Shared Hoppers: A Novel Risk Factor for the Transmission of Clostridium difficile

Abstract

Shared Hoppers: A Novel Risk Factor for the Transmission of Clostridium difficileTo the Editor-The environment plays a central role in transmission of Clostridium difficile infection (CDI) within hospitals. Surfaces and objects become contaminated with spores when in contact with feces, and these hardy spores may endure for months. Patient placement factors-such as rooming with or residing in a bed previously occupied by a CDI patient-are cited as risk factors for acquisition. 1,2 One geographic feature that may increase risk for CDI is the presence of a shared hopper room in the patient care area. A hopper is a flushable, raised basin with an extendable arm that produces a high-pressure spray when flushed. This rimless basin is used by hospital staff to dispose of waste fluids and wash out receptacles. C. difficile has been isolated from air samples after flushing lidless toilets, leading to contamination of proximate surfaces. 3 Our trauma-surgical intensive care unit (TSICU) historically has had the highest burden of CDI in our facility. The 2010 rate of hospital-acquired CDI for the TSICU was 3.5 cases per 1,000 patient-days compared with other intensive care units (range, 1.5-2.4 cases per 1,000 patient-days). Despite implementation of infection prevention measures-including hand hygiene with soap and water, a nurse-driven early CDI testing strategy, empirical contact precautions while awaiting test results, environmental cleaning with hypochlorite (bleach) solution, and cleaning audits-the high rates persisted. During the spring of 2011, we observed a cluster of CDI cases in our TSICU. Two patients acquired CDI while housed in a double room adjacent to a patient in contact precautions with CDI in a private room. The 2 rooms were joined by a shared hopper room. Neighboring patients who did not share the hopper, however, did not become infected. We hypothesized that transmission occurred by healthcare worker contamination of hands, uniform, and fomites via splashing and droplet aerosol during hopper flushing and use of the sprayer. We sought to examine patient and environmental risk factors for CDI acquisition.We conducted a case-control study at Harborview Medical Center, a 413-bed, level 1 trauma and burn center with a 24-bed TSICU. The study spanned the 12-month period from December 15, 2010, through December 14, 2011. Generally, cases were defined as those with new onset diarrhea and a positive polymerase chain reaction (PCR) test for C. difficile toxin B greater than 48 hours from TSICU admission. Patients with a recent acute or long-term care hospital stay were excluded to minimize misclassification of exposure. The control group had a TSICU stay of greater than 36 hours and no positive C. difficile PCR test for at least 30 days after discharge from the TSICU. Approximately 3 concurrent controls were randomly selected within 1 week of admission for each case.Electronic health records were reviewed for a history of CDI within the past 3 years. Potential risk factors for acquisition were determined for...

Intensive Care Unit Wastewater Interventions to Prevent Transmission of Multispecies Klebsiella pneumoniae Carbapenemase–Producing Organisms

“…We recently demonstrated a mechanism for dissemination in a sink laboratory model where biofilm spread from the sink trap to the sink drain and organisms were then dispersed when impacted by water from the sink faucet [7]. Particle and organisms have been shown to disperse to the wider environment from toilet flushing [8], albeit this work has been performed largely in relation to Clostridium difficile [9][10][11]. Gram-negative organisms, including CROs, could plausibly be similarly dispersed by hopper/toilet flushing.…”