1 To use or not to use Sporicidal agents everywhere?Barley Chironda RPN, CIC National Healthcare Sales Director Infection Control Specialist Clorox HealthCare To use or not to use Sporicidal agents everywhere?

2 Disclaimer Disclosures: Employee of Clorox HealthCare ™ and a volunteer with IPAC Canada ™ in many roles as well as a volunteer with the C.diffFoundation™. Views expressed are those of the presenter and do not reflect the organizations I belong. The funding source for this talk was made possible by funding from Clorox Healthcare ™.

3 Agenda Review background of C.difficile and Interventions aimed at preventing transmission. Discuss the current state and challenges leading to sustained transmission of C.difficile. Discuss universal sporicidal use as a strategy to reduce transmission of C.difficile. Highlight Future considerations Q&A

4 Background

5 Background Clostridium difficile (C. difficile) has become one of the most significant pathogens in acute-care hospital settings in North America.   A 2015 report released by Centers for Disease Control and Prevention (CDC), nearly 500,000 Americans suffer from C. difficile infections (CDI) in a single year, in which 1 in 5 patients can exhibit recurrence1. The epidemiology of C. difficile infection has evolved within the last decade costing hospitals upwards of $4.8 billion each year in excess health care costs1. Although most cases of C. difficile infections (CDI) are healthcare–related, a percentage of cases (~35%) occurs in the community and appear to be unrelated to antibiotic use or prior health care exposure2.  Nearly 1–3% of healthy adults and 15–20% of infants are asymptomatic C. difficile carriers and part of their normal microbial gut community2. Despite proactive infection control measures (e.g. hand hygiene, antibiotic stewardship and environmental cleaning), C. difficile associated disease still remains problematic.  1) Lessa FC, Mu Y, Bamberg WM, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med. 2015;372(9):825–34. 2) Furuya-Kanamori, L., Marquess, J., Yakob, L., Riley, T. V., Paterson, D. L., Foster, N. F., … Clements, A. C. A. (2015). Asymptomatic Clostridium difficile colonization: epidemiology and clinical implications. BMC Infectious Diseases, 15, 516.

6 Interventions Recommended for reduction of HAcdi

7 Process of CDI Disease Transmission: Chain of InfectionHand hygiene Contact precautions Identification of cases Appropriate use of antibiotics Environmental disinfection 1)Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. Annex C – Testing, Surveillance and Management of Clostridium difficile. Annexed to: Routine Practices and Additional Precautions in All Health Care Settings. Toronto, ON: Queen’s Printer for Ontario; –Source of Chain of Infection Image

8 Take Away From Guidance the DocumentsCases on the rise CDI spread is complex EPA Registered Sporicide must be used for C.difficile disinfection C.difficile Management is Multifactorial and Multi Collaborative State concern and concerns from studies Role of community cases Role asymptomatic carriage Human Factors –errors Perform environmental decontamination of rooms of patients with CDI using an approved sporicidal product in an outbreak or hyper endemic setting. 1)Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. Annex C – Testing, Surveillance and Management of Clostridium difficile. Annexed to: Routine Practices and Additional Precautions in All Health Care Settings. Toronto, ON: Queen’s Printer for Ontario; 2013. 2)Lessa FC, Mu Y, Bamberg WM, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med. 2015;372(9):825–34. 3) Furuya-Kanamori, L., Marquess, J., Yakob, L., Riley, T. V., Paterson, D. L., Foster, N. F., … Clements, A. C. A. (2015). Asymptomatic Clostridium difficile colonization: epidemiology and clinical implications. BMC Infectious Diseases, 15, 516.

9 Drivers For C.difficile Management PlanInfection Control Strategies For C.difficile Guidance Documents OSHA HealthCare Facility Policy Infection Control Best Practices Safety Data Sheets Organizational Culture Local Epidemiology

10 What we know so far Lots of guidance documentsWe know how to fight C.difficile

11 Current State Of HACDI

12 C.difficile: Impact Point Prevalence: CDC Funded Study1 Trend:450,000 annual C. difficile infections 29,000 attributable deaths annually $1B in excess costs annually 35%(159,700) attributed to community Trend: 10 year retrospective US patient discharge chart review2 The incidence of CDI among hospitalized adults in the United States nearly doubled from Little evidence of improvement in patient mortality or hospital LOS 1)Lessa et al, NEJM, 372: , 2015 2) Reveles, K. R., Lee, G. C., Boyd, N. K., & Frei, C. R. (2014). The rise in Clostridium difficile infection incidence among hospitalized adults in the United States: AJIC: American Journal of Infection Control, 10(42),

