In his presentation, "You are What You Eat: Clostridium difficile and You," at the annual SHEA scientific meeting held earlier this week, Curtis Donskey, MD, of the Louis Stokes Cleveland Veterans Affairs Medical Center, reviewed the sources of Clostridium difficile transmission. Infected patients are the major reservoir for transmission of Clostridium difficile infection (CDI), and as infection preventionists know, the use of contact precautions and thorough environmental cleaning are key interventions to prevent transmission.
The current epidemic strain of Clostridium difficile is challenging these essential basic practices, so Donskey reminded attendees to persist with interventions -- especially in light of studies showing suboptimal cleaning practices being used in many hospitals; numerous high-touch surfaces in patient rooms are frequently not cleaned by housekeeping staff.
Donskey reminded attendees that the Centers for Disease Control and Prevention (CDC) recommends that rigorous cleaning be conducted, but also that hospitals address the persistent sources of C. diff, found to be items such as blood pressure cuffs, stethoscopes and other patient-care items that travel from patient to patient unless they have been reserved specifically for that CDI patient. Donskey also advised attendees to ensure that someone -- whether it's nursing staff or housekeeping staff -- regularly cleans any electronic medical equipment, which many staff tend to shy away from cleaning due to the sensitive nature of the devices.
Donskey reviewed three general principles relating to the management of CDI:
- Quantity matters: As CDI is dependent upon environmental transmission and hand carriage, focus hygiene efforts on the most contaminated sites and sources.
- Contact counts: Focus on high-touch surfaces.
- Focus on super-shedders first, but don't forget about potential asymptomatic carriers.
Donskey also outlined seven special approaches that practitioners can take to help prevent the transmission of C. difficile:
1. Because spores can be shed before, during and after CDI, expedite identification and isolation of CDI patients, and use pre-emptive isolation while test results are pending.
2. Prolong the duration of contact precautions after CDI treatment is completed; the cost consideration could be an issue for some hospitals.
3. Improve patient bathing to reduce the burden of spores on the skin; however, there is some indication that bathing may not be a silver bullet.
4. Daily disinfection of high-touch surfaces during CDI treatment is as important as terminal cleaning.
5. Use more sensitive diagnostic tests for CDI.
6. Do not screen for and isolate asymptomatic carriers, as more data is needed here; assess for environmental and skin contamination.
7. Explore interventions that address airborne dispersal of spores, otherwise known as the "fecal cloud." This aspect of CDI transmission is currently under debate and more studies are needed. See Donskey's paper, "Preventing Transmission of Clostridium difficile: Is the Answer Blowing in the Wind?" published in Clinical Infectious Diseases, Vol. 50, No. 11, 2010.