Cluster of Clostridium difficile cases in an Abdominal Transplant (ATP) service- Two Steps Forward, One Step Back

Background: UPMC Presbyterian is one of the oldest and largest solid organ transplantation programs in the US, performing >17,000 adult procedures, including kidney, liver, intestinal and multi-visceral transplants.  Successful recovery and continued function of the allograft organ depends upon a careful balance of medications, including immunosuppressants, antivirals, antibiotics, ulcer prophylaxis, nutrition support and others depending on a pts. underlying condition. 

Patients often have multiple admissions, long lengths of stay and risk factors for CD infection (CDI). Proactive investigation and reduction initiatives begun in 2000 have maintained HW HAI rates at <0.8/1000 pt. days. Patients may not meet NHSN GI criteria (acute onset of diarrhea, nausea or abdominal pain) with no other recognized cause. CDI rates do not reflect the reservoir of asymptomatic, colonized pts. who tend to have increased GI output and fluid drainage issues. During a 3 week period, a cluster of CD occurred in a 24 bed progressive care unit (PCU) (M) which exceeded 2 SD of ATP mean cases. The unit was recently renovated for “Smart” room technology to improve nursing efficiency and provide a more home-like pt. experience. 

Objective: Identify the sudden increase in CD cases associated with unit M when there was no obvious practice change in the unit or service.

Methods: All CD pt. data is maintained in an Access database and cases are reviewed by a CD Task Force. Theradoc® is used by IPs for culture review and documentation. A multidisciplinary team reviewed environmental issues and practices.  

Results:  Thirty pts. were identified with toxigenic CD from 4 sites-unit M, a 28 bed ICU (I), a similar non-renovated PCU (L) and the outpatient clinic. The cluster included 6 HAIs (3-M, 3-I), 5 cases identified by OP and 11 cases were colonized (7-M, 4-I, L).

Discussions during environmental rounds identified issues with housekeeper (HK) perceptions for disinfection of electronics including touch screen monitors that are part of the Smart room technology. Nurses document task completion while in the room, which then downloads into the EHR. While bleach wipes are used for all environmental surfaces, HK incorrectly identified that only microfiber cloths were to be used on the monitors. Patient handsets that provide access to emails, games and educational programs were also not being disinfected until discharge. Review of pt. room assignments identified some potential transmissions. HKs were not given any instruction on cleaning the new electronics in the Smart room. The CDI returned to baseline when an additional HK was added to the unit.

Conclusions: HAI data is not reflective of bioburden which may be present in a unit. Square footage and pt. turnover are not appropriate metrics for HK needs. While new technology is being designed for improving efficiency and pt. comfort, the key personnel involved in maintaining the environment must be engaged.