infection control & hospital epidemiology july 2017, vol. 38, no. 7 original article
A Multicenter Randomized Trial to Determine the Effect of an Environmental Disinfection Intervention on the Incidence of Healthcare-Associated Clostridium difficile Infection
Amy J. Ray, MD, MPH;1,2 Abhishek Deshpande, MD, PhD;3 Dennis Fertelli, BS;4 Brett M. Sitzlar, BS;4 Priyaleela Thota, MD;4 Thriveen Sankar C, MBA;4 Annette L. Jencson, CIC;4 Jennifer L. Cadnum, BS;4 Robert A. Salata, MD;1,2 Richard R. Watkins, MD;5 Ajay K. Sethi, PhD;6 Philip C. Carling, MD;7 Brigid M. Wilson, PhD;8 Curtis J. Donskey, MD2,8
objective. To determine the impact of an environmental disinfection intervention on the incidence of healthcare-associated Clostridium difficile infection (CDI).
design. A multicenter randomized trial. setting. In total,16 acute-care hospitals in northeastern Ohio participated in the study.
intervention. We conducted a 12-month randomized trial to compare standard cleaning to enhanced cleaning that included monitoring of environmental services (EVS) personnel performance with feedback to EVS and infection control staff. We assessed the thoroughness of cleaning based on fluorescent marker removal from high-touch surfaces and the effectiveness of disinfection based on environmental cultures for C. difficile. A linear mixed model was used to compare CDI rates in the intervention and postintervention periods for control and intervention hospitals. The primary outcome was the incidence of healthcare-associated CDI.
results. Overall, 7 intervention hospitals and 8 control hospitals completed the study. The intervention resulted in significantly increased fluorescent marker removal in CDI and non-CDI rooms and decreased recovery of C. difficile from high-touch surfaces in CDI rooms. However,
no reduction was observed in the incidence of healthcare-associated CDI in the intervention hospitals during the intervention and post- intervention periods. Moreover, there was no correlation between the percentage of positive cultures after cleaning of CDI or non-CDI rooms and the incidence of healthcare-associated CDI.
conclusions. An environmental disinfection intervention improved the thoroughness and effectiveness of cleaning but did not reduce the incidence of healthcare-associated CDI. Thus, interventions that focus only on improving cleaning may not be sufficient to control healthcare- associated CDI.
Infect Control Hosp Epidemiol 2017;38:777–783
Effective disinfection of contaminated environmental surfaces and equipment is essential to preventing transmission of Clostridium difficile spores in healthcare facilities.1–3 In several quasi-experimental studies, substitution of sporicidal disin- fectants for nonsporicidal agents has been associated with reductions in CDI.1 Therefore, sporicidal disinfectants are recommended for disinfection of surfaces in rooms of patients with C. difficile infection (CDI), particularly in outbreak and hyperendemic settings.3 However, even when sporicidal disinfectants are used, it is not uncommon for spore contamination to be detected on surfaces after completion of
manual cleaning and disinfection.1,4 Such contamination has been attributed primarily to suboptimal application of disinfectants, a common problem in healthcare facilities.4–7 In recent years, 2 strategies have been demonstrated to improve eradication of spores from surfaces in CDI rooms in settings where sporicidal disinfectants are used. First, moni- toring of cleaning with feedback to environmental services (EVS) personnel has been effective in improving disinfection of spores.4,7 For example, recovery of spores from surfaces in CDI rooms after cleaning was significantly reduced through an intervention that included feedback on the thoroughness of
Affiliations: 1. Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio; 2. Case Western Reserve University School of
Medicine, Cleveland, Ohio; 3. Cleveland Clinic Foundation, Cleveland, Ohio; 4. Research Service, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio; 5. Department of Medicine, Akron General Medical Center, Akron, Ohio; 6. Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin; 7. Carney Hospital and Boston University School of Medicine, Boston, Massachusetts; 8. Geriatric Research, Education and Clinical Center, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio.
© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2017/3807-0003. DOI: 10.1017/ice.2017.76 Received November 14, 2016; accepted March 27, 2017; electronically published May 2, 2017
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