Eradication of Environmental Clostridium difficile:
Results of a Four Year Decontamination
Programme using Dry Mist Hydrogen Peroxide
Nottingham University Hospitals (NUH) is a large teaching hospital split over two separate Environmental Sampling Results: Health Care of the Older Person
Percentage of
C. difficile
Percentage of Samples
Rooms Positive for
CFU per 10
Throughout 2005-06 NUH reported increasing rates of Clostridium difficile infection (C. Positive for C. difficile
C. difficile
difficile). At that time, rooms occupied by toxin positive patients received a terminal three-stage clean and disinfection with 10,000 parts per million hypochlorite solution at the point Environmental sampling and selective culture confirmed reservoirs of C. difficile in wards providing Healthcare of the Older Person, including dirty utilities and isolation rooms which had been cleaned and released for re-occupation. Following a single decontamination cycle using dry mist hydrogen peroxide (HP) 100 (10/10)
23.6 (48/203)
environmental C. difficile contamination was significantly reduced (previously published data S. Shapey et al 2008). This prompted a Trust-wide program of targeted HP decontamination, including: • Terminal decontamination of isolation rooms occupied by patients known to be positive • Proactive whole ward deep cleaning of wards with the highest C. difficile rates. NUH HA C. difficile Rates per 1000 bed days
20 (2/10)
1.0 (2/203)
H202 program m e introduced
Environmental sampling in 2006 confirmed the presence of C.difficile contamination in 100% of rooms sampled (n=8 for isolation rooms, n=2 for dirty utilities). 24.5% (n=40) of samples from isolation rooms and 20% (n=8) in dirty utilities were positive, with 6.8 colony forming units (CFU) of C. difficile recovered per 10 samples overall. Ribotyping confirmed the presence of mixed strains in four of the rooms and identified all three UK endemic strains (ribotypes: 001, 027, 106). These were consistent with ribotyping results for clinical isolates from NUH patients at that time. In 2011, C.difficile was isolated from only 2 swab samples: 1 macerator rim and 1 nurse call buzzer (ribotypes 005 and 039 respectively, both 1 CFU per swab). All broth enrichment This is a significant reduction in C.difficile environmental contamination for isolation rooms and dirty utilities within wards providing Healthcare to Older Patients. CONCLUSIONS
In 2006 a mixture of endemic strains contaminated all clinical areas tested. Since the introduction of targeted HP decontamination there has been a significant reduction in Targeted HP decontamination was one of a number of control measures introduced in 2007. environmental contamination with C.difficile in isolation room and dirty utilities within Since then C. difficile infection rates have significantly reduced and ribotyping results for clinical isolates suggest that the remaining cases are sporadic. Since 2007 NUH has implemented a variety of initiatives to reduce C.difficile acquisition. This study replicates environmental sampling carried out in 2006 in order to quantify the Despite increased testing of clinical samples, infection rates are now at the lowest levels effectiveness of the four year HP decontamination programme in removing environmental recorded for this Trust. Ribotyping provides additional evidence that the remaining cases are sporadic and therefore unlikely to have been acquired within the organisation This study demonstrates that environmental reservoirs for endemic strains of C. difficile have virtually been eradicated and provides evidence that the hydrogen peroxide decontamination programme has been beneficial. MATERIALS AND METHODS
Contamination of macerators is not unexpected and good infection prevention and control practice should be sufficient to control this potential source of infection. The significance of this single isolate from a nurse-call buzzer is the subject of ongoing investigations In 2006, 203 surface swabs and curtain sweeps from ten rooms in Healthcare of the Older Person (2 dirty utilities and 8 isolation rooms, cleaned for reoccupation), were tested for the presence of C. difficile by direct inoculation onto Brazier’s cycloserine-cefoxitin-egg yolk agar (BCCEY). After 96 hours incubation under anaerobic incubation (37ºC) plates were BIBLIOGRAPHY
examined for isolates which resemble C. difficile. Identification was confirmed by standard laboratory tests and isolates were stored at -80ºC. A selection of stored isolates were later examined using PCR ribotyping (Stubbs et al 1999) and compared with endemic strains circulating within the inpatient population at that time. Best E L et al, The potential for airborne dispersal of Clostridium difficile from Symptomatic Patients, CID This study replicated environmental sampling carried out in 2006. To improve sensitivity, Shapey S et al, Activity of a dry mist hydrogen peroxide system against environmental Clostridium difficile contamination in elderly care wards, J Hosp Infect 2008, doi:10.1016/j.jhin.2008.06.008 solid surfaces were tested using both direct inoculation onto BCCEY (S. Shapey et al 2008) Stubbs SL et al, PCR targeted to the 16S-26S rRNA gene intergenic spacer region of Clostridium difficile and the enrichment method described by Best et al 2010. and construction of a library consisting of 116 different PCR ribotypes. J Clin Microbiol 1999; 37: 461-463


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