C. diff Prevalence and Prevention

Infection preventionists received confirmation late last year of one of their concerns – that the incidence of Clostridium difficile infection (CDI) was increasing in U.S. hospitals. A large-scale national prevalence study conducted by the Association for Professionals in Infection Control and Epidemiology (APIC) found that the CDI rate was 6.5 to 20 times greater than previous estimates.1 The National Prevalence Study of Clostridium difficile in U.S. Healthcare Facilities indicated that 13 out of every 1,000 inpatients were either infected or colonized with C. difficile. Based on this rate, the study estimated that there are at least 7,178 inpatients on any one given day in American healthcare institutions, representing an associated cost of $17.6 million to $51.5 million.1

C. diff Prevalence

One must compare the APIC study with previous estimates. According to a Consumers Union policy brief on hospital-acquired C. difficile infections, in 1993 an estimated 86,000 patients were discharged from hospitals with C. diff infections. By 2005 there were more than 300,000 CDI hospital discharges.2 According to data from the National Hospital Discharge Survey and the National Inpatient Sample, the number of cases tripled between 1993 and 2005 and has more than doubled between 2001 and 2005.2

The APIC survey presents a one-day snapshot in time of the prevalence of CDIs in U.S. hospitals, with APIC’s members collecting data on their CDI patients on one day between May and August 2008. Survey results were collected from 12.5 percent of all medical facilities in the U.S.; a total of 1,443 patients was identified with CDI from among the 648 participating hospitals.1

“We thought the rates would be higher but did not really know the extent,” says William Jarvis, MD, principal investigator of the study and president and co-founder of Jason and Jarvis Associates, a private consulting firm in healthcare epidemiology. “Our number of responses is the highest for any survey or analysis of CDI data. It was 12.5 percent of all acute-care facilities, but 20 percent of all inpatients. There is no doubt that given that all patients with diarrhea are not tested for C. diff and given that most (nearly 90 percent) of testing is done using the enzyme immunoassay (EIAs) that using one test is 73 percent to 75 percent sensitive, the actual number of CDIs is even higher than we found.”

Equally alarming to prevalence data is the presence of emerging strains that are growing more toxic and are increasingly resistant to antibiotics. The Consumers Union policy paper reports, “In 2005, CDC researchers documented the presence of a strain of C. diff that was found in hospitals from six states. This BI/NAP1 strain was also found to be resistant to fluoroquinolones, unlike other C. diff strains. BI/NAP1 also produces 20 times as much of each of the two main toxins of C. diff as well as an additional toxin. Since C. diff toxins are the mechanism by which it damages the lining of the colon and causes sepsis, a 20-fold increase in the amount of toxin produced leads to significantly more damage to patients. As of October 2008, the more toxic strain has been documented in 40 states in the U.S.”2

“This might very well be tip of the iceberg,” says Nancy Haberstich, a registered nurse certified in infection prevention and control who works as a consultant to the industry. “C. diff is certainly not a new pathogen or one that is unique to certain facilities. But APIC has exposed it with the recent survey (as they did with MRSA). Shining the spotlight on C. diff helps us all focus upon strategies for prevention and elimination. I think C. diff is probably the primary pathogen issue in healthcare settings at this time and meanwhile, we have accepted the expansion of MRSA into the community. They both call attention to the need for antimicrobial stewardship, which I believe is the primary issue for the whole continuum of care.”

Why C. diff is Dangerous

CDIs are transmitted by hand contact with items and/or surfaces contaminated by an infected patient’s feces. The bacteria’s spores can last in the environment or on inanimate objects for weeks or months. One study revealed that C. diff was found on the hands of nearly 60 percent of doctors and nurses caring for infected patients, and that 20 percent of people entering the hospital without the bacteria were exposed to the bacteria during their stay.2 The Consumers Union policy paper explains, “During antibiotic therapy, beneficial bacteria in the colon are killed off but C. diff survives and multiplies. The bacteria release toxins that cause inflammation and damage the mucosal lining of the colon leading to severe diarrhea. Serious infections can result in colitis, sepsis and death. Elderly patients, patients with severe underlying illness and patients undergoing immunosuppressive therapy are at higher risk for becoming infected since their immune response to the bacteria and its toxins is diminished. But the picture is changing with the emergence of a new strain that strikes patients who do not fit this description.”2

C. diff is insidious, striking patient populations normally under the radar. The APIC prevalence study found that 54.4 percent of patients with CDI were identified within 48 hours of admission and 84.7 percent were being treated for general medical conditions like diabetes, pulmonary or cardiac problems and were on wards throughout the hospital.1

“Our results show that the majority of CDI patients are admitted to the hospital already infected,” says APIC president Janet E. Frain, RN, CIC, CPHQ, CPHRM, director of integrated services at Sutter Medical Center in Sacramento, Calif. “Hospitals need to be looking for patients with severe diarrhea, and if CDI is suspected, promptly institute appropriate precautions such as gloves, gowns and separating patients, to avoid spreading the infection. Early recognition of CDI is critical so that prevention measures can be implemented.”

