American Journal of Infection Control 42 (2014) 674-5
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Hospital Clostridium difficile outbreak linked to laundry machine malfunction Shelini Sooklal MD *, Ayesha Khan MD, Saman Kannangara MD Department of Internal Medicine, Easton Hospital, Easton, PA
Key Words: Nosocomial Feces Floor Mop Stool
Clostridium difficile is a gram-positive, spore-forming anaerobic bacillus that is associated with diarrheal disease. C difficile is shed in the feces of affected individuals and its spores can survive on surfaces for prolonged periods of time. These spores can contaminate a hospital environment by spread through health care workers and suboptimal environmental cleaning practices. We report an outbreak of health care facility-onset C difficile infection that was eventually linked to contaminated mop pads after a laundry machine malfunction. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Clostridium difficile is a gram-positive, spore-forming anaerobic bacillus that is associated with diarrheal disease. C difficile infection (CDI) is a frequent nosocomial illness, and is an increasing problem in hospitals globally. C difficile has been identified as the pathologic agent in 10%-20% of cases of antibiotic-associated diarrhea, and has been implicated in as many as 50% of epidemic outbreaks.1 CDI rates have also been rising: from 1996 to 2003 CDI rates per 100,000 population almost doubled in the United States.2 Data from the Centers for Disease Control and Prevention show that the rate of the discharge diagnosis of C difficile infection increased from 31 cases per 100,000 persons per year in 1996 to 61 cases per 100,000 persons per year in 2003.3 C difficile is shed in the feces of affected individuals and its spores can survive on surfaces for prolonged periods of time. The spores can contaminate a hospital environment and be spread by health care workers and suboptimal environmental cleaning practices. At an academic community hospital in Pennsylvania the infection control team noted a disturbing trend during June 2013. The number of cases of health care facility-onset CDI had drastically increased. Health care facility-onset CDI was defined as a C difficile polymerase chain reaction-positive result of a stool specimen that was collected >3 calendar days after hospital admission. During the period January 2013-March 2013, 3 cases of health care facilityonset CDI were recorded. However, during the period April 2013June 2013 (second quarter 2013), this number climbed to 11. The * Address correspondence to Shelini Sooklal, MD, 250 S 21st St, Easton, PA 18045. E-mail address: [email protected] (S. Sooklal). Conflicts of interest: None to report.
Fig 1. Health care facility-onset cases of Clostridium difficile infection.
epidemic curve in Figure 1 demonstrates these findings by monthly incidence rate. The standardized infection ratio for second quarter 2013 was 1.67, with a standardized infection ratio P value of .05. This demonstrates that this increased CDI rate is statistically significant for the second quarter 2013. A multidisciplinary team was assembled to investigate this phenomenon. The number of hospital admissions between the 2 time periods in question was comparable and the case mix also was comparable. There was no significant difference in the community-onset CDI prevalence rate. Seasonal variation could not have accounted for the marked increase in cases because most cases of C difficile infection occur during the period November-January, coinciding
0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2014.02.012
S. Sooklal et al. / American Journal of Infection Control 42 (2014) 674-5
with influenza season annually. Further analysis of the distribution of cases failed to link the outbreak to any particular floor or hospital wing. Allocation of nursing staff had not changed. No major additions to members of the health care staff who have direct patient contact had occurred that could have altered the standard of infection control. Stool samples for C difficile polymerase chain reaction testing were collected according to hospital protocol. Neither laboratory equipment nor reagents had been changed during the period under investigation. Quality control measures were implemented daily. Patients with suspected CDI, as well as confirmed CDI, were placed in isolation rooms. On discharge, all surfaces were wiped with a solution containing acetic acid, hydrogen peroxide, octanoic acid, and peroxyacetic acid (Virasept; Ecolab Inc, St Paul, Minn). This disinfectant is designed to clean hard surfaces and has activity against C difficile spores. The rooms were also mopped with a 10% dilution bleach solution. Each mop pad was only used once to clean a single room then returned to the housekeeping department to be disinfected by washing with a 100 ppm bleach solution in a designated washing machine. A breakthrough came when laundry records were examined. The quantity of bleach used during the time period in question was compared with the number of loads of mop-pad washes that were done. It was deduced that approximately 100 loads of mop pads were washed without bleach. An examination of the designated washing machine for mop pads revealed that this machine had been accidentally switched to the microfiber setting. In this setting, preloaded bleach would not have been added to the washing load. The poorly cleansed mop pads were then reused, likely spreading C difficile spores. The servicing company for the washing machine was immediately contacted, the error rectified, and the microfiber setting was made obsolete. All mop pads and rags used for cleaning hard
