Diarrhea May Resolve, but C. difficile Spores Remain

Patients with Clostridium difficile-associated disease frequently are contaminated on multiple skin sites that may remain a source of transmission even after the diarrhea has resolved.

In this study of 27 patients with C. difficile-associated disease, spores were transmitted to the gloved hand of an investigator after contact with various patient skin areas, including patients' hands and forearms, in addition to the groin, abdomen, and chest, said Dr. Curtis J. Donskey, director of infection control of the Veteran's Affairs Medical Center, Cleveland, and his associates.

"We've illustrated that C. difficile is widely distributed over the skin of patients and that health care workers should be wearing sterile gloves when touching these patients, even for such apparently minor contact as adjusting an intravenous catheter," Dr. Donskey said in an interview.

The 27 male patients had received a diagnosis of C. difficile-associated disease (CDAD) during the period from October 2006 to January 2007. Their ages ranged from 50 to 91 years (mean 68), and 12 were nursing home residents.

Patients' clinical conditions included diabetes mellitus (11), cancer (3), end-stage renal disease (3), previous CDAD (8), fecal incontinence (3), and dementia (4); several patients had multiple conditions. All patients had received antibiotics in the previous 3 months, the investigators said (Clin. Infect. Dis. 2008;46:447–50).

Within 3 days of the diagnosis of CDAD, skin cultures were obtained by applying premoistened, sterile rayon swabs to each patient's groin, abdomen, chest, and forearm. Culture specimens also were obtained from the surface of one of the patient's hands.

Of the 27 patients, 35% had spores on the hand, 20% on the forearm, 40% on the chest, 55% on the abdomen, and 60% on the groin.

To determine whether spores on skin could be transmitted to the hands of health care workers, an investigator donned sterile gloves and contacted the same skin sites of the final 10 subjects enrolled. After each skin contact, the gloved hand was imprinted onto appropriate agar plates. Contamination percentages were similar: hand and chest, 40%; forearm, 30%; abdomen, 50%; and groin, 70%.

All but two patients had contamination on more than one skin site, and the number of colonies acquired on gloves ranged from 1 to more than 100, Dr. Donskey and his associates said, adding that contact with the groin typically yielded the highest number of colonies.

A total of 17 patients with CDAD and confirmed C. difficile on the chest and/or abdomen had follow-up culture specimens taken on treatment days 5–14. Of those 39 culture specimens, 31 were collected after resolution of diarrhea, which occurred 3–7 days into treatment. The median time from resolution of diarrhea to detection of negative skin cultures was 7 days, and 10 of the 17 patients remained hospitalized and had culture specimens taken after 9–14 days of treatment. Of those, six had positive chest and/or abdominal culture results, although diarrhea had resolved in all of these patients by day 7, the investigators said.

"We may not be keeping these patients in isolation as long as we should. The current guidelines for C. difficile management suggest that you can take patients out of isolation once their diarrhea has resolved, but our paper implies that it may be reasonable to continue isolation beyond that point," Dr. Donskey told this news organization.

The authors concluded that the data outlined in their brief report confirm that the skin of CDAD-affected patients provides a major potential source of C. difficile transmission.

"Our findings reinforce the importance of wearing gloves when contacting the skin of CDAD-affected patients," said Dr. Donskey. "We observe that health care workers will use careful precautions when doing detailed exams on patients, or when examining their abdomen or groin, but they may be less likely to comply with the recommendations to wear gloves when touching patients' hands or arms, thus risking the spread of C. difficile."

This study was supported by a grant from the Department of Veterans Affairs Advanced Research Career Development Award.

Dr. Donskey has received research funding from Ortho-McNeil Inc., Merck & Co., ViroPharma Inc., Elan Pharmaceuticals Inc., and IPSAT (Intestinal Protection System in Antibiotic Treatment) Therapies Ltd., and is on the speakers bureaus of Elan and Ortho-McNeil.