Stopping the administration of antibiotics that created susceptibility in the patient and placing them on alternate antibiotics is a standard course of treatment for C. diff infection. While most cases resolve, however, because of more virulent strains, complications loom large. The Consumers Union policy paper notes, “Pseudomembrane colitis and sepsis result directly from the bacteria and the severe diarrhea that this disease is known for can cause dehydration and change electrolyte balance in the blood enough to cause renal failure or heart attack. As a whole, patients with CDIs have around 4.5 times the average death rate, are sicker and have more complex cases than patients without the disease. Over the period from 1993 to 2005, 46 percent of people with CDI were at major or extreme risk of death, compared to 11.9 percent of all hospital patients. Infected patients also had hospital stays that averaged 13 days, as compared to five days for patients as a whole. Another consequence of C. diff infections are their potential for recurrence. One study in Massachusetts Hospitals found that 14 percent of patients who survive the disease had one or more readmissions for C. diff infections within the following two years. A 2008 national study found that about half of CDI patients were infected when admitted; however, 73 percent were healthcare acquired infections.1 Recurrence of the disease adds to the suffering of patients and increases the costs of treatment. This tendency to recur highlights the importance prevention plays in stopping the spread of C. diff infections.”2

Contributing Causes of CDI

One of the prime contributors to CDI is inadequate infection prevention and control strategies in hospitals, including lack of rigorous hand hygiene and environmental surface decontamination. According to the APIC prevalence study, 73 percent of CDIs were healthcare-acquired, and the Consumers Union policy paper reports, “The risk of becoming infected has been reported as 1,300 times greater in acute-care hospitals than outside of healthcare facilities. One study found that the risk of becoming colonized by C. diff bacteria was directly related to the length of a hospital stay, ranging from a 10 percent chance for a stay between one and two weeks to a 50 percent chance for a stay greater than four weeks in duration. C. diff occurs naturally in only 3 percent of healthy adults.”2

An absence of antibiotic stewardship can also aggravate C. diff prevalence, seeing that some of the most commonly used antibiotics — Cephalosporins, clindamycin, ampicillin and amoxicillin — kill normal intestinal flora but allow C. diff to flourish.2 The BI/NAP1 is also resistant to fluoroquinolones. According to the CDC, up to one-third of physician prescriptions for antibiotics in the U.S. may be unnecessary.2

Gastric acid suppression medications, the use of proton pump inhibitors such as Nexium, Prilosec and Prevacid, and the use of H2-receptor agonists such as Zantac and Pepcid are also risk factors for CDI because they may make it easier for C. diff to survive in the digestive tract. One study found that almost half of hospitalized patients taking these medications may be taking them unnecessarily.2 According to the Consumers Union policy paper, “Major financial incentives for pharmaceutical companies to market these drugs are behind this dangerous trend. Direct-to-consumer advertisement was responsible for 12 percent of the increase in prescription drug sales in 2000, and proton pump inhibitors like Nexium and Prilosec were among the most heavily advertised.”2

Transmission of C. diff and Prevention Strategies

To reduce the risk of transmission, APIC published its “Guide to the Elimination of Clostridium difficile in Healthcare Settings.” APIC recommendations include a risk assessment to identify high-risk areas for CDI within the institution; surveillance program to outline activities and procedures to provide early identification of CDI cases; adherence to hand hygiene guidelines; use of contact precautions (e.g., gloves, gowns and separating CDI patients from other patients); environmental and equipment cleaning and decontamination, especially items that are close to patients such as bedrails and bedside equipment; and antimicrobial stewardship programs with focus on restriction of antibiotics associated with CDI and unnecessary antimicrobial use. APIC’s evidence-based elimination guides translate CDC recommendations into practice.

The Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, authored by William Rutala, PhD, MPH, David Weber, MD, and the Healthcare Infection Control Practices Advisory Committee (HICPAC), states,“ The source of healthcare-associated acquisition of Clostridium difficile in non-epidemic settings has not been determined. The environment and carriage on the hands of healthcare personnel have been considered possible sources of infection... Because C. difficile spore-production can increase when exposed to nonchlorine-based cleaning agents and the spores are more resistant than vegetative cells to commonly used surface disinfectants, some investigators have recommended use of diluted solutions of hypochlorite (1,600 ppm available chlorine) for routine environmental disinfection of rooms of patients with CDAD, to reduce the incidence of C. difficile diarrhea, or in units with high C. difficile rates. Because no EPA-registered products exist that are specific for inactivating C. difficile spores, use of diluted hypochlorite should be considered in units with high C. difficile rates. Acidified bleach and regular bleach (5,000 ppm chlorine) can inactivate 106 C. difficile spores in less than 10 minutes. However, studies have shown that asymptomatic patients constitute an important reservoir within the healthcare facility and that person-to-person transmission is the principal means of transmission between patients. Thus, combined use of handwashing, barrier precautions, and meticulous environmental cleaning with an EPA-registered disinfectant (e.g., germicidal detergent) should effectively prevent spread of the organism.”

Rutala notes, “MDROs survive in the environment and personnel who come in contact with contaminated objects or surfaces may contaminate their hands and in the absence of hand hygiene, transfer the MDROs to patients. Thus, a regular disinfection schedule is a component in prevention. Unfortunately, environmental services may be under-resourced, disinfection may not be thorough or complete, and we do not know the precise frequency for decontaminating non-critical equipment (e.g., blood pressure cuffs) and surfaces in the immediate patient environment. Some of the changes that may facilitate improvement in environmental disinfection include: prepare a checklist for disinfecting items in patient rooms to make it clear who is responsible (e.g., environmental services, nursing); identify the frequency for disinfection and what procedure will be used; and ensure competency (e.g., environmental tracers, competency training/tests).”

Several studies show that hospitals that make an active effort to reduce C. diff infections can achieve strong results. Staff education, improved environmental cleaning, improved isolation of CDI patients and more cautious use of antibiotics have all proven to be effective in significantly reducing the rate of CDI. Antibiotic regulation within hospitals has proven effective in responding to C. diff. The restriction of use of the antibiotic clindamycin following an outbreak in one Virginia hospital resulted in a 70 percent reduction in CDIs. Using this strategy, the hospital recorded a net savings of around $150,000 per year from 1994 to 1996 from avoided CDIs. Restriction of the use of fluoroquinolones and cephalosporins in response to the epidemic BI/NAP1 strain of C. diff may also be an important aspect of infection control.2

The most basic way to prevent CDI is to keep patients from being colonized by C. diff. According to the Consumers Union policy paper, “The CDC’s Guidelines for Infection Control in Health Care Facilities places hand hygiene first in its list of strategies to combat infections from C. diff and similar pathogens. Unfortunately, studies have documented handwashing compliance among doctors in as few as 18 percent of cases and among nurses in less than half of cases. While the introduction of alcohol-based hand rubs has improved hygiene practices in many hospitals, these cannot help in the case of C. diff, where handwashing must be done with soap and water. Since the bacteria’s spores can survive the alcohol disinfectant, healthcare workers who may have been exposed to C. diff must was their hands with soap and water for at least 15 seconds to prevent the spread of this bug. Improved cleanliness in hospital wards is also necessary to limit the spread of C. diff. Use of a hypochlorite cleaning solution is the most effective way to eliminate the bacteria. Hospitals that have stepped up efforts to more thoroughly clean hospital wards have effectively controlled the spread of C. diff. However, reports show that hospital cleaning budgets are being cut every year and that these reduced numbers of cleaning staff are often inadequately trained.”2

“Environmental contamination is especially important with C. diff; however, it is, and always has been, an important aspect in the prevention of healthcare-acquired infections in general,” says Haberstich. “C. diff is just calling us back to some of the strategies that need renewed focus. However, we can’t forget the fact that hands transmit most infections and the portal of entry for C. diff is the mouth or eventually the bloodstream. So, environmental surfaces must be decontaminated so that hands or fomites don’t allow transmission to the vulnerable patients (those who have received antimicrobial agents).”