13 Why transmission rates are not improving

14 Why are rates not FallingOutpatient Challenges Inpatient Challenges

15 C.difficile Sources in the Community C.difficile Spores are EverywherePets Tainted Food Sources Water Prior Hospitalization CDI is a growing concern in the community and severe disease is being diagnosed in groups of patients who lack classical risk factors for CDI – antibiotic exposure, recent hospitalisation and advanced age. Exposure to antibiotics remains the most significant inciting factor for developing disease, although it is not always a precursor. Certain high-risk groups, such as haematology or oncology patients and patients with IBD, are more susceptible to infection in the community. There are several potential reservoirs of C. difficile in the community that need further investigation, including environmental, animal, food and human sources. Primary care providers are an integral part in the developing knowledge of CA CDI, with timely diagnosis and management necessary to deliver effective treatment Outpatient Antibiotics Infants Soil Clostridium difficile infection: Early history, diagnosis and molecular strain typing methods Authors C. RodriguezJ. Van Broeck B. Taminiau et al. Source Information August 2016, Volume97(Issue Complete) Page p.59To-78 - Microbial Pathogenesis Lund, B. M., & Peck, M. W. (2015). A Possible Route for Foodborne Transmission of Clostridium difficile? Foodborne Pathogens and Disease, 12(3), 177–182.

16 C.difficile Epidimeology in General Public3-5% of General Public Test Positive for C.difficile 1 in 20

17 Why are rates not FallingOutpatient Challenges Inpatient Challenges

18 Current Challenges in C.difficile In-Patient Hospital Management

19 In Patient Challenges Complex Transmission Tenacity of C.difficileMicrobiologic Testing Environmental Contributions Infection Control Laspes Role of asymptomatic or C.difficile Carriers

20 Transmission Complexities

21 Mode of Transmission HospitalsUp to 50% of people admitted to hospital could be C.difficile Positive(1) Hands: _Shutterstock_RF_Handshake_ psd Delayed Isolation and detection of C.difficile Patients 50% of surfaces in a C.difficile patients room where positive after cleaning(1)

22 C.difficile Epidimeology in Acute Care50% of Adult Inpatients tested positive for C.difficile 10 in 20 on a Hospital Inpatient Unit

23 Tenacity Of C.difficileCDC's designation of disinfectants as high-, intermediate-, and low-level, when compared with EPA's designated organism spectrum. However, exceptions to this general guide exist, and manufacturer's label claims and instructions should always be followed

24 Prior Room Occupancy Up to 50% ChanceA New admission admitted to an environment that housed prior positive patient C.difficile Positive Patient moved to new environment for contact precautions leaving seeded room Up to 50% Chance A meta-analysis of the combined data from included studies overwhelmingly indicated an increased risk of acquisition when put in a room that previously housed a patient with C.difficile1. Current environmental cleaning practices fail to reduce the risk of acquisition as spores can be airborne up to 48hrs after discharge of C.difficile Patient1. Receipt of antibiotics by prior bed occupants was associated with increased risk for CDI in subsequent patients. Antibiotics can directly affect risk for CDI in patients who do not themselves receive antibiotics2. Mitchell BG, Dancer SJ, Anderson A, Dehn E. Risk of organism acquisition from prior room occupants: a systematic review and meta-analysis. J Hosp Infect 2015;91:211‒217. Freedberg DE, Salmasian H, Cohen B, Abrams JA, Larson EL. Receipt of Antibiotics in Hospitalized Patients and Risk for Clostridium difficile Infection in Subsequent Patients Who Occupy the Same Bed. JAMA Intern Med. Published online October 10, doi: /jamainternmed

25 Stool Management C. difficile was recoverable from air sampled at heights up to 25 cm above the toilet seat Contamination could permit transmission of C. difficile from asymptomatic carriers, and thus explain some CDI cases where no apparent linked CDI cases are found. Lidless conventional toilets increase the risk of C. difficile environmental contamination, and we suggest that their use is discouraged, particularly in settings where CDI is common Best EL, Fawley WN, Parnell P, Wilcox MH. The potential for airborne dispersal of Clostridium difficile from symptomatic patients. Clin Infect Dis 2010;50:

26 Stakeholder in C.difficile ManagementMultiple Players Stakeholder in C.difficile Management Lab EVS IPAC Transport staff ASP Pharmacy Epi Quality Team Clinical Staff In cases when you have to use sporicidal disinfectants, is there ever a delay initiating switch to sporicidal products from non sporicidal?—30%--YES1 Are there ever gaps that lead to failure to use a sporicidal agent for Cdiff patients —40%--Yes/Sometimes1 1) Becker's Webinar Registration Survey Results List Lab, Evs, Leadership, IPAC, Transport Staff, Ipac, ASP, Pharmacy, Epi, Nursing, Clinical Staff, Quality Improvement

27 Asymptomatic CarriageColonized no symptoms C Diff exposure & acquisition Antimicrobials Admitted to healthcare facility Infected Symptomatic Current guidance suggests isolation should continue until 48 h after diarrhea resolution -our data show that the potential for transmission persisted for up to 8 wk1 Outbreaks have been linked to asymptomatic patients2 1/3 of C.difficile transmissions arise from asymptomatic carriers and there is an severe underestimation of their role 3 45% of C.difficile cases are genetically unrelated3 Difference between colonized and infected (both will test positive, symptoms, ) Colonization rates increased with hospitalizations Interestingly individual colonized with c diff over longer periods of time appear to have decreased rather than increased risk for development of CDI Guerrero, D.M., et al., Asymptomatic carriage of toxigenic Clostridium difficile by hospitalized patients. J Hosp Infect, (2): p Walker AS, Eyre DW, Wyllie DH, Dingle KE, Harding RM, O'Connor L, et al. (2012) Characterisation of Clostridium difficile Hospital Ward–Based Transmission Using Extensive Epidemiological Data and Molecular Typing. PLoS Med 9(2): e doi: /journal.pmed Eyre, D.W., et al., Diverse sources of C. difficile infection identified on whole-genome sequencing. N Engl J Med, (13): p

28 Diagnosis Challenges Microbiology Testing

29 C. Difficile Lab Diagnosis ChallengesAn electronic search for literature concerning the laboratory diagnosis of CDI was performed. Studies evaluating a commercial laboratory test compared to a reference test were also included in a meta-analysis. The commercial tests that were evaluated included enzyme immunoassays (EIAs) detecting glutamate dehydrogenase, EIAs detecting toxins A and B and nucleic acid amplification tests. Recommendations were formulated by an executive committee, and the strength of recommendations and quality of evidence were graded using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system. No single commercial test can be used as a stand-alone test for diagnosing CDI. Therefore, the use of a two-step algorithm is recommended. Crobach MJ, Dekkers OM, Wilcox MH, Kuijper EJ. European Society of Clinical Microbiology and Infectious Diseases (ESCMID): data review and recommendations for diagnosing Clostridium difficile-infection (CDI). Clin Microbiol Infect 2009;15:

30 Cleaning OpportunitiesC.difficile was recovered on 49% of sites in rooms occupied by patients with CDI and on 29% of sites in rooms occupied by asymptomatic carriers.1,2 Computer touch screens can be potential reservoirs of opportunistic pathogens in hospitals cleaning instructions such as Mild Soap , Lint free cloth and water current increase risk of infection transmission4 Non Sporicidal agents have been shown to promote sporulation of hyper virulent strains like NAP12 Published literature has shown that as levels of environmental contamination increase, so does the prevalence of C. difficile hand carriage among health care workers3 Guerreiro, Isabelle et al Using expert process to ombat Clostridium difficile infections American Journal of Infection Control , Volume 0 , Issue 0 Wilcox MH, Fawley WN. Hospital disinfectants and spore formation by Clostridium difficile. Lancet 2000;356:1324 Underwood S, Stephenson K, Fawley WN, et al. Program and abstracts of the 45th Annual Interscience Conference on Antimicrobials and Chemotherapy (Washington, DC). 2005. Effects of hospital cleaning agents on spore formation by North American and UK outbreak Clostridium difficile (CD) strains [abstract LB ]. Hirsch, Elizabeth B., et al. "Surface microbiology of the iPad tablet computer and the potential to serve as a fomite in both inpatient practice settings as well as outside of the hospital environment." PloS one 9.10 (2014): e

31 Recap of Challenges in InpatientAsymptomatic Carriers Non sporicidal agents C.difficile Tenacity Toilet Lids Missed Lab Diagnosis Poor Hand Hygiene Compliance Missed Case Identification Touch Screens –Lint Free

