A response to the relationship between different types of sharps containers and Clostridium difficile infection rates in acute care hospitals

Published:February 03, 2016DOI:
      As director of infection prevention (IP) at the Robert Wood Johnson University Hospital Hamilton for 13 years, I read with interest the October, 1, 2015, AJIC article by Pogorzelska-Maziarz.
      • Pogorzelska-Maziarz M.
      Relationship between sharps disposal containers and Clostridium difficile infections in acute care hospitals.
      Reusable sharps containers are prevalent in U.S. health care facilities. According to experts, of the 2.36 million sharps containers in U.S. acute care hospitals, approximately 50% of sharps containers are reusable. This letter helps inform health care leaders that their health care workers have every reason to continue believing in the safety and efficacy record of reusable containers.
      Our industry blames Clostridium difficile infection rates on many different causes. Sharps containers are not on my hit list for causes—regardless of if they are reusable or not. The reality is that there are so many variables in its transmission than what is cited in the survey. As stated in a recent Centers for Disease Control and Prevention webinar, antibiotic use is a large contributor to C difficile transmission, and reusable sharps containers were never mentioned as a possible factor.
      These containers are meant for discarding dirty materials, not to be touched or to come close to patients. They are removed weekly by a third party and sent directly to the loading dock. Once picked up from the loading dock, they go to a plant for disinfecting before they are reused and therefore not sent to a landfill, making them environmental sustainable.
      I am skeptical of this survey's scientific credibility for many reasons, including that it used regression analysis. If other variables are not removed, it is difficult to determine causality from mere coincidence. Also, this survey only looked at hospitals that use reusable sharps containers and not other factors, such as the type of hospital testing methodology conducted for C difficile. We recommend taking a look at changes in cleaning and examining antibiotic use for any relationship to be determined.
      I would not let this survey alarm health care leaders who favor reusable sharps containers for many reasons. The survey was sponsored by BD, a maker of single-use disposable sharps containers. The author is a paid consultant by BD. These attributes make a survey biased and present conflicts of interest.
      All of these factors affect outcomes and are reasons why we cannot give credence to this survey. By nature of calling a survey a survey, answers are presented as opinions. This means sometimes that the answers are not accurate. We recommend surveys and studies are always peer reviewed for credibility. There was no peer review conducted here.
      In the medical field, those who apply stringent expectations for publication consider 2 important factors to be successful: response rates and sample representativeness. This survey had a 30% response rate. Experts say response rates approximating 60% should be the goal for most research.
      On sample representativeness, most respondents interviewed were from environmental services (EVS), not IP professionals. As an IP, I know my hospital's C difficile rates and report this information to the Centers for Disease Control and Prevention each month. The EVS team does not always know this information. To successfully determine our C difficile rates, we perform appropriate isolation and testing of symptomatic patients. This sweep is part of our surveillance. IPs have the best grasp of C difficile rates in their hospitals.
      Although the EVS team does not track transmission, they do terminal cleaning when a patient is discharged. The exception is if the sharps container were to become filled past the fill line. This is a rare occurrence in our facilities because we use the best practice of proactively exchanging our sharps containers. We recommend that if sharps containers reach the fill line that the EVS team is notified to remove them to a biohazardous dirty room for transport.
      As the survey states, “further work is needed to replicate this finding.”
      • Pogorzelska-Maziarz M.
      Relationship between sharps disposal containers and Clostridium difficile infections in acute care hospitals.
      There is not enough scientific fact to prove reusable sharps containers are a credible source for C difficile transmission.


        • Pogorzelska-Maziarz M.
        Relationship between sharps disposal containers and Clostridium difficile infections in acute care hospitals.
        Am J Infect Control. 2015; 43: 1081-1085