An increasing body of literature is indicating that contaminated environmental surfaces play an important role in transmission of some healthcare-associated pathogens. Eckstein, et al.3 explain, “Patients colonized or infected with healthcare-associated pathogens often shed these organisms onto their skin and into the environment. Although direct contact with patients is generally considered the major source for acquisition of pathogens on healthcare workers’ hands and subsequent transmission to other patients, several recent studies suggest that contaminated environmental surfaces may also play an important role in pathogen transmission. For example, we found that vancomycin-resistant Enterococci (VRE) and Staphylococcus aureus were frequently acquired on hands of investigators after contact with contaminated objects such as bed rails and bedside tables in colonized patients’ rooms; daily disinfection of environmental surfaces in VRE-colonized patients’ rooms was associated with reduced acquisition of VRE on investigators’ hands. Environmental decontamination with 10 percent bleach has also been associated with reductions in Clostridium difficile infections.”3

Eckstein, et al.3 assessed the adequacy of cleaning practices in rooms of patients with Clostridium difficile-associated diarrhea (CDAD) and VRE colonization or infection and examined whether an intervention would result in improved decontamination of surfaces. They cultured high-touch surfaces such as bedrails, telephones, call buttons, door knobs, toilet seats, and bedside tables in rooms of patients with CDAD and VRE colonization or infection before and after housekeeping cleaning, and again after disinfection with 10 percent bleach performed by the research staff. After the housekeeping staff received education and feedback, additional cultures were collected before and after housekeeping cleaning during a 10-week follow-up period. The researchers explain that housekeepers were instructed to use a 10 percent bleach solution for terminal disinfection of CDAD patients’ rooms, with disinfection performed using a clean cloth or mop soaked in the bleach solution. They were reminded to clean all frequently touched objects.

Patients with VRE colonization or infection were included as a comparison group because they are currently managed with standard precautions and routine terminal cleaning is performed. According to the housekeeping staff, routine terminal disinfection was to include bed rails and bedside tables, but telephones, call buttons, and door handles were not cleaned unless they were obviously soiled. The disinfectant used for routine decontamination of patient rooms was a quaternary ammonium compound.

Of the 17 rooms of patients with VRE colonization or infection, 16 (94 percent) had one or more positive environmental cultures before cleaning versus 12 (71 percent) after housekeeping cleaning, whereas none had positive cultures after bleach disinfection by the research staff. Of the nine rooms of patients with CDAD, 100 percent had positive cultures prior to cleaning versus seven (78 percent) after housekeeping cleaning, whereas only one (11 percent) had positive cultures after bleach disinfection by researchers. Eckstein, et al. report that after an educational intervention, rates of environmental contamination after housekeeping cleaning were significantly reduced. Overall, 30 of 54 (56 percent) total environmental cultures were positive for C. difficile before cleaning and 24 of 54 (44 percent) were positive after housekeeping cleaning.3

Eckstein, et al. concluded, “Our findings provide additional evidence that simple educational interventions directed at housekeeping staff can result in improved decontamination of environmental surfaces. Such interventions should include efforts to monitor cleaning and disinfection practices and provide feedback to the housekeeping staff.”3

Eckstein et al. emphasize the importance of environmental cleaning interventions coupled with the monitoring the efficacy of decontamination with feedback to the housekeeping staff: “Such monitoring of cleaning performance has been recommended in recently published guidelines from the CDC and the Society for Healthcare Epidemiology of America (SHEA). Although our intervention included environmental cultures, less labor-intensive methods of monitoring cleaning practices may also be effective. For example, Carling et al. used an invisible fluorescent marker to monitor cleaning practices; feedback to housekeeping staff led to a sustained improvement in cleaning of surfaces. Hayden et al. performed environmental cultures, but also observed cleaning practices and provided feedback to housekeepers. Frequently touched surfaces in rooms of patients with CDAD or VRE colonization or infection were often contaminated with these pathogens after terminal cleaning by housekeeping staff. Simple educational interventions directed at housekeepers can result in improved environmental decontamination, but these interventions should include efforts to monitor cleaning practices and provide feedback to the housekeeping staff.”3

Haberstich agrees that environmental cleaning, as outlined in APIC’s Guide, is an effective strategy against C. diff. “Quats will kill the vegetative C. diff organism but it takes bleach to kill the spores. It seems that a quat with detergent is still the best way to clean the dirt and debris and the bleach can then kill any spores hanging around. I think we should work harder to ensure that the chemicals are mixed properly and maintained appropriately before use. I do not like the suggestion in the APIC Guide of using a picture of a bleach bottle on the patient’s door to direct the cleaning procedure, as I am worried about the family or employees applying bleach to the hands.”

