy, and call for routine collection of occupancy information when reviewing all infections. It is important to review what infection prevention processes possibly could be impacted during moderate occupancy that appear to function well at low and high occupancies3.

Per Centers for Disease Control and Prevention (CDC), patients who present with diarrheal illness or are suspected or confirmed with CDI should be placed on contact precautions with appropriate personal protective equipment (PPE) use. An EPA-approved hospital disinfectant with a sporicidal claim, like Sani-Cloth® Bleach wipes, should be used to clean and disinfect surfaces around the patient. Hand hygiene for both the patient and the caregiver should consist of soap and water in an outbreak setting. For patients who are bedbound, or unable to perform soap and water hygiene in a non-outbreak setting5, an alcohol hand wipe, like Sani-Hands® wipes, is an optimal substitute6. Pokrywka, et al found a significant reduction in healthcare-onset CDI when bedbound patients were provided with a wipe containing at least 65.9% alcohol. These patients were educated by hospital staff to perform hand hygiene at the appropriate moments (before and after having visitors, after returning from testing or a procedure, before touching dressing incisions, prior to meals, and after toileting). The researchers in this study concluded “although alcohol is not considered to be an effective agent for killing Clostridium difficile spores, it can be theorized that the alcohol wipes provided mechanical cleaning of the patients’ hands, which removed organic debris and, potentially, spores from the skin surface6”.

Clostridium difficile infection is often due to multiple factors, and many preventive measures can be taken to keep patients safe from hospital-acquired CDI. A close review of these infections within a facility, along with concurrent occupancy tracking, may provide some insight on best practices which fall to the wayside. What we do know is that hand hygiene, appropriate antibiotic use, environmental cleaning and disinfection, and PPE use can stop the spread of this dangerous infection—and should be practiced consistently along the entire spectrum of hospital occupancy.

  1. Needleman, J., Buerhaus, P., Pankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse staffing and inpatient hospital mortality.New England Journal of Medicine,364(11), 1037-1045.
  2. Robert A. Weinstein, Patricia W. Stone, Monika Pogorzelska, Laureen Kunches, Lisa R. Hirschhorn; Hospital Staffing and Health Care–Associated Infections: A Systematic Review of the Literature,Clinical Infectious Diseases, Volume 47, Issue 7, 1 October 2008, Pages 937–944,
  3. Abir, M., Goldstick, J., Malsberger, R., Setodji, C. M., Dev, S., & Wenger, N. (2018). The Association of Inpatient Occupancy with Hospital-Acquired Clostridium difficile Infection.Journal of hospital medicine.
  4. Accessed July 23, 2018
  5. Accessed July 23, 2018
  6. Marian Pokrywka MS, CICa,*, Michele Buraczewski BSNb, Debra Frank MSN, BSNc, Heather Dixon MSN, BSNd, Juliet Ferrelli MS, MT(ASCP), CICa, Kathleen Shutt MSe, Mohamed Yassin MD, PhD. Can improving patient hand hygiene impact Clostridium difficile infection events at an academic medical center? American Journal of Infection Control, Volume 45, Issue 9, 959 – 963.


Holly Montejano MS, CIC, CPHQ, VA-BC
holly Clinical Science Liaison, PDI Gulf Coast


Holly’s passion for infectious disease epidemiology developed during her undergraduate studies at University of Connecticut, where she studied biology and anthropology – and the profound impact of disease on people, public health and within healthcare systems. This passion led to a graduate program focused in infectious disease epidemiology and a post-graduate epidemic intelligence service (EIS) fellowship in public health, and a graduate certification in infection control at the University of South Florida.

After several years as a public health epidemiologist, Holly transitioned into infection prevention and healthcare epidemiology where she currently is part of a dynamic clinical affairs team, supporting the Gulf Coast region as a Clinical Science Liaison (CSL).


Phone: 321.439.7923

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Interior design
Beach staycations
Little League baseball and softball


University of Connecticut, Storrs, CT
Bachelor of Science in Biology and Anthropology

Colorado State University, Fort Collins, CO
Master of Science in Environmental and Radiological Health Sciences (Epidemiology and Infectious Disease)

Certification Board of Infection Control (CBIC)- CIC
Certified Professional in Healthcare Quality (NAHQ)- CPHQ
Vascular Access- Board Certified (VA-BC)
Lean Six Sigma Yellow Belt Certification
Prosci Change Management Certification

Why I love what I do

Infectious disease epidemiology – from both a biological and anthropological standpoint – have always been a passion of mine. Studying the effects of disease on populations (from a public health standpoint and from that of an Infection Preventionist) has fueled my interest in patient safety and quality outcomes initiatives. My work of providing clinical expertise and evidence-based guidance on infection prevention products (which are used in communities and healthcare systems daily) bolsters the satisfaction I experience in this role.

Areas of Expertise

Microbiology and infectious disease transmission
Infection Prevention
Patient Safety and healthcare quality
Safety culture
Public Health
Vascular access
Environmental disinfection
Performance Improvement

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