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Approaches to the detection of Clostridioides difficile in the healthcare environment

  • R.J. Grainger
    Correspondence
    Corresponding author. Address: Department of Clinical Microbiology, RCSI Education and Research Centre, Beaumont Hospital, Dublin 9, Ireland. Tel.: +353 18093748.
    Affiliations
    Department of Clinical Microbiology, RCSI Education and Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
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  • N.T. Stevens
    Affiliations
    Department of Clinical Microbiology, RCSI Education and Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
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  • H. Humphreys
    Affiliations
    Department of Clinical Microbiology, RCSI Education and Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland

    Department of Microbiology, Beaumont Hospital, Dublin, Ireland
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Published:August 24, 2019DOI:https://doi.org/10.1016/j.jhin.2019.08.017

      Summary

      Clostridioides difficile, a spore-forming bacillus, is a major cause of healthcare-associated infection, and can survive for prolonged periods in the inanimate environment. Environmental sampling to detect C. difficile is not routine but may be undertaken as part of outbreak management and during research projects. We conducted a literature search covering the period between 1980 and 2018 to review methods for the detection of this pathogen in the environment. There are many acceptable sampling methods used for environmental screening, including contact plates, cotton swabs, flocked swabs and sponges. Most recent studies suggest that sponges are the most effective method of sampling and have the added benefit of being capable of sampling larger and curved areas. Culture methods are the most common laboratory method of detecting C. difficile from environmental samples. However, the results are variable depending on the type of agar used and the turnaround times can be long. Molecular methods such as real-time polymerase chain reaction (RT-PCR), although more commonly used to detect C. difficile from faecal specimens, has been used with varying degrees of success in environmental sampling. Further studies are needed to determine whether molecular techniques could offer a more reliable, faster method of environmental sampling, giving infection prevention and control teams more reassurance that patients are being placed in adequately decontaminated hospital environments.