Haberstich says the C. diff problem raises the issue of healthcare worker awareness in general. “I think healthcare employees have become desensitized to our education in applied microbiology and accuse infection preventionists of ‘making up more rules’ and confusing them. That is why I searched for a fresh new approach to teaching applied microbiology to health professionals and patients — and came up with nanobugs — cartoon microbes that entertain and educate about practical microbiology for the purpose of infection prevention. I created the C. diff nanobug image of an anaerobic spore-former. I think that if this image is used, patients, staff and family members can understand — with the help of our teaching — why handwashing is best and why bleach is needed. We developed a static cling with the C.diff nanobug image and the message to ‘wash well.’”

Education of all healthcare workers can be an effective weapon against C. diff. “I think the best way to improve compliance is with education of staff, patients and families about the nature of this pathogen and therefore the reason for the persistence of C. diff in healthcare settings,” says Haberstich. “In the process of education we have to admit that this infection occurs as a result of antimicrobial therapy.”

Jarvis recommends several action items for healthcare professionals. “They need to organize a multi-disiciplinary team to implement the recommendations,” he advises. “Also, the improvement in antibiotic stewardship may require a full-time or part-time physician focused on this issue. Next, environmental cleaning requires making sure environmental services personnel understand their critical role in infection prevention. Last, hospital administrators need to demand accountability from all clinicians that they must comply (not a request) with recommended infection control recommendations.”

In the near future, there may be an even greater impetus for C. diff prevention. Last summer, the Centers for Medicare and Medicaid Services (CMS) proposed adding CDIs to its list of preventable hospital-acquired conditions for which Medicare will not compensate healthcare institutions for additional costs of treatment; however, numerous comments from the healthcare community pointed to a lack of evidence-based prevention guidelines and “a difficulty distinguishing between infections occurring in the community and in hospitals. CMS indicated it might consider this proposal in the future because of strong support from consumers and healthcare purchasers.”2

The Consumers Union policy paper reports that while CDIs are not on the CDC’s list of diseases that must be reported nationally, some states are passing legislation to require CDI reporting: “A 2008 California law requires hospitals to report C. diff infections specifically, as well as the rates of several other hospital-acquired infections. Twenty-five states have hospital-acquired infection reporting laws, upon which C.diff reporting could be built. Mandatory public disclosure of hospital-specific C. diff infection rates will allow consumers to see which hospitals offer better protection against CDI and will motivate hospitals to improve their infection control practices in the case of this particularly prevalent infection.”2

Haberstich counts herself among those who oppose C. diff being added to the CMS list. “We need to implement the strategies and techniques outlined in the APIC Guide and focus our attention on prevention and not satisfying regulators,” she says. “I do think that antibiotic stewardship is the most important element in prevention and more attention should be given to this — utilizing infection preventionists and intensivists in the healthcare settings — including long-term care.”

References

1. APIC prevalence study. www.apic.org

2. Sayeed S, McGiffert L and McCauley M. Consumers Union Policy Brief. Hospital-Acquired C. difficile Infections. November, 2008.

3. Eckstein BC, Adams DA, Eckstein, EC, Rao A, Sethi AK, Yadavalli GK and Donskey CJ. Reduction of Clostridium Difficile and vancomycin-resistant Enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods. BMC Infect Dis. 2007;7:61.

C. diff Roundtable

ICT asked some industry representatives to share their perspectives on C. diff prevention and control. Roundtable participants include:

• From Contec, Inc.: Lisa Strickland, R&D associate; Kedar Patel, product manager for disinfectants; and Kathy Miscioscio, senior technical service consultant

• From Professional Disposables International, Inc. (PDI): Jean Fleming, RN, MPM, CIC, clinical director of infection prevention and education

• From Medivators Reprocessing Systems, Minntech: Thomas Arcand, product manager

• From ICP Medical: T. Nicholas Anderson and Tom Huling

ICT: What do healthcare workers (HCWs) need to know about pathogen persistence on hospital surfaces and methods for reducing C. diff transmission?

