Advertisement

A microbiological study to investigate the carriage and transmission-potential of Clostridium difficile spores on single-use and reusable sharps containers

      Background

      A 2015 study matching use of disposable and reusable sharps containers (DSCs, RSCs) with Clostridium difficile infection (CDI) incidence found a decreased incidence with DSCs. We conducted microbiologic samplings and examined the literature and disease-transmission principles to evaluate the scientific feasibility of such an association.

      Methods

      (i) 197 RSCs were sampled for C. difficile at processing facilities; (ii) RSCs were challenged with high C. difficile densities to evaluate efficacy of automated decontamination; and (iii) 50 RSCs and 50 DSCs were sampled in CDI patient rooms in 7 hospitals. Results were coupled with epidemiologic studies, clinical requirements, and chain-of-infection principles, and tests of evidence of disease transmission were applied.

      Results

      C. difficile spores were found on 9 of 197 (4.6%) RSCs prior to processing. Processing completely removed C. difficile. In CDI patient rooms, 4 of 50 RSCs (8.0%) and 8 of 50 DSCs (16.0%) had sub-infective counts of C. difficile (P = .27). DSCs were in permanent wall cabinets; RSCs were removed and decontaminated frequently.

      Conclusion

      With C. difficile bioburden being sub-infective on both DSCs and RSCs, sharps containers being no-touch, and glove removal required after sharps disposal, we found 2 links in the chain of infection to be broken and 5 of 7 tests of evidence to be unmet. We conclude that sharps containers pose no risk of C. difficile transmission.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Lessa F.
        • Mu Y.
        • Bamberg W.
        • Beldavs Z.
        • Dumyati G.
        • Dunn J.
        • et al.
        Burden of Clostridium difficile infection in the United States.
        N Engl J Med. 2015; 372: 825-834
      1. National and State Healthcare-Associated Infections Progress Report (2014 data).
        (National Center for Emerging and Zoonotic Infectious Diseases, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta GA; Available from:)
        • Magill S.
        • Edwards J.
        • Bamberg W.
        • Beldavs Z.
        • Dumyati G.
        • Kainer M.
        • et al.
        Multistate point-prevalence survey of healthcare-associated infections.
        N Engl J Med. 2014; 370: 1198-1208
        • Weber D.
        • Rutala W.
        • Miller M.B.
        • Huslage K.
        • Sickbert-Bennett E.
        Role of surfaces in the transmission of emerging health care associated pathogens: norovirus, Clostridium difficile, and Acinetobacter species.
        Am J Infect Control. 2010; 38: S25-S33
        • Weber D.J.
        • Rutala W.A.
        The role of the environment in transmission of Clostridium difficile Infection in healthcare facilities.
        Infect Control Hosp Epidemiol. 2011; 3: 207-209
        • McDonald L.C.
        • Gerding D.N.
        • Stuart Johnson S.
        • Bakken J.S.
        • Carroll K.C.
        • Coffin S.E.
        • et al.
        Clinical practice guidelines for clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).
        Clin Infect Dis. 2018; 66: e1-48
        • Curry S.R.
        • Muto C.A.
        • Schlackman J.L.
        • Pasculle A.W.
        • Shutt K.A.
        • Marsh J.W.
        • et al.
        Use of multilocus variable number of tandem repeats analysis genotyping to determine the role of asymptomatic carriers in Clostridium difficile transmission.
        Clin Infect Dis. 2013; 57: 1094-1102
        • Starr J.M.
        • Campbell A.
        • Renshaw E.
        • Poxton I.R.
        • Gibson G.J.
        Spatio-temporal stochastic modelling of Clostridium difficile.
        J Hosp Infect. 2009; 71: 49-56
        • Eyre D.W.
        • Griffiths D.
        • Vaughan A.
        • Golubchik T.
        • Acharya M.
        • O'Connor L.
        • et al.
        Asymptomatic Clostridium difficile colonization and onward transmission.
        PLoS ONE. 2013; 8 (e78445)
        • Samore M.H.
        • Ventkataraman L.
        • DeGirolami P.C.
        • Arbeit R.D.
        • Karchner A.W.
        Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial clostridium difficile diarrhea.
        Am J Med. 1996; 100: 32-40
        • Best E.L.
        • Fawley W.N.
        • Parnell P.
        • Wilcox M.H.
