Increased environmental sample area and recovery of Clostridium difficile spores from hospital surfaces by quantitative PCR and enrichment culture.

Kevin Antoine Brown,Andrew Simor,Laura K Macdougall,Samira Mubareka,George Broukhanski,Gary Garber,Allison Mcgeer,Kim Valenta,Nick Daneman,Jennie Johnstone

doi:10.1017/ice.2018.103

Abstract

Clostridium difficile spores play an important role in transmission and can survive in the environment for several months. Optimal methods for measuring environmental C. difficile are unknown. We sought to determine whether increased sample surface area improved detection of C. difficile from environmental samples. Samples were collected from 12 patient rooms in a tertiary-care hospital in Toronto, Canada. Samples represented small surface-area and large surface-area floor and bedrail pairs from single-bed rooms of patients with low (without prior antibiotics), medium (with prior antibiotics), and high (C. difficile infected) shedding risk. Presence of C. difficile in samples was measured using quantitative polymerase chain reaction (qPCR) with targets on the 16S rRNA and toxin B genes and using enrichment culture. Of the 48 samples, 64·6% were positive by 16S qPCR (geometric mean, 13·8 spores); 39·6% were positive by toxin B qPCR (geometric mean, 1·9 spores); and 43·8% were positive by enrichment culture. By 16S qPCR, each 10-fold increase in sample surface area yielded 6·6 times (95% CI, 3·2-13) more spores. Floor surfaces yielded 27 times (95% CI, 4·9-181) more spores than bedrails, and rooms of C. difficile-positive patients yielded 11 times (95% CI, 0·55-164) more spores than those of patients without prior antibiotics. Toxin B qPCR and enrichment culture returned analogous findings. Clostridium difficile spores were identified in most floor and bedrail samples, and increased surface area improved detection. Future research aiming to understand the role of environmental C. difficile in transmission should prefer samples with large surface areas.

Highlights

Patient rooms were selected based on a categorization of risk of contamination: high-risk rooms were defined as those of patients with active C. difficile diarrhea identified by hospital infection control staff; medium-risk rooms were those of patients with a history of in-hospital antibiotic use in the last 14 days; and low-risk rooms were those of patients without a history of C. difficile or in-hospital antibiotic use in the previous 14 days
We considered the impact of increasing sample surface area on C. difficile recovery using culture and cultureindependent techniques
We found that increased sample surface area was associated with increased counts of spores recovered and increased proportions of samples that were positive by all laboratory techniques

Summary

Introduction

Increased environmental sample area and recovery of Clostridium difficile spores from hospital surfaces by quantitative PCR and enrichment culture. We sought to identify whether increased sample surface area was associated with increased detection of C. difficile from environmental samples collected from patient rooms in a tertiary-care hospital in a nonoutbreak setting. We used an efficient split-plot sampling design[14,15] to assess the impact of sample surface area on C. difficile detection from hospital environmental samples while controlling for room-level clustering of bacterial burden.

Results

Conclusion