disinfection and c.difficileinfection 781
figure 3. Incidence of healthcare-facility–onset, healthcare-facility–associated (HO-HCFA) Clostridium difficile infection (CDI) for 8 control (top panel) versus 7 intervention (bottom panel) hospitals during the preintervention, intervention, and postintervention periods. The thicker lines show mean values for control and intervention hospitals; the thinner lines show data for individual hospitals. For 2 control and 2 intervention hospitals, data was not available during the postintervention period. For 1 intervention hospital, data was not available for quarter 1 and quarter 2 of the preintervention period. Abbreviation: Q, quarter of the study year.
figure 4. Correlation between positive cultures in Clostridium difficile infection (CDI) and non-CDI rooms after postdischarge cleaning and incidence of healthcare-facility–onset, healthcare-facility–associated (HO-HCFA) CDI for control and intervention hospitals.
transmission. Such sources could include portable equipment, which may be infrequently cleaned, and floors that are typically cleaned with nonsporicidal products.1,19 In a recent study, a benign virus placed on the floor in a patient room rapidly disseminated to high-touch surfaces, adjacent rooms, and personnel work areas.19 Third, the intervention may not have adequately addressed environmental shedding by asymptomatic carriers of toxigenic C. difficile, an important potential reservoir for transmission.20–22 Although efforts were made to improve cleaning in all rooms, CDI rooms were the major focus of the intervention. More intensive efforts to clean and disinfect non-CDI roomsmight be required to reduce the risk for transmission by undetected
carriers. Fourth, interventions that focus solely on environ- mental disinfection may be insufficient to prevent transmission of C. difficile. It is possible that interventions that include envir- onmental disinfection as a bundle component may be more effective. Recent studies have suggested that antimicrobial stew- ardship focused on high-risk antibiotics such as fluoro- quinolones should be emphasized for control of C. difficile.23,24 Finally, the intervention may have been unsuccessful
because a significant proportion ofCDI cases that are currently classified as healthcare-associated may not be acquired in hospitals. In a recent large study from the United Kingdom that used whole-genome sequencing to type C. difficile isolates, only a minority of CDI cases were linked to other cases in
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