A pilot study to assess the impact of an educational patient hand hygiene intervention on acquisition of colonization with health care-associated pathogens

Patient hand hygiene is a commonsense measure that has been associated with reductions in colonization or infection with bacterial and viral pathogens in quasi-experimental studies. We conducted a nonblinded pilot randomized trial to assess the impact of an educational patient hand hygiene intervention on acquisition of colonization by selected health care-associated pathogens in hospitalized patients. For patients with negative admission cultures, the intervention did not reduce the new acquisition of colonization by pathogens compared with that of standard care.

Contaminated clothing of methicillin-resistant Staphylococcus aureus (MRSA) carriers is a potential source of transmission

We examined the burden of methicillin-resistant Staphylococcus aureus (MRSA) on the clothing of MRSA carriers in a hospital and long-term care facility and assessed the potential for clothing to be a source of transmission. Of 50 MRSA carriers studied, 37 (74%) had MRSA recovered from clothing. For a subset of carriers with clothing contamination, transfer of MRSA from clothing to gloved hands and to a wheelchair occurred in 8 of 13 (62%) and 5 of 10 (50%) carriers, respectively. These findings suggest that measures to reduce clothing contamination should be investigated as a potential means to reduce MRSA transmission in healthcare settings.

2267. The Effect of Opportunistic Infection (OI) Prophylaxis on the Gastrointestinal Microbiome (GIM) and Immune Reconstitution (IR) in Veterans With HIV and AIDS

Background

Methods

Results

Conclusion

Disclosures

1179. Incidence of Bacteremia and Bacteriuria With Antibiotic-Resistant Enterobacteriaceae After Transrectal Ultrasound-Guided Biopsy of the Prostate (TRUSBP)

Background

Infection with Escherichia coli after TRUSBP is common, but other Enterobacteriaceae also occur. In the absence of microbiological data, prophylaxis with co-trimoxazole (TMP-SMX) or fluoroquinolones (FQ) is usually prescribed. We estimated the incidence of bacteremia and bacteriuria after TRUSBP with distinct species of Enterobacteriaceae and their rate of resistance to common antibiotics.

Methods

Using Veterans Healthcare Administration (VHA) databases, we identified patients undergoing TRUSBP between January 1, 2013 and December 31, 2017. We determined the incidence of Enterobacteriaceae isolated from urine and blood cultures obtained within 30 days of TRUSBP. Using microbiology data from VHA, we determined rates of resistance to TMP-SMX, FQ (ciprofloxacin as marker), ESC (ceftriaxone as marker), and carbapenems (Carb) (ertapenem as marker).

Results

Overall, 377 (0.3%) and 1,739 (1.4%) of 126,761 TRUSBPs were complicated by bacteremia or bacteriuria with Enterobacteriaceae, respectively. E. coli was predominant (91% of blood and 81% in urine). Rates of FQ resistance were low in Klebsiellaand Enterobacter but exceeded 60% in E. coli. In general, TMP-SMX resistance exceeded 30%. Of note, 16.6% of blood and 11% of urine Enterobacteriacaea were resistant to ESC, while Carb-resistance was rare.

Conclusion

FQ and ESC-resistant Enterobacteriaceae are prevalent in bacteremia and bacteriuria after TRUSBP. Antibiotics used for prophylaxis and empirical treatment are likely to be ineffective. The prevention and management of TRUSBP-related infections should include microbiology-guided approaches.

Disclosures

All authors: No reported disclosures.

536. Clostridium difficile Colonization in the First Year of Life

Background

Recent years have witnessed an explosive increase in community-associated Clostridium difficile infection (CA-CDI) in adults. Contact with infants, a population known to be asymptomatically colonized by C. difficile (CD), has been identified as a risk factor for CA-CDI, rendering it vital to explore the epidemiology and determinants of acquisition in babies.