PDI: HCWs need to be aware that C. difficile is a spore-forming microorganism and the spores can exist in the environment for months and can thereby be a continuous source of transmission if no preventative surface disinfection is performed (see Kramer, Schwebke, and Kampf, 2006). C. difficile spores contaminate the environment of rooms occupied by patients with C. difficile infection (CDI). When surfaces in the environment become contaminated, the likelihood of hand contamination of healthcare workers increases. Therefore, patient bathrooms, furniture and “high touch” surfaces such as door knobs, bed rails, IV fluid pumps and surfaces that come in direct contact with patients, i.e., thermometers, BP cuffs, stethoscopes become reservoirs for infection. Patients with CDI should be placed in contact precautions (private rooms when possible) to help reduce patient-to-patient spread of the organism. Use of barriers (gloves and gowns) to prevent transmission is necessary along with observing strict hand hygiene practices. Proper environmental decontamination of rooms housing patients with CDI must be performed.

Contec, Inc.: Just as proper handwashing practices contribute to effective infection control, proper cleaning is also an essential element of infection control. A study presented in November by Dr. William Rutala at APIC’s C. diff conference showed that pathogens can be removed by wiping, even without applying a disinfectant. Proper cleaning and disinfection are key elements of a successful hospital infection control program. Implementation of proper cleaning procedures will require training, tools suited for the task, and monitoring to confirm effectiveness and consistency, but will result in a safer environment for patients and the staff.

Minntech: C. difficile is an opportunistic pathogen found in the colon of people who are immune suppressed or have undergone an extended course of antibiotic therapy. C. diff is tenacious on surfaces because it is a spore former, so elimination from environmental surfaces is extremely difficult. To remove from surfaces, a two-step process is required:

1. Cleaning with a medical-grade detergent which has the specific properties of low foaming, neutral pH and bacteriostatic. Detergents are recommended. Enzymatic detergents are not recommended because they do not contain the specific properties and therefore are not as effective on C. diff.

2. Use an approved product that is effective against spore-forming organisms, such as an oxidizing chemistry. Bleach is not recommended because it is rapidly deactivated by organic soils found in the colon.

ICP Medical: It is well documented that C. diff spores can survive on surfaces for months and are resistant to many disinfectants. Appropriate PPE should always be worn and extra care given to avoiding any contact in the room (e.g., backing into the privacy curtain).

ICT: What is your best piece of advice for proper environmental surface cleaning in the healthcare environment?

PDI: The use of sodium hypochlorite (household bleach) in 1:10 dilution is recommended in outbreak situations and settings where endemic rates of C. difficile are high. There are concerns associated with the use of sodium hypochlorite including corrosion and pitting of equipment over time, and triggering of respiratory difficulties in HCWs using solutions. Because of these concerns, the use of sodium hypochlorite should be limited to outbreak situations as recommended by the CDC “Guidelines for Environmental Control in Healthcare Facilities, 2002.” For general surface disinfection and in non-outbreak situations, use disinfectant products with EPA-registration for hospital use. Active cleaning and disinfection protocols are critical for preventing transmission of any infection. The friction created with active cleaning removes microbial burden and dirt. Cleaning is necessary for optimal disinfection to occur. It is important to note that ongoing transmission of C. difficile may be a marker for poor adherence to environmental decontamination and other infection prevention measures.

Contec, Inc.: Since contaminated environmental surfaces play a role in the transmissions of pathogens such as C. diff, proper cleaning and disinfecting techniques are crucial. Proper wiping removes pathogens and doesn’t just push the soil around. Wiping should be performed in unidirectional strokes, exposing a clean section of wipe for each pass and with a slight overlap to ensure that the entire surface is cleaned. When wiping or mopping, start in the least soiled area and clean the dirtiest areas last. Rinse frequently or use disposable products to minimize “pushing the dirt around” and re-depositing the contaminant. Select disinfectants based on efficacy, contact time, and the safety profile of the biocide. Train healthcare workers and housekeepers to eliminate “grey zones,” and monitor the environment to confirm the effectiveness of cleaning.

ICP Medical: Recent guidelines only direct cleaning if there is visual contamination and focus on hard surfaces which are relatively straightforward to clean; however, the spores have been found in every imaginable soft surface, nook, and cranny. Environmental contamination rates after detergent cleaning range over 50 percent. We recommend a thorough terminal cleaning following every episode of care, especially for an isolation patient. This would include privacy curtains and all surfaces. Extra care must be taken in collecting the linens and curtains for laundering so that the spores are not transferred throughout the facility during transport. Alternatively, consider the use of disposable sheets and curtains, especially for use in isolation rooms.

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