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      References

        • Hall I.C.
        • O'Toole E.
        Intestinal flora in newborn infants with a description of a new pathogenic anaerobe.
        Am J Dis Child. 1935; 48: 390-402
        • Bouza E.
        Consequences of Clostridium difficile infection: understanding the healthcare burden.
        Clin Microbiol Infect. 2012; 18: 5-12
        • Bouza E.
        • Muñoz P.
        • Alonso R.
        Clinical manifestations, treatment and control of infections caused by Clostridium difficile.
        Clin Microbiol Infect. 2005; 11: 57-64
        • Kramer A.
        • Schwebke I.
        • Kampf G.
        How long do nosocomial pathogens persist on inanimate surfaces? A systematic review.
        BMC Infect Dis. 2006; 6: 130
        • Sethi A.K.
        • Al-Nassir W.N.
        • Nerandzic M.M.
        • Bobulsky G.S.
        • Donskey C.J.
        Persistence of skin contamination and environmental shedding of Clostridium difficile during and after treatment of C. difficile infection.
        Infect Control Hosp Epidemiol. 2010; 31: 21-27
        • Weber D.J.
        • Rutala W.A.
        • Miller M.B.
        • Huslage K.
        • Sickbert-Bennett E.
        Role of hospital surfaces in the transmission of emerging health care-associated pathogens: norovirus, Clostridium difficile, and Acinetobacter species.
        Am J Infect Control. 2010; 38: S25-S33
        • Dancer S.J.
        The role of environmental cleaning in the control of hospital-acquired infection.
        J Hosp Infect. 2009; 73: 378-385
        • Otter J.A.
        • Yezli S.
        • French G.L.
        The role played by contaminated surfaces in the transmission of nosocomial pathogens.
        Infect Control Hosp Epidemiol. 2011; 32: 687-699
        • Boyce J.M.
        Environmental contamination makes an important contribution to hospital infection.
        J Hosp Infect. 2007; 65: 50-54
        • Kaatz G.W.
        • Gitlin S.D.
        • Schaberg D.R.
        • Wilson K.H.
        • Kauffman C.A.
        • Seo S.M.
        • et al.
        Acquisition of Clostridium difficile from the hospital environment.
        Am J Epidemiol. 1988; 127: 1289-1294
        • Samore M.H.
        • Venkataraman L.
        • DeGirolami P.C.
        • Arbeit R.D.
        • Karchmer A.W.
        Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridium difficile diarrhea.
        Am J Med. 1996; 100: 32-40
        • Wilcox M.H.
        • Fawley W.N.
        • Wigglesworth N.
        • Parnell P.
        • Verity P.
        • Freeman J.
        Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection.
        J Hosp Infect. 2003; 54: 109-114
        • Shaughnessy M.K.
        • Micielli R.L.
        • DePestel D.D.
        • Arndt J.
        • Strachan C.L.
        • Welch K.B.
        • et al.
        Evaluation of hospital room assignment and acquisition of Clostridium difficile infection.
        Infect Control Hosp Epidemiol. 2011; 32: 201-206
        • Kim K.H.
        • Fekety R.
        • Batts D.H.
        • Brown D.
        • Cudmore M.
        • Silva Jr., J.
        • et al.
        Isolation of Clostridium difficile from the environment and contacts of patients with antibiotic-associated colitis.
        J Infect Dis. 1981; 143: 42-50
        • Roberts K.
        • Smith C.F.
        • Snelling A.M.
        • Kerr K.G.
        • Banfield K.R.
        • Sleigh P.A.
        • et al.
        Aerial dissemination of Clostridium difficile spores.
        BMC Infect Dis. 2008; 8: 7
        • Dumford 3rd, D.M.
        • Nerandzic M.M.
        • Eckstein B.C.
        • Donskey C.J.
        What is on that keyboard? Detecting hidden environmental reservoirs of Clostridium difficile during an outbreak associated with North American pulsed-field gel electrophoresis type 1 strains.
        Am J Infect Control. 2009; 37: 15-19
        • Dubberke E.R.
        • Reske K.A.
        • Olsen M.A.
        • McMullen K.M.
        • Mayfield J.L.
        • McDonald L.C.
        • et al.
        Evaluation of Clostridium difficile-associated disease pressure as a risk factor for C difficile-associated disease.
        Arch Intern Med. 2007; 167: 1092-1097
        • Morales L.
        • Rodriguez C.
        Gamboa-Coronado MDM Molecular detection of Clostridium difficile on inert surfaces from a Costa Rican hospital during and after an outbreak.
        Am J Infect Control. 2016; 44: 1517-1519
        • Ali S.
        • Muzslay M.
        • Wilson P.
        A novel quantitative sampling technique for detection and monitoring of Clostridium difficile contamination in the clinical environment.
        J Clin Microbiol. 2015; 53: 2570-2574
        • Engelhardt N.E.P.
        • Foster N.F.
        • Hong S.
        • Riley T.V.
        • McGechie D.B.
        Comparison of two environmental sampling tools for the detection of Clostridium difficile spores on hard bathroom surfaces in the hospital setting.
        J Hosp Infect. 2017; 96: 295-296
        • Brown K.A.
        • MacDougall L.K.
        • Valenta K.
        • Simor A.
        • Johnstone J.
        • Mubareka S.
        • et al.
        Increased environmental sample area and recovery of Clostridium difficile spores from hospital surfaces by quantitative PCR and enrichment culture.
