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Removal of Microorganisms - As Important as Disinfection
"Disinfectant/detergent formulations registered by EPA are used for environmental surface cleaning, but the actual physical removal of microorganisms and soil by wiping or scrubbing is probably as important, if not more so, than any antimicrobial effect of the cleaning agent used."
Source: Centers for Disease Control (CDC) and Prevention Healthcare Infection Control Practices Advisory Committee (HICPAC) "Guidelines for Environmental Infection Control in Health-Care Facilities."
By Crystal Phend, Senior Staff Writer, MedPage Today
Healthcare workers are just as likely to pick up Clostridium difficile spores from bed rails and other surfaces around a hospital room as from touching an infected patient's skin, researchers found.
Gloves tested positive for the spore form of the diarrheal bacteria 50% of the time after contact with the most commonly touched objects around a patient - the same proportion as from commonly-examined skin sites - according to a prospective study by Dubert M. Guerrero, MD, of Case Western Reserve's University Hospitals in Cleveland, and colleagues.
The mean number of C. difficile colonies picked up was similar as well (14 versus 7 CFU per handprint, P=0.22), they reported at the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), San Francisco, September 2009.
"These results reinforce the importance of environmental disinfection and glove use when touching surfaces in rooms of C. difficile-infected patients, the researchers noted.
At most hospitals, it's common procedure to keep gown, gloves, and warning signs outside infected patients' rooms, Guerrero said.
But other studies have shown that "healthcare workers are less likely to wash their hands if they just touch the bed rail or the bedside table than if they examine the patient," said co-author Curtis Donskey, MD, of the Cleveland VA Medical Center.
It's not necessarily a time issue; rather, healthcare workers "often don't appreciate how important environmental surfaces can be," Donskey said. They may go into a room as a group - most with no intention of touching the patient - and forget that they rested a hand on the bed rail, he noted.
The same is true for many infectious diseases that have become endemic in hospitals, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, commented John Boyce, MD, of the Hospital of Saint Raphael in New Haven, Conn., who was not involved in the study.
For the prospective observational study, Guerrero's group cultured handprints from gloved hands after contact with 120 skin sites of 30 patients infected with C. difficile as well as with 120 surfaces around the patients.
Half of the patients produced at least one positive culture for C. difficile spores on their skin, and the same proportion tested positive for spores on the surfaces around them.
The tested skin sites - chest, abdomen, hands, and forearms - were about equally contaminated. Of the environmental surfaces, the bed rail stood out as a source of transmission: 43% of contacts produced positive cultures compared with 20% of table touches and 17% for both the phone and call button.
Healthcare workers picked up the greatest mean number of colonies of C. difficile from the abdomen - 29 CFU per handprint.
The researchers also tested relative contamination levels after touching an infected patient's groin and found it to be far worse than any other site, environmental or other areas of the skin, with an average of 121 CFU transferred per handprint. However, this area is not commonly examined in real world practice and, thus, may not represent as great a risk, Guerrero said.
Given the importance of environmental surfaces in C. difficile transmission, more studies are needed to determine how to decrease the burden of spores, which have proven remarkably difficult to kill, the researchers noted.
Spores often continue to shed from the skin even after treatment and most antiseptic soaps are ineffective. For cleaning environmental surfaces, bleach is one of the only disinfectants that kill spores, Donskey said.
Possible routes may be by adjusting the frequency and timing of environmental cleaning and by assessing novel sporicidal agents for disinfecting.
The study was funded by the Department of Veterans Affairs and Cleveland VA Medical Center as well as by a Wyeth Pharmaceuticals Antimicrobial Resistant Fellowship.
Guerrero disclosed a financial relationship with Wyeth Pharmaceuticals.
Primary source: Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC)
Source reference: Guerrero DM, et al "Hand acquisition of Clostridium difficile after contact with environmental surfaces versus skin of patients with C. difficile infection" ICAAC 2009; Oral session K-1911.
Reviewed by Zalman S. Agus, MD; Emeritus Professor University of Pennsylvania School of Medicine and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner
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