Bleach wipe program vanquishes C. diff

Environmental effort has huge impact

It sometimes seems, to paraphrase Mark Twain, that everybody talks about infection prevention but nobody does anything about it. Well, give the glory to the environmental services team at the Mayo Clinic in Minnesota, Rochester, MN. Talk about a hands-on intervention.

They wiped out Clostridium difficile — literally — from troublesome areas and patient rooms with recurrent cases. And we're not just talking spore counts on environmental surfaces as a measure of success. The outcome was measured in human terms — patient C. diff infections.

"We actually went seven months on our GI unit — which had the highest rates in the entire institution — without a case. I thought that was phenomenal," says Robert Orenstein, D.O. an infectious disease clinician at the clinic. "It was a big team effort and we want to recognize environmental services for what they did. We got buy-in and that is key. You have to make them part of the process and show them what good they're doing."

Orenstein and colleagues found that a daily cleaning regimen using germicidal bleach wipes reduced the incidence and time between cases of healthcare acquired Clostridium difficile infections on two units that had been hard hit by the troublesome pathogen. There has been an ongoing discussion about how big a role the patient environment plays in C. diff infections, but given the high incidence in the units Orenstein figured it was a logical target for intervention.

"We thought if we could reduce the environmental burden of disease we would lower the colonization pressure and bring down the rates," he says.

The standard cleaning protocol for the rooms called for a quaternary ammonium compound solution, a common disinfectant that lacks the sporicidal activity of bleach. Orenstein and colleagues decided to try using a bleach wipes product in patient rooms.

"Instead of changing a lot of things — where nurses and physicians have to change their behavior — we decided to just have environmental services clean with this different agent," he notes. "Our isolation compliance has been quite good — close to 90% for contact precautions. We monitored that through the study and the only intervention was the switch to the bleach wipes."

The bleach wipe cleaning was done not only in the rooms of C. diff patients — but in every room in the units. Every day. "Our thinking was that there is probably a lot of C. diff outside of the patient room that allows transmission and if you don't get rid of those sources then you are probably going to have some ongoing transmission," Orenstein says.

A dramatic decline

The program began without any particularly high expectations, but the C. diff rates started falling dramatically within the first couple of months.

"We all got a little excited about that, but then we thought it's probably too early," he says. "But as we monitored every month on these two units the drop was really quite dramatic."

Indeed, the overall incidence of healthcare acquired C. diff infection (CDI) fell from 18.4 per 10,000 patient days to 3.7 after the intervention. Moreover, the time between healthcare acquired cases of CDI went from 13 days to 74 days. The approach may be effective for hospitals in a similar situation of a heavy C. diff burden, he notes.

"I think the environment plays a large role, but there are a bunch of different factors," he says. "If you have sporadic cases on your units I don't know that this intervention is going to be the best. This intervention works in areas where there is a lot of contamination of the environment."

Factors to consider are the expense of the wipes and impact of bleach on workers and patients. "Like any bleach product, it has an odor. The wipes have a masking agent so it reduces the odor somewhat but it does smell and if you are in a closed space and you get a lot of bleach on one of those wipes, it's irritating."

Patient problems haven't really been an issue, though an exception was granted to a patient that said she was allergic to bleach. Worker issues were largely resolved by wearing standard surgical masks and avoiding applying the wipes in a closed space without ventilation (e.g. in the bathroom with door closed.) "We found if they did it in a closed space it was irritating or if they pulled out a bundle of the wipes at once," he says. "But if they didn't do that and they ventilated the room and didn't close the door when they were in the bathroom [they had no problems cleaning]."

Orenstein even had the chlorine levels in the air measured by an industrial hygienist to ensure cleaning with the wipes did not expose workers to any health hazard. "'We said, `We understand that this is not the most pleasant experience and there are some irritating effects, but look at what you are doing for our patients.'"