Persistence of skin contamination and environmental shedding of Clostridium difficile during and after treatment of C. difficile infection.
BACKGROUND
Current guidelines for control of Clostridium difficile infection (CDI) suggest that contact precautions be discontinued after diarrhea resolves. However, limited information is available regarding the frequency of skin contamination and environmental shedding of C. difficile during and after treatment.


METHODS
We conducted a 9-month prospective, observational study involving 52 patients receiving therapy for CDI. Stool samples, skin (chest and abdomen) samples, and samples from environmental sites were cultured for C. difficile before, during, and after treatment. Polymerase chain reaction ribotyping was performed to determine the relatedness of stool, skin, and environmental isolates.


RESULTS
Fifty-two patients with CDI were studied. C. difficile was suppressed to undetectable levels in stool samples from most patients during treatment; however, 1-4 weeks after treatment, 56% of patients who had samples tested were asymptomatic carriers of C. difficile. The frequencies of skin contamination and environmental shedding remained high at the time of resolution of diarrhea (60% and 37%, respectively), were lower at the end of treatment (32% and 14%, respectively), and again increased 1-4 weeks after treatment (58% and 50%, respectively). Skin and environmental contamination after treatment was associated with use of antibiotics for non-CDI indications. Ninety-four percent of skin isolates and 82% of environmental isolates were genetically identical to concurrent stool isolates.


CONCLUSIONS
Skin contamination and environmental shedding of C. difficile often persist at the time of resolution of diarrhea, and recurrent shedding is common 1-4 weeks after therapy. These results provide support for the recommendation that contact precautions be continued until hospital discharge if rates of CDI remain high despite implementation of standard infection-control measures.
Sethi
Ajay K
AK
Department of Epidemiology and Biostatistics, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
Al-Nassir
Wafa N
WN
Nerandzic
Michelle M
MM
Bobulsky
Greg S
GS
Donskey
Curtis J
CJ
D000368:Aged; D000369:Aged, 80 and over; D015373:Bacterial Typing Techniques; D016360:Clostridioides difficile / Q000145:classification / Q000235:genetics / Q000302:isolation & purification / Q000502:physiology; D003015:Clostridium Infections / Q000188:drug therapy* / Q000382:microbiology; D004761:Enterocolitis, Pseudomembranous / Q000188:drug therapy* / Q000382:microbiology; D004783:Environmental Microbiology; D005243:Feces / Q000382:microbiology; D005260:Female; D006757:Hospital Units; D006801:Humans; D008297:Male; D008795:Metronidazole / Q000627:therapeutic use; D008875:Middle Aged; D021521:Ribotyping; D012867:Skin / Q000382:microbiology*; D013171:Spores, Bacterial / Q000302:isolation & purification / Q000502:physiology; D016896:Treatment Outcome; D014640:Vancomycin / Q000627:therapeutic use
D008795:Metronidazole; D014640:Vancomycin