Hand imprint cultures taken after contact with a CDADpatient's abdomen (left) and chest (right)reinforce the importance of wearing gloves when conducting exams. The Case Western Reserve University School of Medicine

Patients with Clostridium difficile-associated disease frequently are contaminated on multiple skin sites that may remain a source of transmission even after the diarrhea has resolved.

In this study of 27 patients with C. difficile-associated disease, spores were transmitted to the gloved hand of an investigator after contact with various patient skin areas, including patients' hands and forearms, in addition to the groin, abdomen, and chest, said Dr. Curtis J. Donskey, director of infection control of the Veteran's Affairs Medical Center, Cleveland, and his associates.

"We've illustrated that C. difficile is widely distributed over the skin of patients and that health care workers should be wearing sterile gloves when touching these patients, even for such apparently minor contact as adjusting an intravenous catheter," Dr. Donskey said in an interview.

The 27 male patients had received a diagnosis of C. difficile-associated disease (CDAD) during the period from October 2006 to January 2007. Their ages ranged from 50 to 91 years (mean 68), and 12 were nursing home residents.

Patients' clinical conditions included diabetes mellitus (11), cancer (3), end-stage renal disease (3), previous CDAD (8), fecal incontinence (3), and dementia (4); several patients had multiple conditions. All patients had received antibiotics in the previous 3 months, the investigators said (Clin. Infect. Dis. 2008;46:447–50).

Within 3 days of the diagnosis of CDAD, skin cultures were obtained by applying premoistened, sterile rayon swabs to each patient's groin, abdomen, chest, and forearm. Culture specimens also were obtained from the surface of one of the patient's hands.

Of the 27 patients, 35% had spores on the hand, 20% on the forearm, 40% on the chest, 55% on the abdomen, and 60% on the groin.

To determine whether spores on skin could be transmitted to the hands of health care workers, an investigator donned sterile gloves and contacted the same skin sites of the final 10 subjects enrolled. After each skin contact, the gloved hand was imprinted onto appropriate agar plates. Contamination percentages were similar: hand and chest, 40%; forearm, 30%; abdomen, 50%; and groin, 70%.

All but two patients had contamination on more than one skin site, and the number of colonies acquired on gloves ranged from 1 to more than 100, Dr. Donskey and his associates said, adding that contact with the groin typically yielded the highest number of colonies.

A total of 17 patients with CDAD and confirmed C. difficile on the chest and/or abdomen had follow-up culture specimens taken on treatment days 5–14. Of those 39 culture specimens, 31 were collected after resolution of diarrhea, which occurred 3–7 days into treatment. The median time from resolution of diarrhea to detection of negative skin cultures was 7 days, and 10 of the 17 patients remained hospitalized and had culture specimens taken after 9–14 days of treatment. Of those, six had positive chest and/or abdominal culture results, although diarrhea had resolved in all of these patients by day 7, the investigators said.

"We may not be keeping these patients in isolation as long as we should. The current guidelines for C. difficile management suggest that you can take patients out of isolation once their diarrhea has resolved, but our paper implies that it may be reasonable to continue isolation beyond that point," Dr. Donskey told this news organization.

The authors concluded that the data outlined in their brief report confirm that the skin of CDAD-affected patients provides a major potential source of C. difficile transmission.

"Our findings reinforce the importance of wearing gloves when contacting the skin of CDAD-affected patients," said Dr. Donskey. "We observe that health care workers will use careful precautions when doing detailed exams on patients, or when examining their abdomen or groin, but they may be less likely to comply with the recommendations to wear gloves when touching patients' hands or arms, thus risking the spread of C. difficile."

This study was supported by a grant from the Department of Veterans Affairs Advanced Research Career Development Award.

Dr. Donskey has received research funding from Ortho-McNeil Inc., Merck & Co., ViroPharma Inc., Elan Pharmaceuticals Inc., and IPSAT (Intestinal Protection System in Antibiotic Treatment) Therapies Ltd., and is on the speakers bureaus of Elan and Ortho-McNeil.

