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      From ward to washer: The survival of Clostridium difficile spores on hospital bed sheets through a commercial UK NHS healthcare laundry process

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          Abstract

          Objective

          To quantify the survival of Clostridium difficile spores on hospital bed sheets through the United Kingdom National Health System (UK NHS) healthcare laundry process (Health Technical Memorandum (HTM) 01-04) in vitro and on bed sheets from patients with C. difficile through the commercial laundry.

          Methods

          Clostridium difficile spores were inoculated onto cotton sheets and laundered through a simulated washer extractor cycle using an industrial bleach detergent with sodium hypochlorite 15% and peracetic acid sour 14% (acetic acid and hydrogen peroxide; pH, 2–4). Spore survival on hospital sheets naturally contaminated with C. difficile was also assessed using a washer extractor plus drying and finishing cycles at a commercial laundry.

          Patients

          Naturally contaminated C. difficile bed sheets were taken from beds of patients that had previously been diagnosed with C. difficile infection (CDI) and had received care on an isolated C. difficile ward.

          Results

          The simulated washer extractor cycle, with an industrial detergent, demonstrated survival of 2 strains of C. difficile NCTC 11209 (0–4 colony-forming units [cfu] per 25 cm 2) and ribotype 001/072 (0–9 cfu per 25 cm 2). Before laundering, naturally contaminated bed sheets had an average spore load of 51 cfu per 25 cm 2, and after washing, drying, and finishing, the spore load was 33 cfu per 25 cm 2. Before and after washing, the C. difficile strain was identified as ribotype 001/072. Both the simulated and in-situ laundering processes failed the microbiological standards of no pathogenic bacteria remaining.

          Conclusions

          Clostridium difficile spores are able to survive laundering through a commercial washer extractor and may be contributing to sporadic outbreaks of CDI. Further research to establish exposure of laundry workers, patients, and the hospital environment to C. difficile spores from bed sheets is needed.

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          Most cited references15

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          Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents.

          Michelle Riggs, Ajay K Sethi, Trina F Zabarsky … (2007)
          Asymptomatic fecal carriage of Clostridium difficile is common in patients staying in health care facilities, but the importance of asymptomatic carriers with regard to disease transmission is unclear. We prospectively examined the prevalence of asymptomatic carriage of epidemic North American pulsed-field gel electrophoresis type 1 and nonepidemic toxigenic C. difficile strains among long-term care patients in the context of an outbreak of C. difficile-associated disease and evaluated the frequency of skin and environmental contamination. Molecular typing was performed by pulsed-field gel electrophoresis. Logistic regression was used to assess factors associated with asymptomatic carriage, and a sensitive and specific prediction rule was developed to identify high-risk patients. Thirty-five (51%) of 68 asymptomatic patients were carriers of toxigenic C. difficile, and 13 (37%) of these patients carried epidemic strains. Compared with noncarriers, asymptomatic carriers had higher percentages of skin (61% vs. 19%; P=.001) and environmental contamination (59% vs. 24%; P=.004). Eighty-seven percent of isolates found in skin samples and 58% of isolates found in environmental samples were identical to concurrent isolates found in stool samples. Spores on the skin of asymptomatic patients were easily transferred to investigators' hands. Previous C. difficile-associated disease (P<.001) and previous antibiotic use (P=.017) were associated with asymptomatic carriage, and the combination of these 2 variables was predictive of asymptomatic carriage (sensitivity, 77%; specificity, 58%; positive predictive value, 66%; negative predictive value, 70%). Our findings suggest that asymptomatic carriers of epidemic and nonepidemic C. difficile strains have the potential to contribute significantly to disease transmission in long-term care facilities. Clinical factors, such as previous C. difficile-associated disease and recent antibiotic use, may be predictive of asymptomatic carriage.
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            Microevolutionary analysis of Clostridium difficile genomes to investigate transmission

            Xavier Didelot, David Eyre, Madeleine Cule … (2012)
            Background The control of Clostridium difficile infection is a major international healthcare priority, hindered by a limited understanding of transmission epidemiology for these bacteria. However, transmission studies of bacterial pathogens are rapidly being transformed by the advent of next generation sequencing. Results Here we sequence whole C. difficile genomes from 486 cases arising over four years in Oxfordshire. We show that we can estimate the times back to common ancestors of bacterial lineages with sufficient resolution to distinguish whether direct transmission is plausible or not. Time depths were inferred using a within-host evolutionary rate that we estimated at 1.4 mutations per genome per year based on serially isolated genomes. The subset of plausible transmissions was found to be highly associated with pairs of patients sharing time and space in hospital. Conversely, the large majority of pairs of genomes matched by conventional typing and isolated from patients within a month of each other were too distantly related to be direct transmissions. Conclusions Our results confirm that nosocomial transmission between symptomatic C. difficile cases contributes far less to current rates of infection than has been widely assumed, which clarifies the importance of future research into other transmission routes, such as from asymptomatic carriers. With the costs of DNA sequencing rapidly falling and its use becoming more and more widespread, genomics will revolutionize our understanding of the transmission of bacterial pathogens.
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              Use of multilocus variable number of tandem repeats analysis genotyping to determine the role of asymptomatic carriers in Clostridium difficile transmission.

              Lee Harrison, Carlene Muto, Brian Curry … (2013)
              Previous studies have suggested that asymptomatic carriers of toxigenic Clostridium difficile are a source of hospital-associated (HA) infections. Multilocus variable number of tandem repeats analysis (MLVA) is a highly discriminatory molecular subtyping tool that helps to determine possible transmission sources. Clostridium difficile isolates were recovered from perirectal swabs collected for vancomycin-resistant Enterococcus (VRE) surveillance as well as from clinical C. difficile toxin-positive stool samples from July to November 2009 at the University of Pittsburgh Medical Center Presbyterian (UPMC). MLVA was performed to determine the genetic relationships between isolates from asymptomatic carriers and patients with HA C. difficile infection (HA-CDI). Asymptomatic carriage and HA-CDI isolates were considered to be associated if the carriage isolate was collected before the HA-CDI isolate and if the MLVA genotypes had a summed tandem-repeat difference of ≤ 2. Of 3006 patients screened, 314 (10.4%) were positive for toxigenic C. difficile, of whom 226 (7.5%) were detected only by VRE surveillance cultures. Of 56 incident cases of CDI classified as HA at UPMC during the study with available isolates, 17 (30%) cases were associated with CDI patients, whereas 16 (29%) cases were associated with carriers. Transmission events from prior bed occupants with CDI (n = 2) or carriers (n = 2) were identified in 4 of 56 cases. In our hospital with an established infection control program designed to contain transmission from symptomatic CDI patients, asymptomatic carriers appear to have played an important role in transmission. Identification and isolation of carriers may be necessary to further reduce transmission of C. difficile in such settings.
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                Author and article information

                Journal
                Journal ID (publisher-id): applab
                Title: Infection Control & Hospital Epidemiology
                Abbreviated Title: Infect. Control Hosp. Epidemiol.
                Publisher: Cambridge University Press (CUP)
                ISSN (Print): 0899-823X
                ISSN (Electronic): 1559-6834
                Publication date (Electronic): October 16 2018
                Pages: 1-6
                Article
                DOI: 10.1017/ice.2018.255
                PubMed ID: 30322417
                SO-VID: a42e389a-a002-4738-adba-f8eb38ee3a90
                Copyright © © 2018
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