        The potential for airborne dispersal of clostridium difficile from symptomatic patients.
        Clin Infect Dis. 2010; 50: 1450-1457
        • Huslage K.
        • Rutala W.A.
        • Sickbert-Bennett E.
        • Weber D.J.
        A quantitative approach to defining “high-touch” surfaces in hospitals.
        Infect Control Hosp Epidemiol. 2010; 31: 850-853
        • Guerrero D.M.
        • Nerandzic M.M.
        • Jury L.A.
        • Jinno S.
        • Chang S.
        • Donskey C.J.
        Acquisition of spores on gloved hands after contact with the skin of patients with Clostridium difficile infection and with environmental surfaces in their rooms.
        Am J Infect Control. 2012; 40: 556-558
        • Neely A.N.
        • Maley M.P.
        • Taylor G.L.
        Investigation of single-use versus reusable infectious waste containers as potential sources of microbial contamination.
        Am J Infect Control. 2003; 31: 12-17
        • Runner J.
        Bacterial and viral contamination of reusable sharps containers in a community hospital setting.
        Am J Infect Control. 2007; 35: 527-530
        • Sjoberg M.
        • Eriksson M.
        • Andersson J.
        • Noren T.
        Transmission of Clostridium difficile spores in isolation room environments and through hospital beds.
        APMIS. 2014; 122: 800-803
      2. Guide to Preventing Clostridium difficile Infections.
        (APIC Implementation Guide. Association for Professionals in Infection Control and Epidemiology; Available from:)
        • Dubberke E.R.
        • Carling P.
        • Carrico R.
        • Donskey C.J.
        • Loo V.G.
        • Clifford McDonald L.
        • et al.
        SHEA-IDSA practice recommendation. strategies to prevent clostridium difficile infections in acute care hospitals: 2014 update.
        Infect Control Hosp Epidemiol. 2014; 35: 628-645
        • Pogorzelska-Marziarz M.
        Relationship between sharps disposal containers and Clostridium difficile infections in acute care hospitals.
        Am J Infect Control. 2015; 43: 1081-1085
        • Dikon A.
        A response to the relationship between different types of sharps containers and Clostridium difficile infection rates in acute care hospitals.
        Am J Infect Control. 2016; 44: 612-618
        • Pogorzelska-Maziarz M.
        Reply to Dikon in response to “A response to the relationship between different types of sharps containers and Clostridium difficile infection rates in acute care hospitals”.
        Am J Infect Control. 2016; 14: 855-856
        • Cadnum J.
        • Hurless K.
        • Deshpande A.
        • Nerandzic M.
        • Kundrapu S.
        • Donskey C.
        Sensitive and selective culture medium for detection of environmental Clostridium difficile isolates without requirement for anaerobic culture conditions.
        J Clin Microbiol. 2014; 52: 3259
        • Kane S.
        Sample Size Calculator.
        (ClinCalc; Available from:)
        http://clincalc.com/stats/SampleSize.aspx
        Date: 2017
        Date accessed: March 13, 2018
        (Updated July 1)
        • Wilcox M.H.
        • Bennett A.
        • Best E.L.
        • Fawley W.N.
        • Parnell P.
        Reply to Snelling et al.
        Clin Infect Dis. 2010; 51: 1104-1105
        • Donskey C.J.
        Preventing transmission of Clostridium difficile: is the answer blowing in the wind?.
        Clin Infect Dis. 2010; 50: 1458-1461
        • Nerandzic M.
        • Donskey C.
        Effective and reduced-cost modified selective medium for isolation of Clostridium difficile.
        J Clin Microbiol. 2009; 47: 397-400
        • Meschke S.
        • Smith B.D.
        • Yost M.
        • Miksch R.R.
        • Gefter P.
        • Gehlke S.
        • et al.
        The effect of surface charge, negative and bipolar ionization on the deposition of airborne bacteria.
        J Appl Microbiol. 2009; 106: 1133-1139
        • Kim K.
        • Fekety R.
        • Batts D.
        • Brown M.
        • Silva J.
        • Waters D.
        Isolation of clostridium difficile from the environment and contacts of patients with antibiotic-associated colitis.
        J Infect Dis. 1981; 143: 42-50
      3. Principles of Epidemiology in Public Health Practice.
        (3rd Ed. An Introduction to Applied Epidemiology and Biostatistics. Oct (Updated May 2012). Office of Workforce and Career Development, Centers for Disease Control and Prevention, U.S. Dept of health & Human Services, Atlanta, GA; Available from:)