        Infect Control Hosp Epidemiol. 2018; 39: 917-923
        • Verity P.
        • Wilcox M.H.
        • Fawley W.
        • Parnell P.
        Prospective evaluation of environmental contamination by Clostridium difficile in isolation side rooms.
        J Hosp Infect. 2001; 49: 204-209
        • Malik D.J.
        • Patel K.V.
        • Clokie M.R.
        • Shama G.
        On the difficulties of isolating Clostridium difficile from hospital environments.
        J Hosp Infect. 2013; 84: 181-183
        • Clabots C.R.
        • Bettin K.M.
        • Peterson L.R.
        • Gerding D.N.
        Evaluation of cycloserine-cefoxitin-fructose agar and cycloserine-cefoxitin-fructose broth for recovery of Clostridium difficile from environmental sites.
        J Clin Microbiol. 1991; 29: 2633-2635
        • Hill K.A.
        • Collins J.
        • Wilson L.
        • Perry J.D.
        • Gould F.K.
        Comparison of two selective media for the recovery of Clostridium difficile from environmental surfaces.
        J Hosp Infect. 2013; 83: 164-166
        • Martirosian G.
        Recovery of Clostridium difficile from hospital environments.
        J Clin Microbiol. 2006; 44: 1202-1203
        • Deshpande A.
        • Kundrapu S.
        • Sunkesula V.C.
        • Cadnum J.L.
        • Fertelli D.
        • Donskey C.J.
        Evaluation of a commercial real-time polymerase chain reaction assay for detection of environmental contamination with Clostridium difficile.
        J Hosp Infect. 2013; 85: 76-78
        • Cadnum J.L.
        • Hurless K.N.
        • Deshpande A.
        • Nerandzic M.M.
        • Kundrapu S.
        • Donskey C.J.
        Sensitive and selective culture medium for detection of environmental Clostridium difficile isolates without requirement for anaerobic culture conditions.
        J Clin Microbiol. 2014; 52: 3259-3263
        • Dubberke E.R.
        • Reske K.A.
        • Noble-Wang J.
        • Thompson A.
        • Killgore G.
        • Mayfield J.
        • et al.
        Prevalence of Clostridium difficile environmental contamination and strain variability in multiple health care facilities.
        Am J Infect Control. 2007; 35: 315-318
        • Buggy B.P.
        • Wilson K.H.
        • Fekety R.
        Comparison of methods for recovery of Clostridium difficile from an environmental surface.
        J Clin Microbiol. 1983; 18: 348-352
        • Bryce E.
        • Zurberg T.
        • Zurberg M.
        • Shajari S.
        • Roscoe D.
        Identifying environmental reservoirs of Clostridium difficile with a scent detection dog: preliminary evaluation.
        J Hosp Infect. 2017; 97: 140-145
        • Otter J.A.
        • Havill N.L.
        • Adams N.M.
        • Cooper T.
        • Tauman A.
        • Boyce J.M.
        Environmental sampling for Clostridium difficile: swabs or sponges?.
        Am J Infect Control. 2009; 37: 517-518
        • Wilcox M.H.
        • Fawley W.N.
        • Parnell P.
        Value of lysozyme agar incorporation and alkaline thioglycollate exposure for the environmental recovery of Clostridium difficile.
        J Hosp Infect. 2000; 44: 65-69
        • Claro T.
        • Daniels S.
        • Humphreys H.
        Detecting Clostridium difficile spores from inanimate surfaces of the hospital environment: which method is best?.
        J Clin Microbiol. 2014; 52: 3426-3428
        • Ali S.
        • Manuel R.
        • Wilson P.
        Diverse sources of C. difficile infection.
        New Engl J Med. 2014; 370: 182-184
        • George W.L.
        • Sutter V.L.
        • Citron D.
        • Finegold S.M.
        Selective and differential medium for isolation of Clostridium difficile.
        J Clin Microbiol. 1979; 9: 214-219
        • Levett P.N.
        Effect of antibiotic concentration in a selective medium on the isolation of Clostridium difficile from faecal specimens.
        J Clin Pathol. 1985; 38: 233-234
        • Debast S.B.
        • Bauer M.P.
        • Kuijper E.J.
        European Society of Clinical Microbiology and Infectious Diseases: update of the treatment guidance document for Clostridium difficile infection.
        Clin Microbiol Infect. 2014; 20: 1-26
        • McDonald L.C.
        • Gerding D.N.
        • Johnson S.
        • Bakken J.S.
        • Carroll K.C.
        • Coffin S.E.
        • et al.
        Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).
        Clin Infect Dis. 2018; 66: 987-994
        • Nonnenmacher C.
        • Kropatsch R.
        • Schumacher S.
        • Mutters R.
        P767 Quantification of Clostridium difficile by real-time PCR in hospital environmental samples.
        Int J Antimicrob Agents. 2007; 29: S190-S191
        • Mutters R.
        • Nonnenmacher C.
        • Susin C.
        • Albrecht U.
        • Kropatsch R.
        • Schumacher S.
        Quantitative detection of Clostridium difficile in hospital environmental samples by real-time polymerase chain reaction.
        J Hosp Infect. 2009; 71: 43-48
        • Bomers M.K.
        • van Agtmael M.A.
        • Luik H.
        • van Veen M.C.
        • Vandenbroucke-Grauls C.M.
        • Smulders Y.M.
        Using a dog's superior olfactory sensitivity to identify Clostridium difficile in stools and patients: proof of principle study.
        BMJ (Clin Res Ed). 2012; 345e7396