The Role of Hospital Beds in Clostridioides difficile Transmission: Insights From a Retrospective Study

In a recent interview with Infection Control Today^® (ICT^®), Lucy S. Witt, MD, the lead author, shared insights into her groundbreaking study on Clostridioides difficile transmission. She is an assistant professor of medicine and infectious diseases at the Emory University School of Medicine, a hospital epidemiologist at Emory Johns Creek Hospital, and the newest member of ICT’s Editorial Advisory Board.

The study, titled "The role of the hospital bed in hospital-onset C difficile, a retrospective study with mediation analysis,” published in Infection Control & Hospital Epidemiology, investigates the significant role hospital beds play in C difficile acquisition. Witt explains the study's methodology, findings, and the crucial interaction between beds and rooms. The exclusive interview sheds light on key insights for infection prevention personnel, emphasizing the importance of addressing various touchpoints and hand hygiene in health care environments to curb C difficile transmission.

ICT: Please give ICT’s listeners the title and some background, how it came about, and what the findings were.

Lucy S. Witt, MD: So myself, along with colleagues at Emory, recently published a study on C difficile. We were looking at whether the bed itself was important to the transmission of C difficile in a hospital because it's…been shown in multiple studies that being in a hospital room where a patient had previously had C difficile, likely puts subsequent patients at risk for acquisition as well. But exactly what part of the hospital room was playing a role hadn't been understood.

We used available technology at the time, which tracked the beds in our hospital, and each bed had 1 mattress, so we could tell you where that bed and that mattress were at any time and could follow those beds and mattresses and see how much of a role the actual bed played, as opposed to the room played in the acquisition of hospital-onset C difficile. And we found that it does play a role.

We employed a more complicated biostatistical analysis called mediation and interaction analysis, where we looked at the bed playing a role and the room playing a role. How much is the interaction between the bed and the room together playing a role? And how much do they play a role individually? What we really found is that both the beds in the room play a role in putting patients at risk for hospital-onset C difficile, but there is an interaction between them.

If you are in both a bed that held a patient who previously had C difficile and a room that held a patient that previously had C difficile, and you're at even higher risk of C difficile, it's really that interaction in the bed in the room is really important to future patients’ risk.

ICT: What is the interaction? Is it because of where it's at? Is it not? Is it because it's not being cleaned properly?

LSW: We don't know; our study did not do swabs of bedrails, light bulbs, light switches, or patient care equipment. So, I can't say for sure, but from prior studies looking at like [adenosine triphosphate] fluorescent markers on health care workers’ hands, there's probably some healthcare worker hands transmitting spores, maybe some inadequate cleaning, as well as interactions between the surfaces themselves. If the bed hits the wall, you know, does a little bit of spore get on the wall? It's complicated and not completely figured out yet. But anyone who works in health care can kind of imagine the different routes that contaminate a bed and a room and make it [riskier] to be in a contaminated bed and room.

ICT: What do you want infection prevention personnel to learn from your study?

LSW: My study, in conjunction with other studies, even looking at other infectious pathogens that are hospital-based problems, I'm thinking Candida auris or [carbapenem-resistant Enterobacteriaceae], that there's so much interaction between the health care environment and the patient that health care workers participate in that patients participate in, your patients are out of bed touching things, health care workers are in the room helping their patients, and that all of those touches are potential contaminations. And I think we, as a group, and we, like the infection prevention world, have been so focused on clean-in and clean-out. These hard stops are easy to see and track and intervene on.

It's becoming more and more obvious that we need to make sure we're focusing on all the 5 moments that the [World Health Organization] has highlighted. When we're interacting with patients, make sure that hands are being cleaned every time you go from surface to body or body to a surface, not just focusing on clean-in, clean-out, [but] focusing on cleaning our hands during all interactions with patients and surfaces in their rooms. And really understanding what is a sterile site? What's a nonsterile site, and what's an in-between site, and then what's a dirty site? And [then] making sure that we wash our hands, use hand sanitizer, use gloves, use gowns at the appropriate place in our care of patients.

ICT: What surprised you from the results of your study?

LSW: I was surprised at how much the interaction between the room and the bed was important. At the beginning of the study, I thought that the bed itself was going to be of the utmost importance, and that was one of the reasons this was undertaken. It was right around the time that our health care system just happened to replace all the mattresses. There had been national reports given to the [Federal Drug Administration] that there had been leakage through mattress covers of human material, so not necessarily transmission of a pathogen through a mattress. But just this concept that we all assumed that mattress covers were impermeable, and it turns out they weren't. So, it was just a lucky coincidence that we happened to have replaced these new mattresses, and this concern for mattresses, and could track them.

Because of those reports about the seepage, I said, “I wonder if beds are really the important part.” And again, a lot of our patients are bed-bound; they might be soiling in their beds. It made sense to me that, okay, the bed could be the smoking gun for the transmission of C difficile. I was surprised at how important the room turned out to be. It reiterated to me again that it's the other surfaces in health care interactions [that] are super important. We need to be doing a good job of cleaning our hands and protecting cross-transmission from surfaces to patients and patients to surfaces.

ICT: Do you have anything else you'd like to add?

LSW: With the increase in C auriswe're seeing across the country. It's going to be interesting to see what effect this has on C difficile. We've already seen rates of C difficile go down after COVID-19 nationally, and C auris is making us rethink what cleaning products should be the everyday cleaning products in our hospitals, how we should disinfect rooms, and how we prevent contamination. I suspect that that's going to have a further effect on C difficile since some of the products overlap in terms of being able to kill C difficile, which some basic products [that] many hospitals used for disinfection and decontamination would not necessarily kill C difficile. So, I think it's going to be interesting to see what the future holds as we all ramp up to try to prevent further spread of C auris in our country.

(The interview was edited for clarity.)