The A, B, BI, and Cs ofClostridium difficile

Abstract

The study by Belmares et al (1) is the most comprehensive, longitudinal study of the molecular epidemiology of Clostridium difficile infection to date. This study is impressive not only because restriction endonuclease analysis typing was performed on three-quarters of C. difficile isolates from 908 cases of C. difficile infection (CDI) at the Minneapolis Veterans Administration Medical Center (MVAMC) collected over a 10 year period, but also because the investigators recognized the importance of conducting this study despite the 18 year time span from the collection of the C. difficile isolates to publication. This study confirms what other less systematic and/or comprehensive studies have suggested, the molecular epidemiology of C. difficile in healthcare facilities is frequently both diverse and dynamic (2–8). This study must be interpreted in conjunction with knowledge of the other studies performed and activities that took place during the same time period at the MVAMC that may have affected C. difficile transmission (9–15). Infection control policies, changes in healthcare delivery, and interventions that took place over the 10 year period included: 1) placing patients with CDI in private rooms only if incontinent and unable to use a bedpan, 2) using a quaternary ammonium disinfectant for cleaning all hospital rooms, 3) authorizing nurses to send diarrheal stool for C. difficile testing without a physician order, 4) restricting the use of clindamycin starting September 1985, 5) donning gloves as the standard for handling all body fluids starting April 1988, and 6) moving all patients into a new building in June 1988. Although this study contributes significantly to our knowledge of C. difficile, it also highlights the need for more studies combining molecular epidemiology with CDI prevention efforts in order to understand the effectiveness of CDI prevention practices.