Hand imprint cultures taken after contact with a CDADpatient's abdomen (left) and chest (right)reinforce the importance of wearing gloves when conducting exams. The Case Western Reserve University School of Medicine

Patients with Clostridium difficile-associated disease frequently are contaminated on multiple skin sites that may remain a source of transmission even after the diarrhea has resolved.

In this study of 27 patients with C. difficile-associated disease, spores were transmitted to the gloved hand of an investigator after contact with various patient skin areas, including patients' hands and forearms, in addition to the groin, abdomen, and chest, said Dr. Curtis J. Donskey, director of infection control of the Veteran's Affairs Medical Center, Cleveland, and his associates.

"We've illustrated that C. difficile is widely distributed over the skin of patients and that health care workers should be wearing sterile gloves when touching these patients, even for such apparently minor contact as adjusting an intravenous catheter," Dr. Donskey said in an interview.

The 27 male patients had received a diagnosis of C. difficile-associated disease (CDAD) during the period from October 2006 to January 2007. Their ages ranged from 50 to 91 years (mean 68), and 12 were nursing home residents.

Patients' clinical conditions included diabetes mellitus (11), cancer (3), end-stage renal disease (3), previous CDAD (8), fecal incontinence (3), and dementia (4); several patients had multiple conditions. All patients had received antibiotics in the previous 3 months, the investigators said (Clin. Infect. Dis. 2008;46:447–50).

Within 3 days of the diagnosis of CDAD, skin cultures were obtained by applying premoistened, sterile rayon swabs to each patient's groin, abdomen, chest, and forearm. Culture specimens also were obtained from the surface of one of the patient's hands.

Of the 27 patients, 35% had spores on the hand, 20% on the forearm, 40% on the chest, 55% on the abdomen, and 60% on the groin.

To determine whether spores on skin could be transmitted to the hands of health care workers, an investigator donned sterile gloves and contacted the same skin sites of the final 10 subjects enrolled. After each skin contact, the gloved hand was imprinted onto appropriate agar plates. Contamination percentages were similar: hand and chest, 40%; forearm, 30%; abdomen, 50%; and groin, 70%.

All but two patients had contamination on more than one skin site, and the number of colonies acquired on gloves ranged from 1 to more than 100, Dr. Donskey and his associates said, adding that contact with the groin typically yielded the highest number of colonies.

A total of 17 patients with CDAD and confirmed C. difficile on the chest and/or abdomen had follow-up culture specimens taken on treatment days 5–14. Of those 39 culture specimens, 31 were collected after resolution of diarrhea, which occurred 3–7 days into treatment. The median time from resolution of diarrhea to detection of negative skin cultures was 7 days, and 10 of the 17 patients remained hospitalized and had culture specimens taken after 9–14 days of treatment. Of those, six had positive chest and/or abdominal culture results, although diarrhea had resolved in all of these patients by day 7, the investigators said.

"We may not be keeping these patients in isolation as long as we should. The current guidelines for C. difficile management suggest that you can take patients out of isolation once their diarrhea has resolved, but our paper implies that it may be reasonable to continue isolation beyond that point," Dr. Donskey told this news organization.

The authors concluded that the data outlined in their brief report confirm that the skin of CDAD-affected patients provides a major potential source of C. difficile transmission.

"Our findings reinforce the importance of wearing gloves when contacting the skin of CDAD-affected patients," said Dr. Donskey. "We observe that health care workers will use careful precautions when doing detailed exams on patients, or when examining their abdomen or groin, but they may be less likely to comply with the recommendations to wear gloves when touching patients' hands or arms, thus risking the spread of C. difficile."

This study was supported by a grant from the Department of Veterans Affairs Advanced Research Career Development Award.

Dr. Donskey has received research funding from Ortho-McNeil Inc., Merck & Co., ViroPharma Inc., Elan Pharmaceuticals Inc., and IPSAT (Intestinal Protection System in Antibiotic Treatment) Therapies Ltd., and is on the speakers bureaus of Elan and Ortho-McNeil.

Hand imprint cultures taken after contact with a CDADpatient's abdomen (left) and chest (right)reinforce the importance of wearing gloves when conducting exams. The Case Western Reserve University School of Medicine