How to Prevent C difficile Infection: A New Guide

Laura A. Stokowski, RN, MS


May 24, 2013

In This Article

CDI Prevention: The Environment of Care

We have known for at least 3 decades that, along with antibiotic exposure and old age, the hospital environment plays a significant role in the transmission of CDI. Despite this knowledge, CDI rates have progressed to epidemic levels. Why haven't we been able to take the hospital out of the equation?

"We have to figure out how to practice prevention no matter where the patient happens to be. We often fail to appreciate the importance of a single act: a single failure to wash our hands, for example. We need to develop standardized approaches -- every time we do X, we do Y, like fastening our seat belt before we start the car," said Ruth Carrico.

Dr. Carrico continued, "We also tend to compartmentalize, and this works to our disadvantage. We sometimes think that care of the patient belongs only to nurses and care of the environment belongs only to environmental services. Things that fall into a gray area don't get done."

These "gray areas" might include items that no one thinks of cleaning, such as the privacy curtains, or the flashlight used by night-shift staff -- items that are touched by multiple individuals in the course of care. Or the handrails of a shared bedside commode -- between patients, the bucket might be disinfected, but not other frequently touched surfaces on this piece of equipment.

Environmental cleaning. The role of the environment has been given the most attention in the past 3 years, as 92% of responding healthcare facilities reported increasing their emphasis on environmental cleaning and equipment decontamination.[1]C difficile spores can live for 5 months on environmental surfaces and can be found in the rooms of infected patients as well as asymptomatic carriers.[2] Contamination of floors and bathrooms is especially heavy. The APIC guide provides recommendations for preventing the spread of spores from isolation rooms to other areas of the hospital, such as:

Using disposable mop heads to clean isolation rooms;

Cleaning high-touch surfaces and items in close proximity to patients -- for example, bedrails, call buttons, intravenous pumps, telephones, television controls, light switches, doorknobs, and windowsills; and

Cleaning all shared patient care items, such as thermometers, blood pressure cuffs, and stethoscopes, and avoiding sharing whenever possible.

Typical hospital disinfectants can kill vegetative forms of C difficile but are not sporicidal. Chlorine-based disinfectants and high-concentration hydrogen peroxide cleaners can kill C difficile spores. Cleaning must take place before disinfection, to remove spores through physical action and rinsing. If disinfecting wipes are used, cleaning staff must be trained in their proper use.[2]

Training new environmental services staff on all appropriate cleaning techniques is crucial. "I have watched people clean a room by starting with the dirtiest area -- the bathroom -- which is precisely the opposite of what should be done. It might be the way they do it at home, but it's not appropriate for the hospital," said Dr. Carrico. She recommends that healthcare facilities use the Association for the Healthcare Environment's manual, Practice Guidance for Healthcare Environmental Cleaning. This manual provides evidence-based research, guidance, and recommended practices that should be considered for inclusion in healthcare environmental services departments.


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