Effect of hypochlorite containing cleaners on occurrence of nosocomial Clostridium difficile infection in acute care patients

Background: Clostridium difficile infection (CDI) is an important cause of morbidity and mortality in hospitalized patients. Control of this organism requires meticulous hand hygiene, environmental cleaning and antimicrobial stewardship. Hospital associated (HA) CDI cases at the Buffalo DVAMC Increased markedly 9/2003. Episodic intensive cleaning of acute-care nursing units utilizing hypochlorite resulted in temporary drops in infections at great expense in personnel overtime. However, improvements were not sustained. Objective: Identify the effect of continuous use of hypochlorite containing cleaning products on the occurrence of hospital associated CDI in acute care patients. Methods: Hospital associated CDI cases at the Buffalo DVAMC were identified by established clinical and laboratory surveillance, including post-discharge surveillance. Recurrent cases were excluded. Patients with suspected or documented CDI were placed in private rooms and contact precautions. Hand hygiene with soap and water was encouraged and antimicrobial use was was evaluated by trained pharmacists (beginning in 2008.) Room cleaning was performed by environmental services staff, sometimes using hypochlorite containing products in rooms with known CDI patients. Medical devices were cleaned by nursing staff using disposable wipes. General purpose cleaners/wipes were widely replaced by hypochlorite containing products in 10/2006 following ongoing evaluation of infections and interventions. Bed days of care (BDOC) were obtained for the acute care units using an administrative database. Results: From 1/2000 - 8/2003 the HA CDI rate was 1.1/1000 BDOC. Beginning 9/2003 the rate increased to 3.7/1000 BDOC. Since the change to hypochlorite containing cleaning products, the rate of HA CDI declined to 3.2/1000 BDOC in the period 10/2006 - 10/2009 (p=0.08). Conclusions: The widespread change to hypochlorite containing cleaning products may have had a modest beneficial effect on occurrence of HA CDI though there may be confounding by individual behaviors including antimicrobial use. The greater effect of earlier episodic use of hypochlorite may have been due to greater attention to cleaning procedures at times of intense concern over case counts.