In the JournalsPerspective

HCWs' hands harbor C. difficile after routine CDI patient care

Nearly 25% of health care workers’ hands are contaminated with Clostridium difficile spores after caring for patients with the infection, researchers reported in Infection Control and Hospital Epidemiology.

“This is the first known study focusing on the carriage of viable C. difficile spores on health care workers hands,” Caroline Landelle, PharmD, PhD, of the Infection Control Unit, Centre Hospitalier Universitaire Albert Chenevier–Henri Mondor, Assistance Publique–Hôpitaux de Paris, Université Paris–Est Créteil, France, said in a press release. “Because C. difficile spores are so resistant and persistent to disinfection, glove use is not an absolute barrier against the contamination of health care workers’ hands. Effective hand hygiene should be performed, even in non-outbreak settings.”

Caroline Landelle, PhD 

Caroline Landelle

Landelle and colleagues compared hand contamination between 66 health care workers (HCWs) caring for patients with CDI and 44 HCWs who were not exposed to patients with CDI. The two groups were observed for 8 weeks. The researchers developed a method of salving C. difficile spores from the HCWs hands after rubbing their fingers and palms in alcohol after patient care.

During the study, there were seven patients with CDI and 16 control patients. All of the HCWs treating these patients had their hands sampled. C. difficile spores were recovered from 16 of 66 samples (24%) taken from the hands of exposed HCWs and from none of the samples taken from the unexposed HCWS. High-risk care, including diaper changing, patient washing and bed linen changing, was associated with the higher numbers of C. difficile colony-forming units per hand.

Nursing assistants were more likely to have hand contamination than other HCWs, including physicians and nurses. Nursing assistants also had more high-risk contacts than other HCWs. The researchers found that 7.8% of the 386 contacts with CDI patients occurred with ungloved hands. HCWs with contaminated hands had a higher number of contacts without use of gloves than HCWs without contaminated hands.

In an accompanying editorial, Aurora Pop-Vicas, MD, MPH, of Warren Alpert Medical School of Brown University said that this study provides insight into why CDIs are so persistent in hospitals. She highlights that more work is needed to implement prevention measures to prevent the horizontal transmission of these infections. In addition, improved antimicrobial stewardship programs and effective environmental cleaning in health care institutions are necessary.

“Although these tasks may seem insurmountable, the recent examples of dramatic reductions in nosocomial CDI incidence across the United Kingdom and Europe and the beginning of nosocomial CDI reduction observed in some US states over the last few years offer significant hope.”

For more information:

Landelle C. Infect Control Hosp Epidemiol. 2013;doi:10.1086/674396.

Pop-Vicas A. Infect Control Hosp Epidemiol. 2013;doi:10.1086/674397.

Disclosure: Landelle and Pop-Vicas report no relevant disclosures.

Nearly 25% of health care workers’ hands are contaminated with Clostridium difficile spores after caring for patients with the infection, researchers reported in Infection Control and Hospital Epidemiology.

“This is the first known study focusing on the carriage of viable C. difficile spores on health care workers hands,” Caroline Landelle, PharmD, PhD, of the Infection Control Unit, Centre Hospitalier Universitaire Albert Chenevier–Henri Mondor, Assistance Publique–Hôpitaux de Paris, Université Paris–Est Créteil, France, said in a press release. “Because C. difficile spores are so resistant and persistent to disinfection, glove use is not an absolute barrier against the contamination of health care workers’ hands. Effective hand hygiene should be performed, even in non-outbreak settings.”

Caroline Landelle, PhD 

Caroline Landelle

Landelle and colleagues compared hand contamination between 66 health care workers (HCWs) caring for patients with CDI and 44 HCWs who were not exposed to patients with CDI. The two groups were observed for 8 weeks. The researchers developed a method of salving C. difficile spores from the HCWs hands after rubbing their fingers and palms in alcohol after patient care.

During the study, there were seven patients with CDI and 16 control patients. All of the HCWs treating these patients had their hands sampled. C. difficile spores were recovered from 16 of 66 samples (24%) taken from the hands of exposed HCWs and from none of the samples taken from the unexposed HCWS. High-risk care, including diaper changing, patient washing and bed linen changing, was associated with the higher numbers of C. difficile colony-forming units per hand.

Nursing assistants were more likely to have hand contamination than other HCWs, including physicians and nurses. Nursing assistants also had more high-risk contacts than other HCWs. The researchers found that 7.8% of the 386 contacts with CDI patients occurred with ungloved hands. HCWs with contaminated hands had a higher number of contacts without use of gloves than HCWs without contaminated hands.

In an accompanying editorial, Aurora Pop-Vicas, MD, MPH, of Warren Alpert Medical School of Brown University said that this study provides insight into why CDIs are so persistent in hospitals. She highlights that more work is needed to implement prevention measures to prevent the horizontal transmission of these infections. In addition, improved antimicrobial stewardship programs and effective environmental cleaning in health care institutions are necessary.

“Although these tasks may seem insurmountable, the recent examples of dramatic reductions in nosocomial CDI incidence across the United Kingdom and Europe and the beginning of nosocomial CDI reduction observed in some US states over the last few years offer significant hope.”

For more information:

Landelle C. Infect Control Hosp Epidemiol. 2013;doi:10.1086/674396.

Pop-Vicas A. Infect Control Hosp Epidemiol. 2013;doi:10.1086/674397.

Disclosure: Landelle and Pop-Vicas report no relevant disclosures.

    Perspective
    Erik Dubberke

    Erik Dubberke

    Existing data indicate that the primary source of C. difficile transmission from one patient to another in health care settings is by contaminated hands of HCWs. This study helps to explain some of the difficulties in preventing C. difficile infection, but there remain several questions in regards to the optimal methods to prevent and/or remove C. difficile spore contamination from HCWs’ hands. After caring for a patient with CDI, 16/66 (24%) of HCWs were contaminated with C. difficile spores. Almost half of the HCWs with contaminated hands (7/16) touched the patient and/or the environment without gloves at some point. Considering gloves were not worn for only 30/386 (7.8%) of observed contacts, it is clear glove use remains a cornerstone to prevent C. difficile transmission. However, it is concerning that hand contamination may have occurred despite wearing gloves. Method of glove removal was not recorded, so it is possible hand contamination occurred during glove removal. Also, if hand contamination occurs, it is not clear if washing hands is sufficient for spore removal. Studies examining the impact of hand hygiene method (hand washing versus alcohol-based hand rub) have failed to demonstrate a reduction in CDI incidence with hand washing. This may in part be explained by the study by Edmonds et al, which found hand washing with recommended methods and products resulted in a less than a 1 log reduction in C. difficile spores. Better methods at decontaminating hands are needed. Of note, the only other independent predictor for contaminated hands, other than not wearing gloves, was high-risk contact with the patient (e.g. bathing the patient, rectal exam, etc). Studies are needed to determine whether there are interventions that can minimize contamination during those activities.

    • Erik Dubberke, MD
    • Associate professor Washington University School of Medicine

    Disclosures: Dubberke reports no relevant financial disclosures.