[Matthias.Maiwald@KKH.COM.SG Subject: Re: AICA Position on Hypervirulent C.difficile Comments: cc: Stephanie Goodrick]

Dear Group,

I am following with interest the AICAlist discussion about hypervirulent
Clostridium difficile and the AICA position paper.

Last year I was given the opportunity to write one of several systematic
reviews for the upcoming NHMRC guidelines; one of the questions given to me
was hand hygiene agents and their activity against C. difficile.

I thought I might just briefly share some of the key findings. As with many
things in life and in medicine, the picture is one of shades of grey rather
than a black-and-white picture.

First, it is very clear that spores of C. difficile (like any bacterial
spores) are not effectively killed by alcohol-based handrubs, and
handwashing with either plain or antimicrobial soap is significantly more
effective at eliminating spores from hands. This is a reversal of the usual
situation with the vast majority of other pathogens, where alcohols are
significantly more effective. This long-known fact has also been confirmed
in a recent publication (Jabbar U et al. Infect Control Hosp Epidemiol
2010; 61 (6): 565-70).

Second, any population of a spore-forming bacterium may consist of spores
as well as vegetative forms in various ratios, depending on the living
conditions (environment) of such a population. It is also clear that the
“usual situation” holds true for the vegetative forms, i.e. that they are
killed/eliminated much more effectively by alcohol than by soap and water.

The effectiveness of the various hand hygiene measures would then depend
on: (1) the ratio of spores to vegetative forms that are on the patient’s
body and surroundings, and (2) whether only spores or both spores and
vegetative forms are involved in transmission of the pathogen.

There is only insufficient published information available concerning these
two latter questions, so that no firm conclusions or recommendations can be
based on these two points (i.e. 1 and 2). However, a published reference
(Jump RL et al. Antimicrob Agents Chemother 2007: 51: 2883-7) that Tom
Riley from Western Australia kindly pointed out to me, contains some
interesting information: (1) The ratio of vegetative forms to spores in
freshly excreted stools of patients with the disease was determined to be
about 10:1 in favour of the vegetative forms, (2) C. difficile vegetative
forms, although they die within about 15 min on dry surfaces, may suvive up
to 6 hours on moist surfaces, and (3) some cited studies show that patients
on gastric acid suppressants (gastric acid kills vegetative forms but not
spores) are at increased risk of acquiring the disease. These three
findings strongly suggest that vegetative forms do play a role in
transmission, although the relative contribution remains unclear.

A senior colleague from Austria (Prof. Manfred Rotter from Vienna), in
personal correspondence, has therefore recommended sequential alcohol-based
handrubbing followed by handwashing in case of accidental contamination of
hands from patients or surfaces that are presumed to be heavily
contaminated with C. difficile. This is based on the above rationale. Of
course, I am not proposing to make this a recommendation, because it would
likely confuse healthcare workers with no special microbiology knowledge
and would deviate from the very reasonable recommendation in the AICA
position paper.
The other consideration (as stated in the AICA position paper) is that a
patient infected with C. difficile certainly qualifies for contact
precautions, which includes the wearing of gloves.

Lastly, in my review I found no evidence and not even a slight indication
that frequent use of alcohol-based hand rubs has any impact in terms of
increasing the incidence of C. difficile infections. This is reassuring in
terms of continuing with alcohol-based hand hygiene as the standard of care
in practically all other clinical situations than C. difficile infection.

The WHO hand hygiene guideline (2009) also contains specific information
pertaining to C. difficile.

Concerning the subsequent (to the one below) AICA e-mails, I have been
critical on several occasions in the past of the TGA approval system for
antiseptics and disinfectants. There appear to be (1) no independent,
non-manufacturer-based testing requirements according to stringent
independent standards, and (2) no public listing of stringently tested,
antimicrobially active and approved disinfectants according to their
proposed use (e.g. surfaces, hands, skin, instruments, etc.). From the
European experience we know that we simply cannot rely on manufacturers’
claims when it comes to antiseptics and disinfectants. The consequence of
(2) is that not an independent body, but instead company representatives
are often the first point of contact and information for healthcare
professionals when it comes to purchasing decisions for antiseptics and
disinfectants.

Best regards, Matthias.

—
Matthias Maiwald, MD, FRCPA, D(ABMM)
Consultant in Microbiology
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 1389
Fax +65 6394 1387

“Wishart,
Michael”
AICALIST@AICALIST.ORG.AU
Sent by: AICA cc
Infexion
Connexion Subject
C.difficile

27/05/2010 02:54
PM

Please respond to
AICA Infexion
Connexion

A PDF of this important AICA Position Paper has now been uploaded on the
AICA website, and can be accessed through the Publications link.

http://aica.org.au/images/PDF_Files/Position%20Statements/AICA_Position%20Statement_cdiff%20May2010%20%282%29.pdf

Cheers
Michael

Michael Wishart

Infection Control Coordinator
Quality & Safety Unit | Greenslopes Private Hospital
Newdegate St, Greenslopes QLD 4120
tel: 07 3394 7919 | pager 047 | fax 07 3394 7985

e: WishartM@ramsayhealth.com.au

Ramsay Health Care is an environmentally responsible corporation, please
consider the environment before printing this email.

—–Original Message—–
C.difficile

AICA have posted information on hyper virulent C.difficile in healthcare
facilities. This will soon be reposted as an actual downloadable
Position Paper, but is currently available in text form at:

http://www.aica.org.au/default.asp?PageID&ReleaseID7&Display=True

Cheers
Michael

Michael Wishart | GPH – Infection Control Coordinator

GPH – Quality & Safety Unit (Infection Control) | Greenslopes Private
Hospital
Newdegate Street, Greenslopes QLD 4120
t: 07 3394 7919 | f: 07 3394 7985
e: WishartM@ramsayhealth.com.au | w: http://www.ramsayhealth.com.au

Ramsay Health Care is an environmentally responsible corporation, please
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