Transmission of Clostridium difficile from asymptomatically colonized or infected long-term care facility residents.

OBJECTIVE: To test the hypothesis that long-term care facility (LTCF) residents with Clostridium difficile infection (CDI) or asymptomatic carriage of toxigenic strains are an important source of transmission in the LTCF and in the hospital during acute-care admissions. DESIGN: A 6-month cohort study with identification of transmission events was conducted based on tracking of patient movement combined with restriction endonuclease analysis (REA) and whole-genome sequencing (WGS). SETTING: Veterans Affairs hospital and affiliated LTCF.ParticipantsThe study included 29 LTCF residents identified as asymptomatic carriers of toxigenic C. difficile based on every other week perirectal screening and 37 healthcare facility-associated CDI cases (ie, diagnosis >3 days after admission or within 4 weeks of discharge to the community), including 26 hospital-associated and 11 LTCF-associated cases. RESULTS: Of the 37 CDI cases, 7 (18·9%) were linked to LTCF residents with LTCF-associated CDI or asymptomatic carriage, including 3 of 26 hospital-associated CDI cases (11·5%) and 4 of 11 LTCF-associated cases (36·4%). Of the 7 transmissions linked to LTCF residents, 5 (71·4%) were linked to asymptomatic carriers versus 2 (28·6%) to CDI cases, and all involved transmission of epidemic BI/NAP1/027 strains. No incident hospital-associated CDI cases were linked to other hospital-associated CDI cases. CONCLUSIONS: Our findings suggest that LTCF residents with asymptomatic carriage of C. difficile or CDI contribute to transmission both in the LTCF and in the affiliated hospital during acute-care admissions. Greater emphasis on infection control measures and antimicrobial stewardship in LTCFs is needed, and these efforts should focus on LTCF residents during hospital admissions.

A Randomized Trial to Determine the Impact of an Educational Patient Hand-Hygiene Intervention on Contamination of Hospitalized Patient's Hands with Healthcare-Associated Pathogens.

We conducted a non-blinded randomized trial to determine the impact of a patient hand-hygiene intervention on contamination of hospitalized patients' hands with healthcare-associated pathogens. Among patients with negative hand cultures on admission, recovery of pathogens from hands was significantly reduced in those receiving the intervention versus those receiving standard care. Infect Control Hosp Epidemiol 2017;38:595-597.

Do piperacillin/tazobactam and other antibiotics with inhibitory activity against Clostridium difficile reduce the risk for acquisition of C. difficile colonization?

BACKGROUND: Systemic antibiotics vary widely in in vitro activity against Clostridium difficile. Some agents with activity against C. difficile (e.g., piperacillin/tazobactam) inhibit establishment of colonization in mice. We tested the hypothesis that piperacillin/tazobactam and other agents with activity against C. difficile achieve sufficient concentrations in the intestinal tract to inhibit colonization in patients. METHODS: Point-prevalence culture surveys were conducted to compare the frequency of asymptomatic rectal carriage of toxigenic C. difficile among patients receiving piperacillin/tazobactam or other inhibitory antibiotics (e.g. ampicillin, linezolid, carbapenems) versus antibiotics lacking activity against C. difficile (e.g., cephalosporins, ciprofloxacin). For a subset of patients, in vitro inhibition of C. difficile (defined as a reduction in concentration after inoculation of vegetative C. difficile into fresh stool suspensions) was compared among antibiotic treatment groups. RESULTS: Of 250 patients, 32 (13 %) were asymptomatic carriers of C. difficile. In comparison to patients receiving non-inhibitory antibiotics or prior antibiotics within 90 days, patients currently receiving piperacillin/tazobactam were less likely to be asymptomatic carriers (1/36, 3 versus 7/36, 19 and 15/69, 22 %, respectively; P = 0.024) and more likely to have fecal suspensions with in vitro inhibitory activity against C. difficile (20/28, 71 versus 3/11, 27 and 4/26, 15 %; P = 0.03). Patients receiving other inhibitory antibiotics were not less likely to be asymptomatic carriers than those receiving non-inhibitory antibiotics. CONCLUSIONS: Our findings suggest that piperacillin/tazobactam achieves sufficient concentrations in the intestinal tract to inhibit C. difficile colonization during therapy.

Utility of a Novel Reflective Marker Visualized by Flash Photography for Assessment of Personnel Contamination During Removal of Personal Protective Equipment.

In an experimental study, the frequency of contamination of healthcare personnel during removal of contaminated personal protective equipment (PPE) was similar for bacteriophage MS2 and a novel reflective marker visualized using flash photography. The reflective marker could be a useful tool to visualize and document personnel contamination during PPE removal. Infect Control Hosp Epidemiol 2016;37:711-713.

Acquisition of Clostridium difficile on Hands of Healthcare Personnel Caring for Patients with Resolved C. difficile Infection.

