Healthcare Workers' Hands and Clostridium difficile Spores: Making Progress?

Abstract

Affiliations: 1. Division of Infectious Diseases, Memorial Hospital of Rhode Island, Warren Alpert Medical School at Brown University, Pawtucket, Rhode Island; 2. Healthcentric Advisors, Providence, Rhode Island; and Department of Health Services, Policy, and Practice, Warren Alpert Medical School at Brown University, Providence, Rhode Island. Received October 1, 2013; accepted October 2, 2013; electronically published November 26, 2013. 2013 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2014/3501-0004$15.00. DOI: 10.1086/674397 A decade into the new Clostridium difficile epidemic, the excessive morbidity, mortality, and healthcare costs associated with C. difficile infection (CDI) are now well recognized. The updated 2010 Society for Healthcare Epidemiology of America (SHEA) and Infectious Diseases Society of America (IDSA) guidelines for CDI prevention and treatment are incorporated into clinical practice, and multifaceted infection control bundles aimed at CDI prevention are adopted in most healthcare settings. Diagnosis using the more sensitive nucleic acid–based modalities is increasingly becoming the new standard. Reporting laboratory-identified CDI to the National Healthcare Safety Network is mandatory for all hospitals receiving payments from the Centers for Medicare and Medicaid Services, and comparisons between hospitals’ CDI rates will soon become publicly available. Similar approaches to preventing healthcare-acquired infections—such as central line–associated bloodstream infections, for example—met with considerable success, with sustained zero rates in many intensive care units across the United States. Unfortunately, this has not been the case with CDI. The number of patients hospitalized with a primary CDI diagnosis in the United States more than tripled during the period 2000–2009. The steady increase in CDI diagnoses over the last decade across acute care settings appears to have stabilized only recently. The study by Landelle et al in this issue offers a vivid insight into why C. difficile might be so stubbornly persistent in our hospitals. The authors set out to quantify healthcare worker (HCW) hand contamination with C. difficile spores during patient care in a French university-affiliated hospital not affected by the hypervirulent NAP1/BI strain. They sampled HCWs’ hands after glove removal at the end of patient care but before performance of hand hygiene and recovered the spores by treatment with 95% ethanol and filtration. Almost a quarter (24%) of HCWs caring for patients with CDI had hand contamination with spores. As expected, the risk of spore contamination was higher when there was contact with infected body fluids through direct contact with patients, their medical equipment, or their adjacent environment (high-risk contact) or when there was a failure to use gloves. Interestingly, 44% of the HCWs with contaminated hands provided at least 1 episode of direct patient care without use of gloves, despite the fact that they were fully aware that they were being observed for study purposes. The amount of hand contamination in a hospital where the hypersporulating NAP1/BI strain is endemic and the degree of noncompliance with contact precautions in unmonitored healthcare settings remain open to speculation. The study by Landelle and colleagues is timely and reenforces basic infection control principles that have become generally accepted: (1) HCWs’ hands become contaminated with C. difficile spores during patient care; (2) glove use, while effective in reducing the incidence of CDI in the hospital setting, does not fully protect against contamination and remains largely underutilized by the exact HCWs who are most exposed during patient care; (3) C. difficile spores are exceptionally resistant to disinfectants such as alcohol; and (4) contaminated HCWs’ hands likely provide an effective vehicle for in-hospital transmission of C. difficile spores. Cognizant of these principles, therefore, HCWs involved in direct care of patients with CDI would presumably seek to remove C. difficile spores from their contaminated hands immediately upon glove removal at the completion of each patient care task. Ironically, 166 years after Semmelweis signaled the importance of antisepsis in medical practice, the appropriate type of hand hygiene in the CDI setting is still a matter of debate. Landelle and colleagues favor the Centers for Disease Control and Prevention’s recommendation of hand hygiene with soap and water for all instances of CDI care. Additional support for this recommendation comes from previous stud-