32 Should We Screen Everyone

33 Where is the Break- Down…C.difficile Screening on Admission Isolated 63% Reduction HACDI Cases 5% of all patients swabbed were noted to be carriers Not Isolated Overall, 7599 of 8218 (92.5%) eligible patients were screened, among whom 368 (4.8%) were identified as C difficile carriers. During the intervention, 38 patients (3.0 per 10 000 patient-days) developed an HA-CDI compared with 416 patients (6.9 per 10 000 patient-days) during the preintervention control period (P < .001). There was no immediate change in the level of HA-CDIs on implementation (P = .92), but there was a significant decrease in trend over time of 7% per 4-week period (rate ratio, 0.93; 95% CI, per period; P = .02). ARIMA modeling also detected a significant effect of the intervention, represented by a gradual progressive decrease in the HA-CDI time series by an overall magnitude of 7.2 HA-CDIs per 10 000 patient-days. We estimated that the intervention had prevented 63 of the 101 (62.4%) expected cases. By contrast, no significant decrease in HA-CDI rates occurred in the control groups. Conclusions and Relevance  Detecting and isolating C difficile carriers was associated with a significant decrease in the incidence of HA-CDI. If confirmed in subsequent studies, this strategy could help prevent HA-CDI. Longtin Y, Paquet-Bolduc B, Gilca R, et al. Effect of Detecting and Isolating Clostridium difficile Carriers at Hospital Admission on the Incidence of C difficile Infections: A Quasi-Experimental Controlled Study. JAMA Intern Med. 2016;176(6): doi: /jamainternmed

34 Use Sporicidal Disinfectants on all CasesC.difficile Status Unknown Asymptomatic C.difficile C.difficile Positive on treatment C.difficile Positive

35 SPORICIDES 1) What are they 2)Disadvantages 3)Proof Of Concept of Universal Sporicidal Use

36 Disinfection and C. difficileSpore Form Non Spore Form A current list of EPA-approved disinfectants with sporicidal claim is available at: E.P.A Registered Sporicide Sodium Hypochlorite Peracetic/Hydrogen Peroxide Combination Non Touch Ultraviolet Light Devices Fogging Systems Spray Systems Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. Annex C – Testing, Surveillance and Management of Clostridium difficile. Annexed to: Routine Practices and Additional Precautions in All Health Care Settings. Toronto, ON: Queen’s Printer for Ontario; 2013

37 PROPERTIES OF AN IDEAL DISINFECTANT11) Rutala, Weber. Infect Control Hosp Epidemiol. 2014;35:

38 Arguments For Sporicidal UseEfficacy1 Guidance Documents1 Endemic C.difficile Rates1 Asymptomatic Colonization or Carriers Error Reduction/Human Factors/Swiss Cheese Hyper Virulent Strains Proactive versus Reactive Strategy 1Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. Annex C – Testing, Surveillance and Management of Clostridium difficile. Annexed to: Routine Practices and Additional Precautions in All Health Care Settings. Toronto, ON: Queen’s Printer for Ontario; 2013

39 Sporicidal Agents Get Better C.difficile Log ReductionMeticulous cleaning with any cleaner/disinfectant reduces the number of spores in the environment1 However, greater reduction and inactivation of spores is achieved when a sporicidal agent is used1 Removal of spores influenced by contact time (duration of wetness) and texture of surface being cleaned2 Technique Reduction in Spores Dry Time Wiping with any disinfectant > 2.9 log10 2-6 minutes Spraying (no wipe) with sporicide 3.4 log10 28-40 minutes Wiping with sporicide 3.9 log10 1. Rutala et al. Infect Control Hosp Epidemiol 2012; 33(12): 2. Gonzalez et al. Am J Infect Control 2015; 43:

40 Reducing CDI Using a Sporicidal Wipe for CleaningBefore/after study in two high-risk medical wards Intervention: Daily and terminal cleaning of all rooms with ATP monitoring before/after (similar pass rate) Quaternary ammonium compound before Hypochlorite wipes with 10 minute contact time after Results: 24.2 to 3.6 cases per 10,000 patient-days (85% decline) Orenstein et al. Infect Control Hosp Epidemiol 2011; 32:

41 Challenges to using sporicide surface compatibilty(degradation to equipment, residue, color safe, ), guidance documents, Occ Concerns, Cost, odor, Toxicity