In an observational study, we found that healthcare personnel frequently acquired Clostridium difficile on their hands when caring for patients with recently resolved C. difficile infection (CDI) (<6 weeks after treatment) who were no longer under contact precautions. Continuing contact precautions after diarrhea resolves may be useful to reduce transmission.

An intervention to reduce health care personnel hand contamination during care of patients with Clostridium difficile infection.

In a quasi-experimental study, an educational intervention to improve the technique for personal protective equipment (PPE) removal in conjunction with disinfection of gloves before removal of PPE reduced acquisition of Clostridium difficile spores on the hands of health care personnel caring for patients with C difficile infection.

Contamination of Health Care Personnel During Removal of Personal Protective Equipment.

IMPORTANCE: Contamination of the skin and clothing of health care personnel during removal of personal protective equipment (PPE) contributes to dissemination of pathogens and places personnel at risk for infection. OBJECTIVES: To determine the frequency and sites of contamination on the skin and clothing of personnel during PPE removal and to evaluate the effect of an intervention on the frequency of contamination. DESIGN, SETTING, AND PARTICIPANTS: We conducted a point-prevalence study and quasi-experimental intervention from October 28, 2014, through March 31, 2015. Data analysis began November 17, 2014, and ended April 21, 2015. Participants included a convenience sample of health care personnel from 4 Northeast Ohio hospitals who conducted simulations of contaminated PPE removal using fluorescent lotion and a cohort of health care personnel from 7 study units in 1 medical center that participated in a quasi-experimental intervention that included education and practice in removal of contaminated PPE with immediate visual feedback based on fluorescent lotion contamination of skin and clothing. MAIN OUTCOMES AND MEASURES: The primary outcomes were the frequency and sites of contamination on skin and clothing of personnel after removal of contaminated gloves or gowns at baseline vs after the intervention. A secondary end point focused on the correlation between contamination of skin with fluorescent lotion and bacteriophage MS2, a nonpathogenic, nonenveloped virus. RESULTS: Of 435 glove and gown removal simulations, contamination of skin or clothing with fluorescent lotion occurred in 200 (46.0%), with a similar frequency of contamination among the 4 hospitals (range, 42.5%-50.3%). Contamination occurred more frequently during removal of contaminated gloves than gowns (52.9% vs 37.8%, P = .002) and when lapses in technique were observed vs not observed (70.3% vs 30.0%, P < .001). The intervention resulted in a reduction in skin and clothing contamination during glove and gown removal (60.0% before the intervention vs 18.9% after, P < .001) that was sustained after 1 and 3 months (12.0% at both time points, P < .001 compared with before the intervention). During simulations of contaminated glove removal, the frequency of skin contamination was similar with fluorescent lotion and bacteriophage MS2 (58.0% vs 52.0%, P = .45). CONCLUSIONS AND RELEVANCE: Contamination of the skin and clothing of health care personnel occurs frequently during removal of contaminated gloves or gowns. Educational interventions that include practice with immediate visual feedback on skin and clothing contamination can significantly reduce the risk of contamination during removal of PPE.

Unlocking the Sporicidal Potential of Ethanol: Induced Sporicidal Activity of Ethanol against Clostridium difficile and Bacillus Spores under Altered Physical and Chemical Conditions.

BACKGROUND: Due to their efficacy and convenience, alcohol-based hand sanitizers have been widely adopted as the primary method of hand hygiene in healthcare settings. However, alcohols lack activity against bacterial spores produced by pathogens such as Clostridium difficile and Bacillus anthracis. We hypothesized that sporicidal activity could be induced in alcohols through alteration of physical or chemical conditions that have been shown to degrade or allow penetration of spore coats. PRINCIPAL FINDINGS: Acidification, alkalinization, and heating of ethanol induced rapid sporicidal activity against C. difficile, and to a lesser extent Bacillus thuringiensis and Bacillus subtilis. The sporicidal activity of acidified ethanol was enhanced by increasing ionic strength and mild elevations in temperature. On skin, sporicidal ethanol formulations were as effective as soap and water hand washing in reducing levels of C. difficile spores. CONCLUSIONS: These findings demonstrate that novel ethanol-based sporicidal hand hygiene formulations can be developed through alteration of physical and chemical conditions.

Four Moments for Patient Hand Hygiene: A Patient-Centered, Provider-Facilitated Model to Improve Patient Hand Hygiene.

We found that a majority of hospitalized patients were aware of the importance of hand hygiene, but observations indicated that performance of hand hygiene was uncommon. An intervention in which healthcare personnel facilitated hand hygiene at specific moments significantly increased performance of hand hygiene by patients.

Sustained increase in resident meal time hand hygiene through an interdisciplinary intervention engaging long-term care facility residents and staff.

