Let’s talk about one of the greatest controversies in hand hygiene – C. diff! If you ask 10 hospital staff members what their C. diff policies are, you will often get 14 different answers and a couple of puzzled looks. This is fairly standard, and there’s even debate among Infection Control specialists and hand hygiene gurus. Let’s take a look at the reasons why and where there is still controversy.
The new CDC guidelines do a great job of covering some of the better-studied aspects of C. diff prevention (such as environmental disinfection, glove usage, and anti-microbial stewardship), but they don’t take a firm stand on hand hygiene. This is understandable because most of the data looking specifically at hand hygiene and C. diff is newer. For example, data from one of our hospitals was just presented at APIC[1]. These types of studies are complicated to perform, due to the complexity of the way infections are spread and transmitted…but like all infection prevention strategies, hand hygiene is still the most important thing providers can do.
There are two schools of thought about whether it is better to use alcohol-based hand rubs (ABHR) or soap and water upon exit of a C. diff patient’s room. The CDC guidelines correctly point out that there is no clinical study demonstrating an incremental benefit to using soap over ABHRs leading to a significant reduction in C. diff infections[2]. However, this doesn’t mean that it is okay to use ABHRs. The reason there is no evidence is that no one has ever conducted the appropriate study, not that they did an appropriate study and found no evidence of a benefit.
Many infection control leaders, especially physicians, will cite this lack of evidence for soap usage as justification for using ABHR when leaving a patient’s room. In reality, many medical decisions don’t have solid evidence and are made based on a combination of the data available, scientific understanding, and medical judgment.
The first thing to understand is that C. diff is a tricky and resilient spore-forming organism with a complicated journey that can lead to an infection. The first step in contracting C. diff is ingesting a spore that can live in the environment for several months. Those spores then grow into bacteria that can live in your colon. Sometimes this infection spreads quickly and leads to an active infection, but in most cases, the bacteria coexist in a balance with your gut flora for an extended period of time. At some point down the road, if your colon flora gets out of balance, the C. diff can spread and lead to an active infection. This balance can be upset by several factors, which commonly include certain types of antibiotics, extended treatments of antibiotics, the stress of hospitalization, and/or immune system compromise. If you never get the spores in the first place, the other factors (antibiotics, disinfection, etc.) don’t really matter because there’s nothing that can lead to an infection.
Despite the complexity of the infection course, transmission of the spores is simple. One person sheds spores through their stool; these spores travel around the hospital and are then ingested by the next person and unfortunately the pattern repeats. The transmission path for C. diff isn’t magic. Fortunately for everyone who enters a hospital, the spores can’t jump or fly through the air; they spread on people’s hands. Hands can, in turn, contaminate surfaces for extended periods of time, which contaminate other hands, leading to a spread of infection. While antibiotics and better room disinfection can help, the fundamental cause of C. diff infections is spores spread by a fecal-oral transmission route. This spread can be stopped by proper hand hygiene.
There have been studies that have looked at glove usage in C. diff reduction which strongly supports contaminated hands as the primary transmission vector, but remember, all hand hygiene guidelines indicate that hand hygiene is required after removing gloves[3] [4] [5]. In many respects, glove usage is an easier-to-measure proxy to hand hygiene.
There have been several studies that have shown that C. diff’s resilient spores are resistant to alcohol and that, if you culture providers’ hands after using ABHR, you can still recover viable spores[6] [7]. If, however, you properly clean your hands with soap and water, the spores are removed, likely due to the mechanical action of rubbing and water.
Considering the data available today, the most prudent course of action is to educate and encourage staff to perform proper hand hygiene with soap and water when exiting a patient’s room. Sure, there is a chance that this message could be confused and, of course, using AHBRs is better than nothing, but I think it is appropriate that we strive for what is best for patients.
Still don’t agree? Go help a nurse take care of a C. diff patient who is actively “shedding spores” right before you eat lunch. How are you going to clean your hands?
Now, let the debate begin! I would be very interested in your thoughts, opinions, and scientific criticisms of this. Additionally, if anyone would be interested in collaborating on a study looking specifically at hand hygiene in the prevention of C. diff, please let me know.
[1] Hermann, C. (2017). New Approach to Hand Hygiene Scores Big in Pilot Project. [online] Healthcarebusinesstoday.com. Available at: https://www.healthcarebusinesstoday.com/new-approach-to-hand-hygiene-scores-big-in-pilot-project/ [Accessed 13 Jul. 2018].
[2] McDonald, L., Gerding, D., Johnson, S., Bakken, J., Carroll, K., Coffin, S., Dubberke, E., Garey, K., Gould, C., Kelly, C., Loo, V., Shaklee Sammons, J., Sandora, T. and Wilcox, M. (2018). IDSA : Clostridium difficile. [online] Idsociety.org. Available at: http://www.idsociety.org/Guidelines/Patient_Care/IDSA_Practice_Guidelines/Infections_By_Organ_System-81567/Gastrointestinal/Clostridium_difficile/ [19 Mar. 2018].
[3] Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol 2010; 31(5):431-455.
[4] Dubberke ER, Gerding DN, Classen D, Arias KM, Podgorny K, Anderson DJ et al. Strategies to prevent clostridium difficile infections in acute care hospitals. Infect Control Hosp Epidemiol 2008; 29 Suppl 1:S81-S92.
[5] Johnson S, Gerding DN, Olson MM, Weiler MD, Hughes RA, Clabots CR et al. Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission. Am J Med 1990; 88(2):137-140.
[6] Johnson S, Gerding DN, Olson MM, Weiler MD, Hughes RA, Clabots CR et al. Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission. Am J Med 1990; 88(2):137-140.
[7] McFarland LV, Mulligan ME, Kwok RY, Stamm WE. Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 1989; 320(4):204-210.
