Bacterial endospores exist solely to help low G and C Gram-positive organisms, such as Bacillus, Clostridium, and Staphylococcus species, survive through the most extreme environmental conditions (Ahmad et al, 1999; Cornell University, 2019). Designed with a uniquely formidable cellular structure, bacterial endospores arise during the absence of key nutrients in their environment and play a significant role in protecting the starving bacteria (Pommerville, 2014). Over several hours, endospores are created by the asymmetrical cell division of a vegetative cell to form a mother cell and forespore that unite as one to build the endospore before releasing it into the environment (Cornell University, 2019).
According to Sonenshein (2000), spore-forming bacteria is characterised by dormancy, refractility and extreme resistance. Consequently, the highly resistant nature of endospores makes it difficult to destroy by heat, dehydration, radiation and chemicals. For example, contaminated medical equipment must be heated to 121°C for a minimum of 15 minutes to ensure complete sterilisation is achieved (Acharya, 2016).
Once favourable environmental conditions return, dormant endospores revert back to vegetative cells which contain pathogenic bacteria. This recurring cycle of germination makes the task of removing bacterial endospores in highly populated healthcare settings particularly challenging.
Bacterial endospores, such as Clostridioides difficile (C. diff), are an infection control nightmare, one that can run endlessly if not managed carefully by infection control managers. During a prevalence study across 175 hospitals in Queensland, 58.3% of patients presented with onset symptoms of C. diff pathogen once hospitalised (Huber et al, 2014).
Case Study: Clostridioides difficile
Clostridioides difficile is an unpleasant pathogen that infects the bowel and presents with the following symptoms; diarrhoea several times a day, a high temperature (fever), loss of appetite, feeling sick and stomach pain (‘Clostridium difficile’, 2018). C. diff is primarily spread through indirect and direct contact and mostly affects Australian’s aged over 65 years (Huber et al, 2014).
Current and Future Trends in Australia
More recent research shows that national multi-centre studies estimate 4,902 C. diff infections occur annually in Australia (Mitchell et al, 2017). The rate of severe C. diff infection cases (currently 113 annually) is expected to increase, however the mortality rate will not be affected (Australian Commission on Safety and Quality in Health Care, 2018b).
Infection Control Challenges
Preventing the spread of C. diff infection requires compliance on all fronts within the healthcare environment, with patients, visitors and staff members all responsible for minimising the risk of infection. The primary challenges that impact the effectiveness of C. diff management includes:
(Clostridium difficile colonies, 1965)
1. Hand Hygiene Compliance
Hand Hygiene is a critical component in preventing the transmission of infectious agents, such as bacteria and viruses, and is of primary importance in aged care facilities. If a nurse caring for a C. diff positive patient does not perform the correct hand washing and hand sanitising technique after patient contact, this can significantly increase the incidence of C. diff infection cases from indirect and direct contact with the bacterium. Whilst alcohol-based hand rubs are considered not as effective as washing your hands with soap and water (Australian Commission on Safety and Quality in Health Care, 2018a), PrimeOn Hand Sanitiser is one that has been tested to reduce C. diff loads on hands by 90%.
2. Antibiotic Stewardship
Patients who are treated with antibiotics are more vulnerable to C. diff infections, particularly in hospital-associated environments. According to Centers for Disease Control and Prevention (2019), patients are 7 to 10 times more likely to get C. diff during a course of antibiotics and following the next month.
3. Access to Educational Resources and Programs
Understanding how to effectively remove C. diff from environmental surfaces, such as an isolated patient’s room, and medical equipment, such as monitors, in healthcare facilities is the only way to stop the infection from spreading to healthcare workers, patients and visitors. If staff education and performance measurement for the terminal cleaning of multi‐drug‐resistant organisms is not actively implemented or supported by the healthcare facility for cleaners, this could lead to more incidences of C. diff infection (CDI) outbreaks (Fernando et al, 2017).
Infection Control Prevention Methods
The Australian Commission on Safety and Quality in Health Care (2018b) confirmed that the best approaches to the future management of C. diff involves continuous national monitoring of CDI prevalence at quarterly intervals and a combination of local and severity surveillance.
Administrative and traditional HAI surveillance covering the incidence of C. diff infections is critical for adequate infection prevention and control responses across each Australian state and territory. According to Australian Commission on Safety and Quality in Health Care (2018b), the recommended method for capturing enhanced surveillance is to focus on severity, instead of exposure classification, as it can lead to better management of local cases and allocation of resources. Currently in Australia, state wide monitoring of severe CDI only occurs in Victoria (Australian Commission on Safety and Quality in Health Care, 2018b).
In the case of Clostridioides difficile management for infection control managers across hospitals and aged care facilities in Australia, sharing findings from local and severity surveillance, and working together to better manage resource allocation will make a big difference in the long-term.
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