780 infection control & hospital epidemiology july 2017, vol. 38, no. 7
(4,407 sites with marker removed of 5,346 total sites in 650 total rooms; range, 64% to 100% for individual hospitals) during the study period (P<.001) (Figure 1A). For daily cleaning in CDI rooms, the average percent marker removal increased from 52% (1,534 sites with marker removal of 2,969 total sites in 435 total rooms; range, 12% to 74% for individual hospitals) to 69% (6,731 sites with marker removal of 9,704 total sites in 1,354 total rooms; range, 35% to 91% for indi- vidual hospitals) (P<.001) (Figure 1B). Figure 2 shows the percentages of rooms with positive cul-
tures for C. difficile after postdischarge cleaning in CDI and non-CDI rooms for the intervention and control hospitals. No significant differences in the percentages of rooms with posi- tive cultures for the control versus intervention hospitals in the baseline period. The intervention resulted in a significant reduction in the percentage of CDI rooms with positive cultures for C. difficile (from 13%, 19 of 144 rooms to 3%, 8 of 304 rooms; P<0.01) after postdischarge cleaning.
The intervention also resulted in reductions in the percentage of non-CDI rooms with positive cultures for C. difficile (from 3% [4 of 125] to 2% [11 of 721]; P=.35). In the control hospitals, there were no significant reductions
in the overall percentage of CDI rooms with positive cultures for C. difficile (19% [10 of 54] and 14%, 8 of 58; P=.23) after postdischarge cleaning. In addition, there was no reduction the percentage of non-CDI rooms with positive cultures for C. difficile (6% [6 of 95] and 5% [10 of 199]; P=.86) after postdischarge cleaning. Figure 3 shows the incidence of HO-HCFA CDI for the
control (top panel) versus intervention (bottom panel) hospitals during the preintervention, intervention, and post- intervention 1-year periods. The incidence of HO-HCFA CDI was not significantly different for the control and intervention hospitals during the preintervention period: average CDI incidence: 5.6 per 10,000 patient days versus 5.8 per 10,000 patient days, respectively (P=.80). Based on a linear mixed model predicting monthly CDI cases per 10,000 patient days across the 3 years with a random hospital effect considering the effect of the intervention and time, no significant differences were observed in CDI rates in the intervention or post- intervention periods across the 2 treatment periods. Moreover, there was no significant correlation between the percentage of positive cultures for C. difficile after cleaning of CDI or non- CDI rooms and the incidence of healthcare-associated CDI (Figure 4).
discussion
We found that contamination of high-touch surfaces with C. difficile spores was common after completion of cleaning prior to the intervention, particularly in CDI rooms. The intervention resulted in improved thoroughness of cleaning based on significant increases in fluorescent marker removal from high-touch surfaces in CDI and non-CDI rooms. The effectiveness of disinfection also improved based on significant reductions in recovery of C. difficile from high-touch surfaces in CDI rooms. However, the intervention did not result in a reduction in the incidence of HO-HCFA CDI in the inter- vention hospitals during the intervention or post-intervention periods. Moreover, there was no correlation between the per- centage of positive cultures after cleaning of CDI or non-CDI rooms and the incidence of healthcare-associated CDI. There are several potential explanations for why the inter-
figure 2. Effect of the cleaning intervention on percentage of rooms with positive cultures for Clostridium difficile from high- touch surfaces after cleaning following patient discharge from C. difficile infection (CDI) (A) and non-CDI (B) rooms in the 7 intervention hospitals. Abbreviation: Q, quarter of the study year.
vention failed to reduce the incidence ofHO-HCFA CDI. First, the level of improvement in disinfection of high-touch surfaces may not have been sufficient to prevent transmission. Although disinfection was improved in the intervention hos- pitals, recovery of spores was not uncommon during the intervention. Moreover, the use of swabs for collection of cultures is relatively insensitive, and it is possible that small numbers of undetected spores persisted on surfaces.18 Second, the intervention focused on high-touch surfaces in patient rooms and may have missed other environmental sources of
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