675
surfaces of rooms were double washed and all hospital rooms were cleaned thoroughly. Patients were relocated in batches during the cleaning process. Further infection control education was extended to all hospital staff members. The importance of hand hygiene, use of gloves, and appropriate patient isolation was stressed. The laundry and housekeeping staff were briefed on the error, and the importance of adherence to cleaning protocols was stressed. During the 2 months following this intervention, no cases of health care facility-onset CDI were recorded. Improved staff education and implementation of infection control measures may have contributed to the decrease in CDI cases. By comparison, Fitzgerald et al4 stated that the efforts of a multidisciplinary team did little to decrease the incidence of CDI at their academic medical center. Additionally, more than 2 decades ago, Fekety et al5 noted that C difficile had been isolated, amongst other places, from bedding, floors, and furniture. Hospital floors are commonly contaminated with C difficile and other pathogens, and our experience suggests that floors may be an underappreciated source of C difficile transmission. References 1. Bartlett JG, Chang TW, Gurwith M, Gorbach SL, Onderdonk AB. Antibiotic-associated pseudomembranous colitis due to toxin-producing clostridia. N Engl J Med 1978;298:531-4. 2. Sunenshine RH, McDonald LC. Clostridium difficile-associated disease: new challenges from an established pathogen. Cleve Clin J Med 2006;73:187-97. 3. McDonald LC, Owings M, Jernigan DB. Clostridium difficile infection in patients discharged from US short-stay hospitals. Emerg Infect Dis 2006;12:409-15. 4. Fitzgerald T, Hermsen E, Sholtz L, Anderson J, Iwen P, Jourdan D, et al. Multidisciplinary interventions for the management and prevention of Clostridium difficile-associated disease at an academic medical center. Am J Infect Control 2009;37:E59. 5. Fekety R, Kim KH, Brown D, Batts DH, Cudmore M, Silva J Jr. Epidemiology of antibiotic-associated colitis; isolation of Clostridium difficile from the hospital environment. Am J Med 1981;70:906-8.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Hospital Clostridium difficile outbreak linked to laundry machine malfunction Shelini Sooklal MD *, Ayesha Khan MD, Saman Kannangara MD Department of Internal Medicine, Easton Hospital, Easton, PA
Key Words: Nosocomial Feces Floor Mop Stool
Clostridium difficile is a gram-positive, spore-forming anaerobic bacillus that is associated with diarrheal disease. C difficile is shed in the feces of affected individuals and its spores can survive on surfaces for prolonged periods of time. These spores can contaminate a hospital environment by spread through health care workers and suboptimal environmental cleaning practices. We report an outbreak of health care facility-onset C difficile infection that was eventually linked to contaminated mop pads after a laundry machine malfunction. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Clostridium difficile is a gram-positive, spore-forming anaerobic bacillus that is associated with diarrheal disease. C difficile infection (CDI) is a frequent nosocomial illness, and is an increasing problem in hospitals globally. C difficile has been identified as the pathologic agent in 10%-20% of cases of antibiotic-associated diarrhea, and has been implicated in as many as 50% of epidemic outbreaks.1 CDI rates have also been rising: from 1996 to 2003 CDI rates per 100,000 population almost doubled in the United States.2 Data from the Centers for Disease Control and Prevention show that the rate of the discharge diagnosis of C difficile infection increased from 31 cases per 100,000 persons per year in 1996 to 61 cases per 100,000 persons per year in 2003.3 C difficile is shed in the feces of affected individuals and its spores can survive on surfaces for prolonged periods of time. The spores can contaminate a hospital environment and be spread by health care workers and suboptimal environmental cleaning practices. At an academic community hospital in Pennsylvania the infection control team noted a disturbing trend during June 2013. The number of cases of health care facility-onset CDI had drastically increased. Health care facility-onset CDI was defined as a C difficile polymerase chain reaction-positive result of a stool specimen that was collected >3 calendar days after hospital admission. During the period January 2013-March 2013, 3 cases of health care facilityonset CDI were recorded. However, during the period April 2013June 2013 (second quarter 2013), this number climbed to 11. The * Address correspondence to Shelini Sooklal, MD, 250 S 21st St, Easton, PA 18045. E-mail address: [email protected] (S. Sooklal). Conflicts of interest: None to report.