42 Survey Results

43 Concerns against Sporicidal UseSafety concerns from patients and staff Damage to equipment and the environment. Damage to patient equipment Cost Limited indications as per local guidance document or facility policy Dubberke, E.R., Carling, P., Carrico, R., Donskey, C.J., Loo, V.G., McDonald, L.C., Maragakis, L.L., Sandora, T.J., Weber, D.J., Yokoe, D.S. and Gerding, D.N. (2016) ‘Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update’, Infection Control & Hospital Epidemiology, 35(S2), pp. S48–S65. doi: /S X

44 Occupational Health ConcernsHealthcare Occupational clinical symptoms(Dermatitis, respiratory symptoms e.g. asthma) as a result of chemical exposures, including low-level disinfectants, are exceedingly rare. The scientific evidence does not support that the use of low-level disinfectants by HCP is an important risk for the development of asthma or contact dermatitis OSHA has not recommended specific exposure limits for peracetic acid. Weber, D. J., Consoli, S. A., & Rutala, W. A. (2016). Occupational health risks associated with the use of germicides in health care. AJIC: American Journal of Infection Control, 44(Supplement), e85-e89. doi: /j.ajic

45 Despite these challenges benefits outweigh the disadvantages show wins

46 Proof of concept for Facility Wide DisinfectionBleach wipes can be used for both daily and discharge cleaning of patient rooms with little impact on patient or employee satisfaction. Involving patients in Process Improvement decisions assured staff-driven improvements are tolerated and accepted by patients Mayo CLinic 85% decrease in CDI facility wide Aronhalt, Kimberly C., et al. "Patient and Environmental Service Employee Satisfaction of using Germicidal Bleach Wipes for Patient Room Cleaning." Journal for Healthcare Quality 35.6 (2013): 30-6.

47 Proof of concept for Facility Wide DisinfectionEnvironmental Cleaning Approach: Standardize cleaning using a hypochlorite based disinfectant for both routine and terminal cleaning areas Significant reduction in hospital-onset CDI rates in participating New York metropolitan regional hospitals. Mayo CLinic $ Million- In Estimated Cost Savings with reduced HAI rates Koll BS, Ruiz RE, Calfee DP, Jalon HS, Stricof RL, Adams A, et al. Prevention of hospital-onset Clostridium difficile infection in the New York metropolitan region using a collaborative intervention model. J Healthc Qual 2014;36:35- 45

48 Non Touch Systems

49 Non Touch Systems Work The major advantages of both systems are the ability to consistently decontaminate hospital room surfaces. Both systems are residual free. The major disadvantage of both systems is that they may only be used for terminal disinfection. Neither system will physically clean a room (eg, remove dust or stains), hence room cleaning must precede disinfection. David J. Weber William A. Rutala Deverick J. Anderson Luke F. Chen Emily E. Sickbert-Bennett John M. Boyce Effectiveness of ultraviolet devices and hydrogen peroxide systems for terminal room decontamination: Focus on clinical trials Authors Source Information May 2016, Volume44(Issue Supplement) Page p.e77To-e84

50 Call to action Guidance Documents to catch up-Recommendations, Role AS Carriers Tougher Equipment Gentler Disinfectants Engineered Sporicdial applications that work all the time Conclusions

51 Recap of Challenges in InpatientAsymptomatic Carriers Non sporicidal agents C.difficile Tenacity Toilets & stool Aerosol Missed Lab Diagnosis Poor Hand Hygiene Compliance Missed Case Identification Touch Screens –Lint Free Successful translation of evidence-based practice guidelines requires that the “work system” as well as the behavioral patterns of the providers are addressed 1 Hebden, J. N., & Murphy, C. (2013). Minimizing ambiguity to promote the translation of evidence-based practice guidelines to reduce health care-associated infections. AJIC: American Journal of Infection Control, 41(1), doi: /j.ajic

52 Guidance Document Era Guidance Documents Under review 1935 to 20072008 to 2016 October

53 Guidance Document ReviewThere is a considerable need for high quality CPGs because they are often used for patient care. Future guidelines of CDI prevention should be developed using validated methodological standards. Furthermore, there is a need for higher quality primary research on this topic, to better inform recommendations. Lytvyn, L., Mertz, D., Sadeghirad, B., Alaklobi, F., Selva, A., Alonso-Coello, P. and Johnston, B.C. (2016) ‘Prevention of Clostridium difficile Infection: A Systematic Survey of Clinical Practice Guidelines’, Infection Control & Hospital Epidemiology, 37(8), pp. 901–908. doi: /ice