Methods

In this prospective cohort study, healthy infants attending a demographically diverse suburban pediatric practice were enrolled at birth and followed through their 2-month, 6-month, and 12-month well child visit. At each visit, stool samples were collected, and questionnaires including interim exposure to potential risk factors for CD acquisition were administered. Stool was inoculated on pre-reduced CCFA agar with a graduated loop. Among CD isolates, toxin genes were identified by PCR.

Results

Fifty infants were recruited; 90% of samples and questionnaires were completed. The average gestational age was 39 weeks and 46% were male. Twenty-eight (56%) infants had at least one sample positive for CD during the study: cross sectional incidence was 0/50 at birth; 9/47 (19%) at 2 months; 22/43 (51%) at 6 months; 6/37 (16%) at 1 year. Of those with positive stool cultures, three(11%) tested positive at multiple visits. Of the 37 (81%) isolates, 30 were PCR-positive for CD toxin. Five stool samples harbored >4.5 log₁₀ cfu of toxigenic CD/g of stool. Proportions of CD+ vs. CD− subjects, respectively, with interim exposure to selected CD risk factors at each visit were as follows: infant healthcare visit 45% vs. 42%; household member healthcare visit 17% vs. 23%; household member with diarrhea 14% vs. 29%; antibiotic exposure 5% vs. 4%; antacid exposure 7% vs. 3%, all P > 0.05. Regarding risks for acquisition of enteric pathogens in general: breastmilk-including nutrition 57% vs. 73% (P < 0.05 only at 2-month visit); 48% CD+ infants had interim daycare attendance vs. 25% CD− (but P > 0.05 at each visit).

Conclusion

Asymptomatic carriage of toxigenic CD occurred in over half of healthy infants during the first year of life, and several had a high organism burden that could increase the risk for transmission. While daycare attendance was more common among colonized infants, the majority of infants who were CD+ had no daycare exposure.

Disclosures

All authors: No reported disclosures.

507. Degree of Concordance of Clostridium difficile Strains in Adults with Community-Associated C. difficile Infection and Infants With C. difficile Colonization

Background

The number of adults afflicted with community-associated Clostridium difficile infection (CA-CDI) has increased dramatically over the past 10 years. Exposure to infants, a population known to be asymptomatically colonized by C. difficile (CD), has been identified as a risk factor for CA-CDI, implying that infants may be a reservoir for adult infection. In the present study, we determined the distribution of CD ribotypes isolated from adults with CA-CDI and compared them to the ribotypes of strains excreted asymptomatically among a cohort of healthy infants from the same geographical location.

Methods

Adult samples submitted to a referral university hospital microbiology laboratory as part of routine care were identified as CD+ by commercial PCR and stored at −80°; the subset of samples from patients meeting IDSA criteria for CA-CDI were selected for further analysis. A cohort of healthy infants attending a suburban, demographically diverse pediatric practice 6 miles from the hospital were enrolled at birth and prospectively followed at 2-, 6-, and 12-month well-visits. Stool collected at each infant visit was cultivated for CD using routine techniques. DNA from both sets of organisms was extracted and subjected to fluorescent PCR ribotyping. Amplicons were assigned to specific ribotypes through sequence analysis, using the nomenclature proposed previously (J Clin Microbiol 2015;53:1192).

Results

To date, 29 adult samples (collected between August 1, 2016 and January 31, 2018) and 32 infant samples (collected between July 1, 2016 and March 31, 2018) have been ribotyped. Eleven (18%) organisms could not be typed (3 adult; 8 infant). The most representative ribotype identified in the adult CA-CDI samples was F014-020 (54%), with small numbers scattered among six other ribotypes. The most prominent ribotypes in infants were F106 (33%), F010 (17%), and F012 (17%); two (8%) infants were colonized with ribotype F014-020. Except for F014-020, there was no concordance of ribotypes among adult CA-CDI and infant isolates.

Conclusion

In this population, a small proportion of asymptomatic infants were colonized by a prominent CA-CDI ribotype in adults, but other ribotypes were unique to each age group.

