Study confirms C. diff can travel through the air
Precautions remain the same, but early isolation is reinforced
As Clostridium difficile (C. diff) began appearing in many hospitals across the country—and subsequently has become more problematic than its more popular antibiotic companion, MRSA—the primary concern was surface decontamination, since C. diff spores contaminated many high-touch areas.
But a study published in the June Clinical Infectious Diseases discovered that C. diff spores could travel through the air, something many experts believed was possible but which had not been scientifically proven.
“The results at one level are not surprising in that it was always predictable that you could isolate C. diff if you looked for it adequately, but people haven’t done that previously. So it does document that C. diff is dispersed into the air, and particularly it would appear early on in the infection,” says Mark Wilcox, BMedSci, BMBS, MD, professor of medical microbiology at the Institute of Molecular and Cellular Biology at the University of Leeds (UK) and lead author of the study.
More importantly, says Wilcox, it gives IPs more evidence regarding the importance of early detection and implantation of prevention methods concerning patients with C. diff infections.
There are two main schools of thought regarding preventing transmission of C. diff infections, says Wilcox.
The first is controlling the prescription of antibiotics, since many antibiotics contribute to the growth of an infection. Many hospitals in the United States have already implemented antibiotic stewardship programs to reduce the amount of antibiotics and offer alternatives.
The second approach is controlling transmission, which involves isolation of patients with potential or confirmed C. diff infections.
Wilcox says the best approach is a combination, with transmission prevention on the first tier, followed by a sound antibiotics stewardship program.
“If you concentrate, as traditionally some people have, on the antibiotic, then it doesn’t matter what I prescribe to some extent, you’re not going to induce a C. diff infection without the transmission,” Wilcox says. “So the key intervention is limiting the transmission, and then the good antibiotic usage or prescribing comes on top of that, but not before. If that’s what you concentrate on, and yet you’ve got poor infection control practice, you’ll still be spreading the organism around.”
Isolating patients early
The most important takeaway from this study is that early isolation of patients with a suspected C. diff infection is the best prevention method, especially if spores can travel through the air to another patient.
This means as soon as there are any signs or symptoms of an infection, facilities should put the patient on isolation precautions even before the lab confirms it through test results.
“What this does do for infection prevention teams is it gives them more ammunition to say that patients who have C. diff infections or are suspected of having a C. diff infection need to be isolated as soon as possible, because if you wait, pending the results of the test or tests, then the cat’s out of the bag potentially,” Wilcox says.
“Anecdotally, when we and others have imposed that early isolation before the results are available, it’s that intervention that tends to be the most helpful in terms of clustering,” he adds.
Cleaning remains important
The study notes that things like changing bed linens or moving curtains can cause a disturbance in the airflow, potentially spreading spores throughout the room.
“Get a patient in isolation as early as possible and then, where possible, keep the doors [to the room] shut, particularly when there is gross airborne disturbance,” Wilcox says. “So if you are doing a lot of bed changing, curtain pulling, whatever, shut the door. The air movement will likely be associated with an increased count of airborne organisms, and that peak of airborne organisms can be allowed to reduce before the door is opened.”
Environmental services teams play a crucial part in prevention efforts, and IPs should provide training and guidance for this department, says Debbie Clark, RRT, MPH, IP and hospital epidemiologist at HealthSouth Rehabilitation Hospital of Tallahassee (FL).
“I think it’s always going to be an environmental cleaning problem,” Clark says. “I’m not saying that the healthcare workers still shouldn’t wash their hands and pay attention to cleaning the patient, but I think it’s going to be more the department of housekeeping in those facilities [that] is going to have to be diligent about cleaning with bleach.”
A growing problem
Clostridium difficile (C. diff) infections have always been on the minds of IPs in some capacity, but not until recently has it become a problem in some facilities.
A recent study at the Duke University Medical Center in Durham, NC, revealed C. diff infections were 21% more prevalent than MRSA infections and nearly as common as bloodstream infections (see story in the June Briefings on Infection Control).
“I think probably the biggest problem with that is the fact that as our population ages, we’re seeing more elderly people, and it’s the elderly that’s going to be adversely affected by C. diff, and it’s also that population that’s contracting C. diff, plus they have a higher mortality,” says Debbie Clark, RRT, MPH, IP and hospital epidemiologist at HealthSouth Rehabilitation Hospital of Tallahassee (FL).
In the UK, C. diff has already been a massive problem that has just begun to trend downward because of the increased focus from hospitals, says Mark Wilcox, BMedSci, BMBS, MD, professor of medical microbiology at the Institute of Molecular and Cellular Biology at the University of Leeds (UK) and lead author of the study that shows C. diff spores can travel through the air.
“In those settings where they haven’t done everything possible to take C. diff seriously and done everything possible to eliminate dissemination, then it will get worse because of the environmental spread of the organism and the survival for months, if not years, of the organism in the environment,” Wilcox says.
For more information on C. diff prevention measures, see the SHEA’s updated guidelines.