What has helped in the arena of C . diff prevention is a greater understanding of the epidemiology involved in CDI . For example , genomic epidemiology has now confirmed the environmental transmission of spores from these colonized patients to other patients , and patients recovering from acute CD infection are associated with significant transmission of spores to their environment , studies show . As Carling , et al . ( 2023 ) emphasize that results from several large studies on next-bed-occupant CDI acquisition “ can only be explained by recipient acquisition of residual CD spores asymptomatically shed onto patient-zone surfaces by the preceding room occupant .”
The solution , Carling and colleagues emphasize , is environmental hygiene as a critical component of horizontal interventions as originally postulated Wenzel and Edmonds ( 2010 ) that are essential for mitigating healthcare-associated infections . As Carling , et al . ( 2023 ) remind us , “ These approaches aim to reduce the risk of infections caused by a broad range of pathogens by the implementation of standard practices that are effective regardless of patient specific conditions . In contrast to the horizontal interventions , ‘ vertical interventions ’ are pathogen and / or condition specific . While vertical and horizontal approaches are often complementary , there is evolving evidence that horizontal interventions in endemic situations may represent a best use of HAI prevention resources .”
In Carling ’ s latest schematic , hand hygiene and environmental hygiene are interdependent in the same way that physical cleaning and liquid chemical disinfectant are , all working together as a horizontal approach .
Carling notes , “ Horizontal healthcare hygienic practices are critical .” An example is hand hygiene , which exists in a vacuum unless appropriate environmental hygiene is practiced . The interplay between the two is essential when it comes to addressing C . difficile transmission . “ Doing well with one element and not the other is like trying to clap with one hand ,” Carling adds .
As Carling and colleagues observe , “ Over the past several years it has become increasingly evident that infection prevention initiatives focused on optimizing hand hygiene have not realized their hoped-for impact on healthcare-associated pathogen ( HAP ) transmission in well-resourced healthcare settings . Accepting our inability to quantify the absolute risk of pathogen acquisition directly from healthcare workers ’ hands , there is good circumstantial evidence that such transmission accounts for a substantial proportion of HAP transmission . Given the fact that patient zone surfaces not contaminated by HAPs cannot be a source of pathogen transmission even in the absence of hand hygiene , further consideration must be given to viewing both environmental hygiene and hand hygiene as being interdependent interventions since these two interventions are intrinsically interdependent , they represent what can be termed ‘ hygienic practices .’”
The interplay between hands and surfaces is even more critical when considering the role of spores in surface contamination in healthcare facilities . As Carling , et al . ( 2023 ) point out , “ Given the extremely low inoculum necessary to cause infection and the fact that CD spores on environmental surfaces have a basically indefinite ability to remain viable decreasing only 0.5 log in 14 months it is not surprising that surfaces contaminated with CD spores have a role in CD transmission .”
However , the challenge of raising awareness of C . diff spores and the need for specific cleaning interventions to tackle them can be difficult . For example , as we know , hands should be washed properly with soap and water – instead of alcohol-based hand sanitizer -- if potentially contaminated with C . difficile . These surfaces also require a higher level of cleaning and disinfection . But is that message resonating with healthcare personnel ? “ Not so much ,” Carling says . “ Certainly not that I see . The real problem is that an asymptomatic carrier is shedding and spreading spores into the healthcare environment that no one is aware of enough to perform special hand hygiene or to wear gloves . Studies have supported the existence of contamination even far away from the patient ; Curtis Donskey showed that years ago . Dev Anderson ’ s recent study also showed qualitatively how many rooms that are contaminated by patients . Taking this , along with the results of the studies examining prior-room occupancy and transmission , shows that we have a significant opportunity for transmission .”
The authors suggest that sporicidal agents are playing an important role in the fight against CDI .
“ I think they ’ re critical for mitigating this unknown pool of potential contamination in the environment ,” Carling says . “ The infective dose of C . diff is very low , and the spores don ’ t die off , so sporicidal disinfectants can be effective when used properly and appropriately .”
Chemical disinfection is part of what should be a programmatic approach to optimizing environmental hygiene to mitigate HO-CDI , Carling and colleagues say . This approach includes key components such as evaluating cleaning and disinfection practice thoroughness , as well as an ongoing monitoring and feedback program .
The researchers point to published evidence supporting objective monitoring to evaluate surface cleaning processes , so much so that the Centers for Disease Control and Prevention ( CDC ) developed the guidance “ Options for Evaluating Environmental Cleaning ” in 2010 and updated it in the guidance “ Best Practices for Environmental Cleaning Procedures ” in 2020 , which recommends the use of a fluorescent marker-based performance monitoring program along with direct observation of cleaning practice .
In October 2020 the CDC published a guidance document to provide hospitals with a detailed roadmap for the development of programs to optimize all aspects of patient-zone environmental hygiene . These Core Components of Environmental Cleaning and Disinfection are :
➊ Integrate environmental services into the hospital ’ s safety culture .
➋ Educate and train all HCP responsible for cleaning and disinfecting patient care areas .
➌ Select appropriate cleaning and disinfection technologies and products .
➍ Standardize setting-specific cleaning and disinfection protocols .
➎ Monitor effectiveness and adherence to cleaning and disinfection protocols .
➏ Provide feedback on adequacy and effectiveness of cleaning and disinfection to staff and stakeholders .
Importantly , a programmatic approach can yield additional benefits of mitigating CD environmental transmission , including
18 october 2023 • www . healthcarehygienemagazine . com