Clostridium difficile infection is a dangerous and sometimes deadly adverse event in immunocompromised patients with cancer. Although transmission risk is high in the hospital setting, even with isolation precautions, oncology providers can use a variety of prevention techniques to reduce the chance for infection in their patients.

In their article in the October 2019 issue of the Clinical Journal of Oncology Nursing, Nielsen, Sanchez-Vargas, and Perez explained the evidence-based program they established at their institution that statistically significantly reduced the incidence of C. difficile infection in patients with cancer.

What the Research Recommends

Nielsen et al. conducted a literature review to identify the reported best practices for preventing C. difficile infections and found seven articles that met the criteria for content and level and quality of evidence. Together, the study reports and systematic review articles recognized the following behaviors as effective C. difficile prevention:

  • Frequently cleaning high-touch surfaces (e.g., bed rails, bed frame, bed tables, patient’s body, bed linens, curtains, IV infusion pump control panels, blood pressure cuffs)
  • Disinfecting portable equipment daily
  • Using disposable cleansing wipes with the correct dwell time
  • Improving cleaning in non-isolation rooms
  • Maintaining rigorous cleaning protocols even in isolation rooms
  • Developing standard thresholds for defining cleanliness
  • Assessing current processes to identify weaknesses and inconsistencies in cleaning practices

Incidentally, nurses perform 75% of the high-touch contacts whereas family and visitors are responsible for just 10%, according to one study that Nielsen et al. reviewed.

Five by Five Initiative to Reduce C. Difficile Infection

Based on their findings from the evidence review, Nielsen et al. assessed the practices, policies, and C. difficile infection rates at their institution and determined that practice change was needed. They developed the Five by Five initiative (see sidebar) to better standardize patient room cleaning with the goal of reducing infections.

Before implementing the initiative, environmental services staff cleaned patient rooms once every 24 hours in a seven-step process: empty waste and linen containers; dust all fixtures and surfaces starting at the door and working clockwise around the room; use a two-step clean-and-disinfect process to clean all high-touch surfaces, horizontal surfaces, spots on walls, and cabinets; dust mop room; clean bathroom; damp mop room; and inspect room for cleanliness. The process involved cleaning four of the five high-touch areas, but because of institutional restrictions on equipment environmental staff could clean, disinfecting the IV pump and poles fell to clinical staff. The authors found that different staff cleaned with different levels of thoroughness because of varied understanding of the requirements, and some were not cleaning the high-touch surfaces.

Patient and visitor education (see sidebar) was included in the program, and staff were trained through online education, start-of-shift huddles, and one-page informational sheets that explained the need for the intervention and the difference it would make for patients.

How Successful Was It?

After implementing the program from November 2017–October 2018 on one 15-bed surgical transplantation unit and three 26-bed medical-surgical oncology units, all of which provided care for immunocompromised patients, Nielsen et al. statistically assessed the outcomes data. All of the units had a statistically significant reduction in C. difficile infections ranging from p < 0.006 to p < 0.02. Infection rates were reduced by 50%, 67%, 86%, and 100%, depending on the unit.

The authors also measured adherence to the cleaning procedures and documenting that cleaning had been completed. Night shift workers had a 60% documentation rate, compared to 39% for day shift staff. The unit with the highest adherence to cleaning procedures averaged 73% over the 12-month pilot period.

When the Five by Five initiative was rolled out to the entire institution, C. difficile infection cases went from 54 preintervention to 35 postintervention. The authors attributed the success to culture change, creativity, and persistence that overcame staff engagement barriers (i.e., current cleaning habits, supply availability, staff education, and individual nurse beliefs). 

Nielsen et al. listed some limitations to the initiative, including:

  • Small pilot sample size
  • Intermittent availability of cleaning towelettes when supplies were on backorder
  • Determining the best way to make the cleaning wipes available to staff in patient rooms
  • Patient refusal to allow the staff to clean according to the procedure because of the disinfectants’ smell
  • Difficulty in having temporary outside staff follow the procedure

For more information on the Five by Five C. difficile initiative and the opportunity to earn 0.5 nursing continuing professional development credits, free for ONS members, refer to the full article by Nielsen et al.

Questions regarding the information presented in this article should be directed to the Clinical Journal of Oncology Nursing editor at