Disclosures

All authors: No reported disclosures.

1728. Effectiveness and Healthcare Personnel (HCP) Perceptions of a Multi-Site Personal Protective Equipment (PPE) Free Zone Intervention

Background

CDC provides guidelines for using contact precautions (CP) when caring for patients with antibiotic-resistant bacteria or Clostridium difficile. However, HCP frequently report discomfort, difficulty of use, and interrupted workflow with CP. Modifying CP guidelines to balance these issues requires testing to assess benefits and maintenance of safe practices. A promising approach using a “PPE Free Zone” strategy within rooms of patients in CP has not been well-studied.

Methods

The PPE Free Zone comprised a 3–6 foot area inside door thresholds of CP patient rooms denoted by red tape placed on the floor. Within the zone, HCP were not required to don PPE. HCP were considered compliant if they performed hand hygiene (HH) and donned appropriate PPE before crossing the zone. Observers at 6 acute care facilities (ACF) were trained on observing HCP HH and use of PPE with CP. Observations were made before and after implementation of a PPE Free Zone. Intervention ACF conducted observations on 8 intervention units and 6 nonintervention units. Models of overall compliance and entry HH compliance were constructed using a generalized linear-mixed effects model with a logistic link function. Pre-intervention observations from all 6 ACF and intervention phase observations from the 3 intervention ACF were used in models.

Results

We observed 4,510 room entries. HH adherence declined over time in both intervention and control units but declined less among intervention units from pre to post intervention (β: 0.71, P = 0.007, Figure 1). Stratified by precautions type, the effect of the PPE Free Zone on HH was only significant for rooms in enteric precautions (P < 0.001). Compliance with PPE use was not significantly different pre- versus postintervention (P = 0.133). When surveyed, HCP had positive views of the PPE Free Zone: 65% (n = 172) agreed or strongly agreed the zone facilitates communication with patients, permits checking on patients more frequently, and saves time [n = 169] (Figure 2).

Conclusion

Although HCP viewed the zone positively and it had a significant effect on HH in enteric precautions rooms, the zone did not improve PPE compliance. Future interventions in the ACF setting should consider the complex sociotechnical system factors influencing behavior change.

Disclosures

All authors: No reported disclosures.

1145. Sparring With Spores: Ultrasounds as a Vector for Pathogen Transmission in the Intensive Care Unit

Background

Portable equipment that is shared among patients can be a potential source of pathogen dissemination. In busy healthcare settings, cleaning of shared medical equipment may be suboptimal. In addition, equipment such as ultrasound probe heads present a challenge because sporicidal cleaning solutions such as bleach cannot be used.

Methods

We conducted a culture survey of ultrasounds in 15 intensive care units (ICUs) at a large tertiary care referral center, including medical, surgical, neurology, cardiology, and cardiovascular ICUs. Multiple high-touch surfaces on different types of ultrasound equipment used in the ICUs were swabbed to assess for the presence of Clostridium difficile and antibiotic-resistant Gram-negative bacilli. To assess cleaning, a fluorescent marker visible only under UV light was placed on high-touch surfaces on each of the cultured ultrasounds and a black light was used determine if the marker was removed after 24 hours and again after 1 week.

Results

Of 15 ultrasounds cultured, 7% were contaminated with C. difficile spores and 7% were contaminated with Gram-negative bacilli. Based on fluorescent marker removal, only 20% of the ultrasounds were cleaned within 24 hours and only 31% were cleaned within 1 week. Ultrasounds with touchscreens were cleaned more frequently than those with no touchscreen. For equipment with a combination of touchscreen features and knobs, the touchscreens were cleaned more often than the knobs which often had residual marker even after 7 days.

