Adjunct IC measures to use in C. diff outbreak

Consider if asymptomatic carriers suspected

Infection control professionals at the Cleveland VA Medical Center took several additional prevention measures because they suspected asymptomatic Clostridium difficile carriers were fueling an outbreak in their long-term care facility.1 The authors' interventions — which, we remind, were taken during an outbreak — are summarized as follows:

  • Sporicidal disinfectant: Because environmental surfaces in asymptomatic carriers' rooms may frequently be contaminated with spores, use of sporicidal disinfectants may be indicated in outbreak settings. Given the high rate of asymptomatic carriage in the long-term care facility, they used a 10% bleach solution for terminal cleaning of all rooms after patients were discharged or transferred from the ward.
  • Emphasis on glove use: Because alcohol-based hand hygiene products do not kill spores, use of gloves may be indicated when caring for patients at high risk for asymptomatic carriage in the context of an outbreak of C. difficile infection.
  • Extending isolation: Current guidelines recommend discontinuation of contact precautions for patients with C. diff-associated disease (CDAD) after diarrhea resolves, but it may be reasonable to extend the duration of contact precautions until the time when the patient is discharged from the hospital. In the study, nearly one-fourth of asymptomatic carriers had had a previous episode of CDAD. A previous study found that as many as one-half of patients with CDAD continued to excrete spores in stool after resolution of diarrhea.2
  • Clinical prediction rule: Because active surveillance for asymptomatic carriage of C. difficile may not be feasible in many health care facilities, a sensitive clinical prediction rule could be useful to allow identification of patients at high risk for carriage. The researchers found that a prediction rule based on history of previous CDAD and antibiotic use in the previous three months had 77% sensitivity to detect asymptomatic carriage. Addition of fecal incontinence as a third variable in the prediction rule increased sensitivity to 83%, with only a modest reduction in specificity.
  • A question of personal hygiene: Another infection control measure was suggested in an accompanying editorial commentary by Carlene Muto, MD, director of infection control at the University of Pittsburgh Medical Center.3 Noting the authors' emphasis on recovery of C. diff from the skin of residents in the study, she questioned whether an upgrade in personal hygiene might be part of the solution. "Before routine cleaning procedures are expanded to include a bleaching step, perhaps a more rigorous personal hygiene initiative could be developed," she wrote.

Asked to respond by Hospital Infection Control, Curtis Donskey, MD co-author of the study and director of infection control at the Cleveland VA Medical Center, e-mailed the following response:

"We didn't look at the personal hygiene of our patients, but we agree with Dr. Muto's point and are currently looking into how well standard hospital bathing practices remove C. difficile from skin. Several researchers have recently reported that daily bathing with chlorhexidine may be a useful infection control strategy for hospital pathogens such as Staphylococcus aureus and vancomycin- resistant enterococcus. Chlorhexidine kills many pathogens but not C. difficile spores, so more work is needed to determine the best approach to remove C. difficile. Because we found C. difficile spores on skin and in the environment, we think that the optimal infection control approach will have to address both skin and environmental contamination."


  1. Riggs MM, Sethi AK, Zabarsky TF. Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis 2007; 45: (Oct. 15, 2007 issue) published electronically at
  2. McFarland LV, Elmer GW, Surawicz CM. Breaking the cycle: Treatment strategies for 163 cases of recurrent Clostridium difficile disease. Am J Gastroenterol 2002; 97:1,769-1,775.
  3. Muto CA. Asymptomatic Clostridium difficile colonization: Is this the tip of another iceberg? Editorial commentary. Clin Infect Dis 2007; 45:999-1,000.