By Kelly Romano, MPH, CIC
Recently a survey purported to demonstrate a causal association between reusable sharps containers and hospital acquired Clostridum difficile (C. diff) infections. It was published in the July 30 edition of Becker’s Hospital Review.
A review of PubMed yields more than 5,000 peer reviewed articles on C. diff. Prior to this survey there has never been a previous article published regarding C. diff infections and sharps containers. Where I work, we use reusable sharps containers and we have a very low healthcare-associated C. diff rate. CDC criteria for high-touch surface exposure do not include containers on its list. The survey referenced two articles on the possible transmission of infection from medical waste containers. The first article(1) discussed reusable infectious waste containers, but does not discuss sharps containers. The authors identified visibly contaminated waste containers which had been received from a single supplier. The hospital decontaminated the containers and instituted behavioral changes including handwashing and the use of personal protection equipment.
The second article(2) examined a 130-bed hospital and its container practices. The author noted a portion of reusable containers were visibly contaminated. On a single day, 30 containers were cultured by one nurse. Numerous microbes were found, most of which were common environmental and skin contaminants. Neither of these articles cited in the survey should be used as a credible reference for the association between C. diff and sharps containers. Typically staff do not touch containers with bare hands. They wear gloves.
Infection Control Associations Point to Other Sources of Transmission
Many agencies such as the Centers for Disease Control (CDC), the Society for Healthcare Epidemiology of America (SHEA), Infectious Disease Society of America (IDSA) and the Association for Professionals in Infection Control and Epidemiology (APIC) have not identified sharps containers as a source for C.diff transmission. Virtually all the literature attributes its transmission to inappropriate antibiotic use, inadequate handwashing by healthcare workers and breaches of personal protective equipment. There is no documentation that sharps containers are linked to a single case of C. diff. Since there are nearly a half million documented C.diff infections per year and 20,000 related deaths annually(3) from it, it is highly improbable that a link between C. diff and sharps containers could escape notice.
Years ago, at my previous facility, we saw an increase in healthcare associated C. diff. We decreased the rate more than 80 percent with a team effort. Over the last four months we have had no healthcare associated cases and only three healthcare associated infections for C. diff in the last fiscal year. These rates are a huge accomplishment.
Achieving Low C. diff Rates
Achieving such low rates is part education and part communication. In many cases, the staff was not aware that alcohol rub does not kill C. diff spores. They can carry it on their hands and potentially transmit it if using alcohol gel instead of washing hands with soap and water. Signs were placed on dispensers saying “do not use for C. diff.” Staff was educated on the importance of cleaning the room with bleach.
Communication between environmental services and the nursing department about patients with “special precautions” is an integrated effort. We receive real-time alerts when a patient is positive for C. diff, and also run reports on C. diff orders. This allows our department to immediately implement “special precautions.” As a follow up to cleaning, the infection prevention department uses ATP swabs to ensure room cleanliness and the environmental services team uses black lights for confirmation that potential exposure is minimized.
Antibiotic Stewardship and Handwashing
Internal hospital surveys have repeatedly shown poor compliance with handwashing, with rates varying from 40 to 90 percent despite the CDC stating a 50- and 75-percent non-compliance rate. Since C. diff is a major hospital acquired infection and all of the literature to date has focused on antibiotic stewardship and handwashing, changing the sharps container based on this single paper would lead to a misdirection of infection control. There is no reason to be alarmed that reusable sharps containers are anything but safe and should continue to be used.
In the survey mentioned above, the author acknowledges methodology weaknesses including self-reported data, the use of administrative data as opposed to clinical data, potential selection bias and difficulty identifying appropriate personnel for the survey. Given the overall design of the survey, it is difficult to see any relationship between an individual and hospital’s C.diff infection rate and the hospital’s use of reusable sharps containers. The survey was funded by a provider of single-use disposable containers and therefore difficult to regard as an independent evaluation.
No Reason for Alarm
Despite increasing C. diff rates industry wide, there is no sound reason to panic or to switch from reusable containers believing they are the culprit. There is no confirmed cause or epidemiological link between this organism and reusable sharps containers. Remember best practices of continuing to follow handwashing protocols, understanding all variables and potential causes of C. diff transmission and recognizing how studies, or in this case surveys, are supported.
1. Neely et al. (2003) http://www.ncbi.nlm.nih.gov/pubmed/12548252
2. Runner (2007) http://www.ncbi.nlm.nih.gov/pubmed/17936144
Disclaimer: Einstein Medical Center Montgomery uses reusable sharps containers that are serviced by Stericycle, Inc.
Kelly Romano, MPH, CIC, is with Einstein Medical Center Montgomery.