Conclusion

Ultrasound equipment can be a vector for transmission of C. difficile and other pathogens in critical care settings. In our facility, cleaning of ultrasound equipment was suboptimal, particularly for ultrasounds that did not have a touchscreen interface. Since ultrasounds are being employed in critical care settings with increasing frequency, there is a need for improved methods for cleaning and disinfection.

Disclosures

A. Deshpande, 3M: Investigator, Research grant. Clorox: Investigator, Research grant. STERIS: Investigator, Research grant.

1213. Evaluation of an Alcohol-Based Antiseptic for Nasal Decolonization of Methicillin-Resistant Staphylococcus aureus (MRSA)

Background

Due to concerns for emergence of mupirocin resistance, there is an interest in use of topical antiseptics for nasal decolonization of Staphylococcus aureus. Alcohol-based nasal antiseptics have recently been developed as an alternative to mupirocin, but there is limited data on efficacy, particularly among patients where the burden of carriage is often high.

Methods

We evaluated the effectiveness of a one-time application of a commercial alcohol-based nasal sanitizer for reduction in nasal methicillin-resistant Staphylococcus aureus (MRSA) in MRSA-colonized patients. Patients received either a single dose or triple dose over 3 minutes; the triple dose is recommended for preoperative dosing. Swabs were used for quantitative culture of MRSA from the anterior nares and vestibule prior to and 10 minutes, 2 hours, and 6 hours after application. For a subset of patients, cultures for MRSA were collected from hands, clothing, groin, and chest/axilla.

Results

Of 34 MRSA carriers enrolled, 27 (79%) had MRSA detected in nares, 32 (94%) were male, and the mean age was 65. Of the 27 carriers positive for nasal MRSA, 15 (56%) received a single alcohol dose and 12 (44%) received a triple dose over 3 minutes. As shown in the figure, the single and triple dose applications significantly reduced MRSA concentrations at 2 hours post-treatment when the initial burden was low (i.e., <2 log₁₀colonies per swab), but there was no significant reduction at 6 hours; there was no significant reduction with either dose when the initial burden was high (≥2 log₁₀colonies per swab).

Conclusion

A single application of an alcohol nasal sanitizer significantly reduced nasal MRSA at 2 hours post-application when the initial burden of colonization was low, but not when a high burden of carriage was present. Additional studies are needed to determine whether higher alcohol doses or repeated applications might result in improved efficacy.

Disclosures

All authors: No reported disclosures.

2397. Comparing Predictive Performance of INCREMENT Scores on Mortality Among Patients With Carbapenem-Non-Susceptible (CNS) Klebsiella pneumoniae (Kp) and Enterobacter cloacae Complex (Ecc) Bloodstream Infections (BSI) in the Veterans Health Administration (VHA)

Background

INCREMENT is an international collaborative study of BSI caused by extended-spectrum β-lactamase (ESBL) or carbapenemase-producing Enterobacteriaceae (CPE) that has developed and validated predictive models for mortality. Most CNS Enterobacteriaceae BSI in the VHA are either Klebsiella pneumoniae (Kp) or Enterobacter cloacae complex (Ecc). We applied the INCREMENT score for CPE to predict mortality in patients with CNS-Kp and CNS-Ecc BSIs in the VHA and compared the distribution and predictive performance of the score across organisms.

Methods

Using nationwide VHA databases, unique patients in the continental United States with Kp or Ecc BSI post 48 hours of hospitalization from 2006 to 2015 were identified. Isolates with intermediate susceptibility or resistance to any tested carbapenem were considered non-susceptible. We used databases and medical records to obtain clinical characteristics, treatment, and outcomes, and applied INCREMENT criteria and definitions to calculate a prediction score. We compared the distribution of the scores by organism and used receiver operating curve methods to compare predictive performance between Kp and Ecc BSI.

