Unexplained Increase in C. difficile Infections Linked to Improperly Set Laundry Machine

June 18, 2014 | Strategic Insights for Health System


​Hospital floors are commonly contaminated with Clostridium difficile and other pathogens and may be an underappreciated source of C. difficile transmission, conclude the authors of a brief report published in the June 2014 issue of the American Journal of Infection Control. At an academic community hospital in Pennsylvania, the infection control team observed that the number of healthcare facility–onset C. difficile infections (CDI) jumped from 3 during the period of January 2013 to March 2013 to 11 during the period of April 2013 to June 2013. Because the number of hospital admissions between the two time periods in question was comparable, the case mix was comparable, and there was no significant difference in the community-onset CDI prevalence rate, the hospital assembled a multidisciplinary team to investigate possible causes. Although an analysis of the distribution of cases failed to link the outbreak to any particular floor or wing of the facility and determined that the allocation of nursing staff had not changed and that no major additions to the healthcare staff had occurred that could have altered the standard of infection control, an examination of the laundry records revealed that the quantity of bleach used during the time period in question was lower than expected, and staff deduced that approximately 100 loads of mop pads had been washed without bleach.

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