Hand hygiene by patients may prevent acquisition and dissemination of health care-associated pathogens, but limited efforts have been made to engage patients in hand hygiene interventions. In a long-term care facility, we found that residents were aware of the importance of hand hygiene, but barriers, such as inaccessible products or difficult to use products, limited compliance. A dramatic and sustained improvement in meal time hand hygiene was achieved through engagement of staff and residents.

Comparison of hand hygiene monitoring using the 5 Moments for Hand Hygiene method versus a wash in-wash out method.

BACKGROUND: One strategy to promote improved hand hygiene is to monitor health care workers' adherence to recommended practices and give feedback. For feasibility of monitoring, many health care facilities assess hand hygiene practices on room entry and exit (wash in-wash out). It is not known if the wash in-wash out method is comparable with a more comprehensive approach, such as the World Health Organization's My 5 Moments for Hand Hygiene method. METHODS: During a 1-month period, a surreptitious observer monitored hand hygiene compliance simultaneously using the wash in-wash out and My 5 Moments for Hand Hygiene methods. RESULTS: For 283 health care worker room entries, the methods resulted in similar rates of hand hygiene compliance (70% vs 72%, respectively). The wash in-wash out method required 148 hand hygiene events not required by the My 5 Moments for Hand Hygiene method (ie, before and after room entry with no patient or environmental contact) while not providing monitoring for 89 hand hygiene opportunities in patient rooms. CONCLUSION: The monitoring methods resulted in similar overall rates of hand hygiene compliance. Use of the wash in-wash out method should include ongoing education and intermittent assessment of hand hygiene before clean procedures and after body fluid exposure in patient rooms.

Tigecycline exhibits inhibitory activity against Clostridium difficile in the intestinal tract of hospitalised patients.

No new acquisition of Clostridium difficile occurred among 12 hospitalised patients receiving tigecycline, and pre-existing colonisation was reduced to undetectable levels in 2 patients. Moreover, 91% of stool suspensions obtained during tigecycline therapy exhibited inhibitory activity against C. difficile. These results suggest that tigecycline achieves sufficient concentrations to inhibit intestinal colonisation by C. difficile.

Evaluation of a sporicidal peracetic acid/hydrogen peroxide-based daily disinfectant cleaner.

OxyCide Daily Disinfectant Cleaner, a novel peracetic acid/hydrogen peroxide-based sporicidal disinfectant, was as effective as sodium hypochlorite for in vitro killing of Clostridium difficile spores, methicillin-resistant Staphylococcus aureus, and vancomcyin-resistant enterococci. OxyCide was minimally affected by organic load and was effective in reducing pathogen contamination in isolation rooms.

Utility of a commercial PCR assay and a clinical prediction rule for detection of toxigenic Clostridium difficile in asymptomatic carriers.

A commercial PCR assay of perirectal swab specimens detected 17 (68%) of 25 asymptomatic carriers of toxigenic Clostridium difficile, including 93% with skin and/or environmental contamination. A clinical prediction rule, followed by PCR screening, could be used to identify carriers at high risk of C. difficile shedding.

Defining the vulnerable period for re-establishment of Clostridium difficile colonization after treatment of C. difficile infection with oral vancomycin or metronidazole.

BACKGROUND: Clostridium difficile is an anaerobic, spore-forming bacterium that is the most common cause of healthcare-associated diarrhea in developed countries. A significant proportion of patients receiving oral vancomycin or metronidazole for treatment of Clostridium difficile infection (CDI) develop recurrences. However, the period of vulnerability to re-establishment of colonization by C. difficile after therapy is not well defined. PRINCIPAL FINDINGS: In a prospective study of CDI patients, we demonstrated that most vancomycin-treated patients maintained inhibitory concentrations of vancomycin in stool for 4 to 5 days after therapy, whereas metronidazole was only detectable during therapy. From the time of elimination of the antibiotics to 14 to 21 days after therapy, a majority of stool suspensions supported growth of C. difficile and deep 16S rRNA sequencing demonstrated persistent marked alteration of the indigenous microbiota. By 21 to 28 days after completion of CDI treatment, a majority of stool suspensions inhibited growth of C. difficile and there was evidence of some recovery of the microbiota. CONCLUSIONS: These data demonstrate that there is a vulnerable period for re-establishment of C. difficile colonization after CDI treatment that begins within a few days after discontinuation of treatment and extends for about 3 weeks in most patients.

Comparison of perirectal versus rectal swabs for detection of asymptomatic carriers of toxigenic Clostridium difficile.

For long-term care and spinal cord injury patients, the sensitivity, specificity, and positive and negative predictive values of perirectal versus rectal cultures for detection of asymptomatic carriers of Clostridium difficile were 95%, 100%, 100%, and 97%, respectively. Perirectal cultures provide an accurate method to detect asymptomatic carriers of C. difficile.