Results

We identified 57 patients with CNS-Ent and 140 with CNS-Kp BSI. The demographics and infection characteristics were highly consistent across organisms, both afflicting patients who were predominantly male, older and chronically ill. Mortality at 14 days was 39% in CNS-Ecc and 38% in CNS-Kp. Similar proportions (65% of Ecc and 68% of Kp) met the criteria for an INCREMENT score: monomicrobial and alive over 48 hours after culture specimen. The distribution of scores was similar within mortality outcomes across organisms, with the highest scores observed in Kp patients who died (Figure 1). The ROC areas under the curve were 0.71 for CNS-Ecc and 0.75 for CNS-Kp (Figure 2). A multivariable logistic model predicting mortality detected neither an organism effect nor an interaction of organism and INCREMENT score.

Conclusion

The INCREMENT score, validated in a CPE cohort predominantly comprised of Kp, performed similarly well across CNS-Ent and CNS-Kp patients in our cohort. This suggests the model is robust to CNS organisms of undetermined resistance mechanism and that the association between INCREMENT and mortality is consistent across Kp and Ecc.

Disclosures

All authors: No reported disclosures.

511. What Is the Current State of Patient Education after Clostridium difficile Infection?

Background

Clostridium difficile infection (CDI) is a common healthcare-associated infection that often recurs after treatment and is associated with reduced quality of life. High-quality patient engagement and education could reduce the risk for transmission and reinfection.

Methods

We surveyed 18 institutions, including academic, Veterans Affairs, and community hospitals, to evaluate if they had CDI-specific patient education practices in place. For three of the institutions, we surveyed CDI patients immediately after hospital discharge regarding the CDI education provided and assessed their knowledge of patient-based prevention measures.

Results

Of the 15 hospitals responding to the survey, 11 (73%) reported having standardized written educational materials regarding CDI. However, Infection Prevention personnel from four (27%) of these hospitals were not confident that the education was being implemented and five (33%) were not confident that the patients understood the education. Of 24 CDI patients surveyed, only 13 (54%) reported receiving any education about CDI from hospital personnel, and only three(12.5%) reported receiving written information. Seven of the 24 (29%) CDI patients reported looking up information online about CDI. Of the 24 CDI patients, three(12.5%) were not aware that soap and water should be used for hand hygiene, 7 (29%) were not aware that bleach should be used for cleaning their bathroom, and 13 (54%) did not choose taking antibiotics as the major risk for recurrence.

Conclusion

Although most hospitals reported having standardized educational materials for CDI patients, our survey of patients demonstrated substantial deficiencies in the education provided and in patients’ knowledge of CDI prevention measures. Engagement of CDI patients in prevention efforts will require improvement in education practices.

Disclosures

All authors: No reported disclosures.

Multisite evaluation of environmental cleanliness of high-touch surfaces in intensive care unit patient rooms

The efficacy of discharge cleaning and disinfection of high-touch surfaces of intensive care unit patient rooms in Brazil, Canada, the Netherlands, and the United States was evaluated and the effect of an educational intervention was determined. Significant site-to-site differences in cleaning regimens and baseline cleanliness levels were observed using ATP levels, colony-forming units, and reflective surface marker removal percent pass rates. An educational intervention that includes rapid feedback of the ATP measurements could significantly improve the quality of the cleaning and disinfection regimens.

The Intersection Between Colonization Resistance, Antimicrobial Stewardship, and Clostridium difficile

PURPOSE OF REVIEW

Colonization resistance refers to the innate defense provided by the indigenous microbiota against colonization by pathogenic organisms. We aim to describe how this line of defense is deployed against Clostridium difficile and what the implications are for interventions directed by Antimicrobial Stewardship Programs.

RECENT FINDINGS

The indigenous microbiota provides colonization resistance through depletion of nutrients, prevention of access to adherence sites within the gut mucosa, production of inhibitory substances, and stimulation of the host's immune system. The ability to quantify colonization resistance could provide information regarding periods of maximal vulnerability to colonization with pathogens and also allow the identification of mechanisms of restoration of colonization resistance. Methods utilized to determine the composition of the gut microbiota include sequencing technologies and measurement of concentration of specific bacterial metabolites. Use of innovations in the quantification of colonization resistance can expand the role of Antimicrobial Stewardship from prevention of disruption of the indigenous microbiota to restoration of colonization resistance.