Fig 1. Health care facility-onset cases of Clostridium difficile infection.
epidemic curve in Figure 1 demonstrates these findings by monthly incidence rate. The standardized infection ratio for second quarter 2013 was 1.67, with a standardized infection ratio P value of .05. This demonstrates that this increased CDI rate is statistically significant for the second quarter 2013. A multidisciplinary team was assembled to investigate this phenomenon. The number of hospital admissions between the 2 time periods in question was comparable and the case mix also was comparable. There was no significant difference in the community-onset CDI prevalence rate. Seasonal variation could not have accounted for the marked increase in cases because most cases of C difficile infection occur during the period November-January, coinciding
0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2014.02.012
S. Sooklal et al. / American Journal of Infection Control 42 (2014) 674-5
with influenza season annually. Further analysis of the distribution of cases failed to link the outbreak to any particular floor or hospital wing. Allocation of nursing staff had not changed. No major additions to members of the health care staff who have direct patient contact had occurred that could have altered the standard of infection control. Stool samples for C difficile polymerase chain reaction testing were collected according to hospital protocol. Neither laboratory equipment nor reagents had been changed during the period under investigation. Quality control measures were implemented daily. Patients with suspected CDI, as well as confirmed CDI, were placed in isolation rooms. On discharge, all surfaces were wiped with a solution containing acetic acid, hydrogen peroxide, octanoic acid, and peroxyacetic acid (Virasept; Ecolab Inc, St Paul, Minn). This disinfectant is designed to clean hard surfaces and has activity against C difficile spores. The rooms were also mopped with a 10% dilution bleach solution. Each mop pad was only used once to clean a single room then returned to the housekeeping department to be disinfected by washing with a 100 ppm bleach solution in a designated washing machine. A breakthrough came when laundry records were examined. The quantity of bleach used during the time period in question was compared with the number of loads of mop-pad washes that were done. It was deduced that approximately 100 loads of mop pads were washed without bleach. An examination of the designated washing machine for mop pads revealed that this machine had been accidentally switched to the microfiber setting. In this setting, preloaded bleach would not have been added to the washing load. The poorly cleansed mop pads were then reused, likely spreading C difficile spores. The servicing company for the washing machine was immediately contacted, the error rectified, and the microfiber setting was made obsolete. All mop pads and rags used for cleaning hard
675
surfaces of rooms were double washed and all hospital rooms were cleaned thoroughly. Patients were relocated in batches during the cleaning process. Further infection control education was extended to all hospital staff members. The importance of hand hygiene, use of gloves, and appropriate patient isolation was stressed. The laundry and housekeeping staff were briefed on the error, and the importance of adherence to cleaning protocols was stressed. During the 2 months following this intervention, no cases of health care facility-onset CDI were recorded. Improved staff education and implementation of infection control measures may have contributed to the decrease in CDI cases. By comparison, Fitzgerald et al4 stated that the efforts of a multidisciplinary team did little to decrease the incidence of CDI at their academic medical center. Additionally, more than 2 decades ago, Fekety et al5 noted that C difficile had been isolated, amongst other places, from bedding, floors, and furniture. Hospital floors are commonly contaminated with C difficile and other pathogens, and our experience suggests that floors may be an underappreciated source of C difficile transmission. References 1. Bartlett JG, Chang TW, Gurwith M, Gorbach SL, Onderdonk AB. Antibiotic-associated pseudomembranous colitis due to toxin-producing clostridia. N Engl J Med 1978;298:531-4. 2. Sunenshine RH, McDonald LC. Clostridium difficile-associated disease: new challenges from an established pathogen. Cleve Clin J Med 2006;73:187-97. 3. McDonald LC, Owings M, Jernigan DB. Clostridium difficile infection in patients discharged from US short-stay hospitals. Emerg Infect Dis 2006;12:409-15. 4. Fitzgerald T, Hermsen E, Sholtz L, Anderson J, Iwen P, Jourdan D, et al. Multidisciplinary interventions for the management and prevention of Clostridium difficile-associated disease at an academic medical center. Am J Infect Control 2009;37:E59. 5. Fekety R, Kim KH, Brown D, Batts DH, Cudmore M, Silva J Jr. Epidemiology of antibiotic-associated colitis; isolation of Clostridium difficile from the hospital environment. Am J Med 1981;70:906-8.
