Cleaning Is Essential

Hygiene is the best defense against today’s superbugs, MRSA and VRE. But it is also the best known shield against the next germ threat, Clostridium difficile or “C. diff.” C. diff. killed more patients in England in 2006 than MRSA, and the same hyper-virulent strain, dubbed ribotype 027, has invaded some hospitals in the U.S. and Canada. In fact, despite almost no news coverage until 2007, C. diff has been causing trouble for several years.

The Centers for Disease Control and Prevention tracked a nearly twofold increase in C. diff infections from 1996 to 2003. Two statewide studies in Oregon and Massachusetts found C. diff infections increasing at an even faster pace. In the Montreal area of Canada, C. diff increased fivefold from 1997 to 2004. Worse still, in both Canada and the U.S., the mortality rate from this disease is rising. Therefore, it’s more important than ever to prevent it with rigorous hygiene, education of caregivers, and prudent use of antibiotics.

So what do we need to know about this bacterial villain? Outside of hospitals, it is normally found in the gastrointestinal tracts of about 5% of the general population. It doesn’t usually cause trouble because other bacteria keep C. diff from getting out of control. In hospitals, the story changes. When a patient is put on antibiotics, the balance of bacteria in his gastro-intestinal system is affected, and C. diff. may take over, causing severe, watery diarrhea and inflammation of the colon.

It’s the out of control nature of watery diarrhea that allows C. diff to spread so fast in a hospital. Although a small number of patients come into the hospital with C. diff spores in their bodies, many more ingest the germ through oral-fecal contamination, meaning traces of one patient’s feces enter another patient’s mouth. How could such a thing happen? The only answer is inadequate cleaning.

Patients pick up the C. diff spores off contaminated bedrails, IV poles, tables, and other surfaces, virtually anywhere their hands can reach. Then they touch their lips, or touch their food and swallow C.diff along with their dinner roll. Caregivers unwittingly carry C. diff spores on their hands, uniforms, and equipment from patient to patient.

A 2006 study in the Journal of Hospital Infection showed that one-third of blood pressure cuffs rolled from room to room carried C. diff spores on the inside of the cuff. It’s a short trip from a patient’s arm to their fingertips and their mouth. Occasionally patients also get C. diff from inadequately cleaned rectal thermometers and endoscopes.

Environmental cleaning is so important that when it is not done regularly and rigorously, placing a patient in a room previously occupied by a patient with C. diff can be a fatal mistake. At Thomas Jefferson University Medical Center in Philadelphia, where C. diff was raging, three patients occupying the same room consecutively came down with C. diff. One died as a result.

In July and August, of 2005, eight infants in the neonatal intensive care unit at Intermountain Healthcare in Provo, Utah contracted C. diff. All eight infected infants had shared one of three beds in a corner of the NICU. The longer the hospital stay and the closer one is to a patient with C. diff, the greater the risk of contracting it.

Training environmental services staff on how to clean more thoroughly is essential. At Case Western Reserve and the Cleveland VA Medical Center, researchers cultured commonly touched surfaces such as bed rails, telephones, call buttons, toilet seats, and bedside tables in the rooms of patients with C. Diff. After routine cleaning, 78% of the surfaces were still contaminated with C. diff spores. But once researchers disinfected the rooms, including surfaces commonly overlooked by cleaners, with bleach, only 1% of surfaces were still contaminated.

Dr. Carlene Muto and her colleagues at the University of Pittsburgh Medical Center –Presbyterian faced a 400% increase in C. diff infections in the year 2000. They responded with a comprehensive strategy that emphasized rigorous cleaning with bleach and rapid identification and isolation of C.diff positive patients to prevent the bacteria from spreading to other patients. (Additional interventions included reliance on soap and water rather than alcohol-based sanitizers to clean caregivers’ hands, and controlled use of antibiotics beginning in 2003). This comprehensive strategy worked. By 2006, C. diff rates were down 71%, and severe cases of C. diff associated diarrhea fell by 89%.

At Intermountain Healthcare, after the eight infants contracted C. diff, the affected corner of the NICU was “cleaned from top to bottom,” according to researchers there, including rockers and scales. “We launched extensive staff education related to C. difficile and its ability to be found on environmental surfaces,” and “the importance of washing hands with soap and water when caring for a patient with C. difficile,” they reported. The results? Not one new case of C. diff in the NICU in the next two years.

Educating hospital personnel on how patients are exposed to C. diff spores is essential. A study at one hospital found that resident physicians and other medical personnel were woefully under informed about C. diff. For example, 39% didn’t know that C. diff spores could be transmitted from patient to patient on equipment such as stethoscopes and blood pressure cuffs. Nearly 20% incorrectly thought C. diff was a blood borne pathogen, and almost 9% incorrectly believed it was transmitted through the air. Only about one third of medical professionals knew that cleaning hands with soap and water was essential, because alcohol sanitizers are often ineffective against C. diff. This knowledge gap is dangerous to patients and costly to hospitals.

Looking Ahead: Though more research needs to be done, preliminary results suggest that adding a lactobacillus acidophilus milk product to the daily diet of patients on antibiotics may be effective at reducing antibiotic-associated diarrhea (AAD), including diarrhea caused by C. diff. A double blind study certain probiotics are effective, compared with a placebo, in reducing the incidence of antibiotic associated diarrhea by about half in patients on a variety of antibiotic regiments. The study suggests that some specific organisms may help restoring the normal balance of bacteria in the gastro-intestinal system to spare patients from life-threatening diarrhea. If more research confirms these initial findings, hospitals may want to consider adding a nutritional supplement routinely to the diets of patients on antibiotics.

Based on an assessment of the increased length of stay required to treat C. diff patients in Massachusetts, researchers estimated “conservatively” that in 2005 alone, treating C. diff added $3.2 billion to the cost of treating hospital patients nationwide.

Cleaning the hospital environment, educating personnel about C. diff., and controlling antibiotic use are essential to meet the C. diff challenge. In addition, hospitals need to consider two other strategies. One is rigorous hand hygiene for patients. Nonambulatory patients are frequently handed a food tray, but have no way to clean their hands before dining. Their hands are contaminated with C. diff spores, which they ingest as they eat. Whenever and wherever C. diff threatens, patients need to be helped to clean their hands routinely before meals.

For additional information and footnotes, please see the 3rd edition of RID’s popular publication, “Unnecessary Deaths: The Human and Financial Costs of Hospital Infections.”