782 infection control & hospital epidemiology july 2017, vol. 38, no. 7
hospitals.25 Other recent studies have reported that a sig- nificant proportion of patients diagnosed with healthcare- associated CDI are already colonized with the infecting strain at the time of admission.26,27 Environmental cleaning would not have an impact on cases where colonization is present on admission. Our findings differ from recent reports suggesting that
adjunctive use of automated room disinfection devices might be effective in reducing CDI rates.10–13 It is possible that use of such devices may offer a benefit over interventions, such as ours, that focus on improving the performance of EVS per- sonnel. However, in a large, cluster-randomized, multicenter, crossover study, adjunctive use of ultraviolet-C room disin- fection devices was associated with reduced colonization or infection with multidrug-resistant organisms but not CDI.28 In that study, room disinfection with bleach was compared to bleach plus adjunctive ultraviolet-C room disinfection. Our study has several strengths. We included monitoring to
CDI cases could be linked to other healthcare-associated cases. Finally, we only examined the impact of the intervention on CDI rates. Admission to a room previously occupied by a patient colonized or infected with healthcare-associated pathogens is associated with an increased risk of acquiring the same pathogen.29 In addition, environmental disinfection interventions have been associated with reductions in coloni- zation or infection with pathogens other than C. difficile in some, but not all, studies.1,30,31 Further work is needed to determine whether the current intervention had an impact on the incidence of infections due to other organisms. In conclusion, our results add to the growing body of evi-
confirm the effectiveness of the intervention. One limitation of many previous studies is that monitoring has often not been adequate to confirm that interventions resulted in actual reductions in spore contamination. Second, we included multiple methods of monitoring, including assessments of both thoroughness of cleaning and effectiveness of surface disinfection. Third, the study was conducted as a randomized trial. Previous reports suggesting that cleaning interventions reduce CDI have been quasiexperimental in design. Our study also has several limitations. First, the quality of
the intervention varied among the different intervention hos- pitals. It involved efforts to improve cleaning by large numbers of EVS personnel with varying levels of support from EVS supervisors, infection control departments, and hospital administrations. In addition, there may have been variability in the ability of different study coordinators to effectively implement the intervention. Despite the potential for variation among facilities, we found evidence of improved cleaning in all intervention hospitals. Second, the study was not blinded. The nonintervention hospitals were aware of the study and coor- dinators were present to conduct monitoring during the baseline period and intermittently during the study. However, monitoring of the control hospitals was much less intensive than for the intervention facilities, and no feedback was provided. Third, as noted previously, the method used for culturing surfaces was relatively insensitive, and we cannot exclude the possibility that low-level contamination was pre- sent that might have contributed to transmission. Fourth, the study was conducted in a setting in which all hospitals were using sporicidal disinfectants in CDI rooms. The intervention may have had an impact on CDI rates in settings in which nonsporicidal disinfectants were used. Fifth, many of the study hospitals were conducting some form of intermittent monitoring of cleaning prior to the beginning of the study. However, none of the hospitals reported routine monitoring with regular feedback to EVS personnel. Sixth, we did not perform molecular typing to determine whether HO-HCFA
dence that environmental disinfection can be improved through interventions that include monitoring and feedback directed toward EVS personnel. Both thoroughness of cleaning and effectiveness of disinfection were significantly improved in the intervention facilities. However, the intervention did not result in a reduction in the incidence of healthcare-associated CDI. Additional studies are therefore needed to identify effective strategies to reduce the incidence of healthcare-associated CDI.
acknowledgments
Financial support: A grant from the Agency for Healthcare Research and Quality to C.J.D. (grant no. 1R1845020004-01A1) and a grant from the Department of Veterans Affairs supported this study. Potential conflicts of interest: C.J.D. has received research funding from
EcoLab, Clorox, GOJO and Altapure and serves on an advisory board for 3M. P.C.C. has served as a consultant for Ecolab and Steris and has licensed patents to Ecolab for a fluorescent marker product and process. All other authors report no conflicts of interest relevant to this article.
Address correspondence to Curtis J. Donskey, MD, Geriatric Research,
Education, and Clinical Center 1110W, Cleveland VA Medical Center, 10701 East Boulevard, Cleveland, Ohio 44106 (
curtisd123@yahoo.com).
references
1. Donskey CJ. Does improving surface cleaning and disinfection reduce health care-associated infections? Am J Infect Control 2013;41:S12–S19.
2. Rutala WA, Weber DJ. The role of the environment in trans- mission of Clostridium difficile infection in healthcare facilities. Infect Control Hosp Epidemiol 2011;32:207–209.
3. Dubberke ER, Carling P, Carrico R, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 Update. Infect Control Hosp Epidemiol 2014;35:628–645.
4. Sitzlar B, Deshpande A, Fertelli D, Kundrapu S, Sethi AK, Donskey CJ. An environmental disinfection odyssey: evaluation of sequential interventions to improve disinfection of Clostridium difficile isolation rooms. Infect Control Hosp Epidemiol 2013; 34:459–465.
5. Carling PC, Briggs JL, Perkins J, Highlander D. Improved cleaning of patient rooms using a new targeting method. Clin Infect Dis 2006;42:385–388.
6. Hayden MK, Bonten MJ, Blom DW, Lyle EA, van de Vijver DA, Weinstein RA. Reduction in acquisition of vancomycin-resistant Enterococcus after enforcement of routine environmental cleaning measures. Clin Infect Dis 2006;42:1552–1560.
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