C diff Dramatically Cut by Dedicated Hospital Cleaning Crew

Steven Fox

April 11, 2013

Once patients formerly colonized with Clostridium difficile have been discharged from hospital, getting rid of residual organisms in their rooms can be a daunting challenge.

Results from a newly published study suggest that daily disinfection by a dedicated and properly educated cleaning staff is dramatically more effective than more conventional methods.

The study, authored by Brett Sitzlar, BS, from Case Western Reserve University School of Medicine, Cleveland, Ohio, and coauthors, appears in the May issue of Infection Control and Hospital Epidemiology.

Sitzlar and colleagues note that during 2002 to 2004, the Louis Stokes Cleveland Veterans Affairs Medical Center in Ohio was hit with a serious outbreak of C difficile and that since that time, the hospital has struggled, with only limited success, using various methods to eliminate the organism from C difficile–infected (CDI) rooms.

"In 2009, we demonstrated that environmental cultures collected from CDI rooms were often positive after completion of terminal room cleaning by environmental services personnel," the authors write. "In response, we initiated an intervention to improve cleaning and disinfection of CDI rooms."

The newly published article details results of that intervention.

The authors devised a 21-month prospective intervention study at the hospital. The study comprised 3 intervention sequences, with each strategy being built on the one previous.

During the first sequence, lasting 14 months, the researchers applied fluorescent markers to high-touch surfaces with the aim of monitoring and gaining feedback on how thoroughly the rooms were being cleaned by the usual cleaning personnel.

During sequence 2, lasting 4 months, they added automated ultraviolet radiation units to the conventional cleaning and fluorescent marker strategy.

In the third and final sequence, they employed an enhanced disinfection strategy that included bleach-wipe cleaning by dedicated staff who had been educated about infection control.

After the rooms were conventionally cleaned and disinfected, the investigators obtained cultures to check for evidence of residual C difficile and thereby assess the efficacy of each subsequently employed strategy.

The investigators say they observed big differences in the effectiveness of the 3 strategies. Compared with traditional cleaning methods, the use of fluorescent markers modestly improved the disinfection of high-touch surfaces (57% vs 67%), and adding ultraviolet devices cut down still more on the percentage of positive cultures, the authors say. Although these improvements were each statistically significant (14% reduction, for a prevalence ratio of 0.86 [95% confidence interval (CI), 0.76 - 0.98]; P = .024; and 48% reduction, for a prevalence ratio of 0.52 [95% CI, 0.43 - 0.62]; P < .001, respectively), C difficile remained detectable in 35% of rooms.

Adding enhanced disinfection, with educated and dedicated cleaning crews, bested the other interventions, dramatically reducing positive cultures to only 7%, representing an 89% reduction (prevalence ratio, 0.11; 95% CI, 0.02 - 0.53; P = .006).

The authors acknowledge that their study is subject to limitations. For one, it is unknown whether institutions could be successful in maintaining the interventions over the long term, and even if that is possible, it is unknown whether such long-term interventions would actually reduce C difficile transmission and infections. Finally, they note, culturing for C difficile was key to the success of the intervention. However, for most healthcare facilities, routinely obtaining such cultures is not presently feasible.

"Ultimately, disinfection was dramatically improved through formation of a dedicated daily disinfection team and implementation of a standardized process for clearing CDI rooms," the authors conclude. "Our experience suggests that culturing of CDI rooms after terminal cleaning could provide a valuable means to assess the effectiveness of cleaning interventions."

This work was supported by the Department of Veterans Affairs and by a grant from the Agency for Healthcare Research and Quality to one of the authors. The other authors have disclosed no relevant financial relationships.

Infect Control Hosp Epidemiol. 2013;34:459-465. Abstract