Emergency Medicine / Infectious Diseases

Out, Damned Spore!

August 26, 2016
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By Carol A. Kemper, MD, FACP

Landelle C, et al. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C difficile infection. Infection Control and Hosp Epidemiol 2014;35(1):10-15.

In spite of Infection Control staffs’ best efforts in all facets of sterilizing rooms exposed to C. difficile (CD), many hospitals continue to demonstrate moderate levels of C. difficile infections (CDI) acquired in-hospital. Though a percentage of these cases undoubtedly involved occult carriers during admission, some patients more than likely contracted the infection as a result of exposure in their hospital. The exposure is caused either through environmental contamination or contaminated hands. Given the steps taken in all hospitals to clean and sterilize rooms, the latter is far more likely.

Recent studies indicate that despite vigorous cleaning, vegetative and spore forms of CD can persist on anywhere from 14% to 59% of healthcare professionals coming into contact with CD patients. CD spores can even resist regular disinfection attempts. For the purposes of research, investigators destroyed vegetative CD on hands, leaving behind only spores — allowing for colony count determination.

Over a period of three months, investigators followed healthcare workers at a large (950 bed) university hospital, documenting each and every contact made, particularly emphasizing contact made by healthcare workers caring for CDI patients. CD cases were defined by patients with diarrhea and a toxin test that returned positive. Any patient determined to have CD was immediately placed under strict contact isolation protocol, in a private room, until 48 hours after the last incidence of diarrhea.

Infection control protocol mandates the donning of gowns and gloves before entering rooms, alcohol gel use prior to wearing gloves or any other aseptic task and after glove removal, preceded by vigorous, thorough hand washing with soap and water. It also advocates for daily cleaning with a hypochlorite solution. Hand-sampling of 66 exposed workers that provided care to a total of seven CDI patients were analyzed and compared with 44 unexposed health workers. CD spores were successfully recovered from the hands of 16 (24%) of the exposed group and none of the unexposed group. Per contaminated hand, two spores were discovered on average. In the exposed group, 30 of the 386 (7.8%) total contacts with patients were sans gloves. Of the 16 contaminated healthcare workers, seven had at least one contact with CDI patients without gloves. This also means that in the study 10.6% of healthcare professionals had contact with a CDI patient while not wearing gloves despite all efforts to ensure that they do wear gloves. Bivariate analysis determined that contamination was associated with longer duration of contact, high-risk exposure (exposure to feces), high number of total contacts, and contact without gloves. Among hospital workers, nursing assistants were the most likely to have hand contamination, with 42% of the nurses testing positive for spores. Physicians (24%) and nurses (19%) each were much less likely to have hand contamination. These rates were consistent with the duties each role fills, as nursing assistants were the most likely to have contact with patients. Logistic regression demonstrated that two factors were particularly correlated to contamination: rate of high risk contact and non-usage of gloves during contact.  

Those in the field of infectious disease know that despite the best, most stringent precautionary measures and advice, medical professionals occasionally do not wear gloves. These recurring lapses in judgement need to be eliminated. Finding an incentives-driven or other system to maximize the amount of times that doctors and other hospital workers when coming into contact with infectious disease is a priority to limit the rates of infectious disease acquired in-hospital.