        https://www.cdc.gov/ophss/csels/dsepd/ss1978/ss1978.pdf
        Date: 2006
        Date accessed: June 13, 2017
      4. Break the Chain of Infection.
        (Association for Professionals in Infection Control and Prevention, Arlington, VA, USA; Available from:)
        • Fekety R.
        • Kim K.-H.
        • Brown D.
        • Batts D.H.
        • Cudmore M.
        • Silva J.
        Epidemiology of Antibiotic colitis: Isolation of Clostridium difficile from the hospital.
        Am J Med. 1981; 70: 906-908
        • Leggett H.C.
        • Cornwallis C.K.
        • West S.A.
        Mechanisms of pathogenesis, infective dose and virulence in human parasites.
        PLoS Pathog. 2012; 8 (e1002512)
      5. Guidelines for Environmental Infection Control in Health-Care Facilities.
        (Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC); U.S. Dept HHS, (CDC) Atlanta, GA; Available from:)
        • Goldstein E.J.C.
        • Johnson S.
        • Maziade P.-J.
        • McFarland L.V.
        • Trick W.
        • et al.
        Pathway to prevention of nosocomial clostridium difficile infection.
        Clin Infect Dis. 2015; 60: S148-S158
        • Ali S.
        • Muzslay M.
        • Wilson P.
        A novel quantitative sampling technique for detection and monitoring of Clostridium difficile contamination in the clinical environment.
        J Clin Microbiol. 2015; 53: 2570-2574
        • Landelle C.
        • Verachten M.
        • Legrand P.
        • Girou E.
        • Barbut F.
        • Brun-Buisson C.
        Contamination of healthcare workers' hands with Clostridium difficile spores after caring for patients with C. difficile infection.
        Infect Control Hosp Epidemiol. 2014; 35: 10-15
        • Adams C.E.
        • Smith J.
        • Watson V.
        • Robertson C.
        • Dancer S.J.
        Examining the association between surface bioburden and frequently touched sites in intensive care.
        J Hosp Infect. 2017; 95: 76-80
        • Best E.
        • Parnell P.
        • Thirkell G.
        • Verity P.
        • Copland M.
        • Else P.
        • et al.
        Effectiveness of deep cleaning followed by hydrogen peroxide decontamination during high Clostridium difficile infection incidence.
        J Hosp Infect. 2014; 87: 25-33
        • Dancer S.
        Controlling hospital-acquired infection: focus on the role of the environment and new technologies for decontamination.
        Clin Microbiol Rev. 2014; 27: 665-690
        • Maurer I.M.
        Ch5 Cleaning the hospital: Care with water.
        in: Hospital Hygiene. 3rd ed. Richard Clay (The Chaucer Press) Ltd, Suffolk UK1985: p52
        • Lawley T.
        • Clare S.
        • Deakin L.
        • Goulding D.
        • Yen J.
        • Raisen C.
        • et al.
        Use of purified clostridium difficile spores to facilitate evaluation of health care disinfection regimens.
        Appl Environ Microbiol. 2010; 76: 6895-6900
        • Kanwar A.
        • Mana T.S.C.
        • Cadnum J.
        • Alhmidi H.
        • Koganti S.
        • Donskey C.J.
        How well does transfer of bacterial pathogens by culture swabs correlate with transfer by hands?.
        Am J Infect Control. 2017; 45: 923-925
        • Jullian-Desayes I.
        • Landelle C.
        • Mallaret M.-R.
        • Brun-Buisson C.
        • Barbut F.
        Clostridium difficile contamination of health care workers' hands and its potential contribution to the spread of infection: review of the literature.
        Am J Infect Control. 2017; 45: 51-58
      6. Guide to Hand Hygiene Programs for Infection Prevention. APIC Implementation Guides, Association for Professionals in Infection Control and Epidemiology.
        (Available from:)
        • Occupational Safety and Health Administration
        Toxic and hazardous substances. Standard number 1910.1030.
        (Bloodborne pathogens; Available from:)
        • Altman D.G.
        • Bland J.M.
        Absence of evidence is not evidence of absence.
        BMJ. 1995; 311: 485
        • Grimmond T.
        Using reusable containers for hospital waste—is there an infection risk?.
        South Afr J Epidemiol Infect. 2013; 28: 197-201
        • Matthews R.
        Storks Deliver Babies (p=0.008).
        (Teaching Statistics. Volume 22, Number 2, Summer; Available from:)