Evaluation of the potential for electronic thermometers to contribute to spread of healthcare-associated pathogens

In a point-prevalence culture survey, 24 of 300 (8%) handles of electronic thermometers in 3 hospitals were contaminated with 1 or more potential pathogens. A DNA marker inoculated onto the handles of electronic thermometers in hospital and long-term care facility settings spread to surfaces in patient rooms, to other types of portable equipment, and to patients' hands. Our findings suggest that effective strategies are needed to reduce the risk for pathogen transmission by electronic thermometers.

Clostridium difficile in Older Adults

Recent increases in the incidence of Clostridium difficile infection (CDI) have been observed in all age groups, but the elderly have been disproportionately affected and long-term care facilities (LTCFs) have borne a significant proportion of the increasing burden. Recurrences are common in older adults and may have significant adverse effects on quality of life. Ensuring appropriate diagnostic testing and management is challenging for older adults in the community and in LTCFs. This review focuses on current concepts related to the epidemiology, diagnosis, and management of CDI in older adults.

Efficacy of manual cleaning and an ultraviolet C room decontamination device in reducing health care-associated pathogens on hospital floors

Recent studies suggest that floors may be an underappreciated source for transmission of health care-associated pathogens. However, there are limited data on the effectiveness of current cleaning and disinfection methods in reducing floor contamination. We demonstrated that manual postdischarge cleaning by environmental services personnel significantly reduced floor contamination, and an automated ultraviolet C room disinfection device was effective as an adjunct to manual cleaning.

Clostridium difficile Infection in Trauma, Surgery, and Medical Patients Admitted to the Intensive Care Unit

BACKGROUND

Clostridium difficile infection (CDI) causes significant morbidity and mortality rates, especially for patients in the intensive care unit (ICU). Data comparing trauma and surgery patients with CDI in the ICU with medical patients with CDI in the ICU are limited.

METHODS

In a single-center study, we analyzed retrospective data from 25 trauma patients and 13 surgery patients aged 18 years or older who had CDI and had been admitted to the ICU. A comparison group of 156 medical patients aged 18 years or greater who had CDI and were admitted to the ICU also was identified.

RESULTS

The trauma/surgery patients had a significantly higher mean number of ventilator days (13.5 ± 9.3 vs. 7.3 ± 7.2; p < 0.0004), Foley catheter days (11.9 ± 6.8 vs. 8.0 ± 7.9; p = 0.005), mean ICU length of stay (LOS) (12.34 ± 9.7 vs. 5.9 ± 5.9 days; p < 0.0003), and mean total LOS (16 ± 9.3 vs. 10.7 ± 8.4 days; p = 0.0008). However, the medical group had a significantly higher mean number of vasopressor days (2.07 ± 3.51) than the trauma/surgery group (0.58 ± 1.55; p < 0.0001). The overall survival rate was significantly higher in the trauma/surgery group than in the medical group (100% vs. 81%, respectively; p = 0.003). A higher percentage of patients in the trauma/surgery group received piperacillin/tazobactam before the diagnosis of CDI than the medical patients (58% vs. 37%, respectively; p = 0.02). The number of days that antibiotics were given prior to the development of CDI was greater in the trauma/surgery group than in the medical group (10.3 ± 6.7 vs. 7.6 ± 7.3 days; p = 0.04). Multiple logistic regression models determined ICU LOS (adjusted odds ratio [aOR] 1.27 days; 95% confidence interval [CI] 1.13-1.41), the presence of chronic obstructive pulmonary disease (COPD) (aOR 3.44; 95% CI 1.19-9.95), and piperacillin/tazobactam use (aOR 3.27; 95% CI 1.24-8.65) to be positively associated with CDI in the trauma/surgery group compared with the medical patients.

CONCLUSIONS

Longer ICU stay, receipt of piperacillin/tazobactam, and having COPD were positively associated with CDI in trauma/surgery patients compared with medical patients. These findings suggest further consideration of the possibility of CDI should be given to patients admitted the surgical ICU for an extended period of time, receiving piperacillin/tazobactam, or having COPD. Additional evaluation of these factors in a larger patient sample is warranted.

Evaluation of an automated ultraviolet-C light disinfection device and patient hand hygiene for reduction of pathogen transfer from interactive touchscreen computer kiosks

Touchscreens are a potential source of pathogen transmission. In our facility, patients and visitors rarely perform hand hygiene after using interactive touchscreen computer kiosks. An automated ultraviolet-C touchscreen disinfection device was effective in reducing bacteriophage MS2, bacteriophage ϕX174, methicillin-resistant Staphylococcus aureus, and Clostridium difficile spores inoculated onto a touchscreen. In simulations, an automated ultraviolet-C touchscreen disinfection device alone or in combination with hand hygiene reduced transfer of the viruses from contaminated touchscreens to fingertips.

Hospital readmissions related to Clostridium difficile infection in the United States

Using a national readmissions database, we report a significant burden of Clostridium difficile-associated readmissions in the United States manifested as a high rate of rehospitalizations and substantial hospital stays and costs.

A cold hard menace: A contaminated ice machine as a potential source for transmission of carbapenem-resistant Acinetobacter baumannii

During an investigation of potential sources of transmission of multidrug-resistant gram-negative bacilli on a spinal cord injury unit, we recovered genetically related carbapenem-resistant Acinetobacter baumannii isolates from the stool of 3 patients, the hands of a nurse, and an ice machine water outlet spout and drain. Our findings suggest that contaminated ice machines could serve as a potential reservoir for dissemination of multidrug-resistant gram-negative bacilli.

Quantitative assessment of interactions between hospitalized patients and portable medical equipment and other fomites

In an observational study, we demonstrated that hospitalized patients frequently had direct or indirect interactions with medical equipment and other fomites that are shared among patients, and these items were often contaminated with health care-associated pathogens. There is a need for protocols to ensure routine cleaning of shared portable equipment.

Sensitizing Clostridium difficile Spores with Germinants on Skin and Environmental Surfaces Represents a New Strategy for Reducing Spores via Ambient Mechanisms

Background

Clostridium difficile is a leading cause of healthcare-associated infections worldwide. Prevention of C. difficile transmission is challenging because spores are not killed by alcohol-based hand sanitizers or many commonly used disinfectants. One strategy to control spores is to induce germination, thereby rendering the spores more susceptible to benign disinfection measures and ambient stressors.

Methods/Results

C. difficile spores germinated on skin after a single application of cholic acid-class bile salts and co-germinants; for 4 C. difficile strains, recovery of viable spores from skin was reduced by ~0.3 log₁₀CFU to 2 log₁₀CFU after 2 hours and ~1 log₁₀CFU to > 2.5 log₁₀CFU after 24 hours. The addition of taurocholic acid to 70% and 30% ethanol significantly enhanced reduction of viable spores on skin and on surfaces. Desiccation, and to a lesser extent the presence of oxygen, were identified as the stressors responsible for reductions of germinated spores on skin and surfaces. Additionally, germinated spores became susceptible to killing by pH 1.5 hydrochloric acid, suggesting that germinated spores that remain viable on skin and surfaces might be killed by gastric acid after ingestion. Antibiotic-treated mice did not become colonized after exposure to germinated spores, whereas 100% of mice became colonized after exposure to the same quantity of dormant spores.

Conclusions

Germination could provide a new approach to reduce C. difficile spores on skin and in the environment and to render surviving spores less capable of causing infection. Our findings suggest that it may be feasible to develop alcohol-based hand sanitizers containing germinants that reduce spores on hands.