54 C.difficile Interventions RecommendationsHorizontal/Universal (All the time) Vertical/Targeted (Sometimes) Hand Hygiene X Antimicrobial Stewardship Environmental Disinfection with Sporicide Goto M et al. The effect of a nationwide infection control program expansion on hospital-onset gram-negative rod bacteremia in 130 Veterans Health Administration medical centers: An interrupted time-series analysis. Clin Infect Dis 2016 Sep 1; 63:642. (http://dx.doi.org/ /cid/ciw423)

55 Error Reduction and Safety by Sporicide Everywherehttps://www.cdc.gov/niosh/topics/hierarchy/

56 Hospital Cleaning Staff Member QuestionC.difficile Outbreak Sporicidal introduction Outbreak resolved Remove sporicide

57 IP and EVS Wish List Ideal disinfectants Updated Guidance DocumentsBetter surface compatibility, Faster Contact times, minimal Occupational Health Concerns Updated Guidance Documents Reflecting current changes, Revisions with new data and Considerations of complexity of C.difficile transmission pathways Improved Surfaces and Equipment Tougher surfaces, special covers, procurement of equipment that’s hardy,

58 Summary.. Multiple sources of CDI--Asymptomatic carriage is relevantHuman Factors is an important consideration in hospital disinfection Better innovation on disinfectants needed Guidance documents are up for renewal Universal Sporicidal Disinfectant use is an effective C.difficile control strategy

59 References Aronhalt, Kimberly C., et al. "Patient and Environmental Service Employee Satisfaction of using Germicidal Bleach Wipes for Patient Room Cleaning." Journal for Healthcare Quality 35.6 (2013): Web. 2 Oct. 2016 Department of Health (2012) Updated Guidance on the Diagnosis and reporting of Clostridium Difficile Eyre, D.W., et al., Diverse sources of C. difficile infection identified on whole-genome sequencing. N Engl J Med, (13): p Guerrero, D.M., et al., Asymptomatic carriage of toxigenic Clostridium difficile by hospitalized patients. J Hosp Infect, (2): p Koll BS, Ruiz RE, Calfee DP, Jalon HS, Stricof RL, Adams A, et al. Prevention of hospital-onset Clostridium difficile infection in the New York metropolitan region using a collaborative intervention model. J Healthc Qual 2014;36:35- 45 US EPA, Guidance for the Efficacy Evaluation of Products with Sporicidal Claims Against Clostridium difficile (June 2014). https://www.epa.gov/pesticide-registration/guidance-efficacy-evaluation-products-sporicidal-claims-against-clostridium Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. Annex C – Testing, Surveillance and Management of Clostridium difficile. Annexed to: Routine Practices and Additional Precautions in All Health Care Settings. Toronto, ON: Queen’s Printer for Ontario; 2013 Mitchell BG, Dancer SJ, Anderson A, Dehn E. Risk of organism acquisition from prior room occupants: a systematic review and meta-analysis. J Hosp Infect 2015;91:211‒217. Reveles, K. R., Lee, G. C., Boyd, N. K., & Frei, C. R. (2014). The rise in Clostridium difficile infection incidence among hospitalized adults in the United States: AJIC: American Journal of Infection Control, 10(42),

60 References Lund, B. M., & Peck, M. W. (2015). A Possible Route for Foodborne Transmission of Clostridium difficile? Foodborne Pathogens and Disease, 12(3), 177–182. McDonald LC, Coignard B, Dubberke E, et al. Ad Hoc CDAD Surveillance Working Group. Recommendations for surveillance of Clostridium difficile-associated disease. Infect Control Hosp Epidemiol 2007; 28:140-5 SHEA/IDSA Compendium of Recommendations. Infect Control Hosp Epidemiol 2008;29:S81–S92. 5 Nagaraja, Aarathi et al. Clostridium difficile infections before and during use of ultraviolet disinfection American Journal of Infection Control , Volume 43 , Issue 9 , Reveles, K. R., Lee, G. C., Boyd, N. K. & Frel, C. R. (2014). The rise in Clostridium difficile Infection incidence among hospitalized adults in the United States: American Journal of Infection Control, 42, David J. Weber William A. Rutala Deverick J. Anderson Luke F. Chen Emily E. Sickbert-Bennett John M. Boyce Effectiveness of ultraviolet devices and hydrogen peroxide systems for terminal room decontamination: Focus on clinical trials Authors Source Information May 2016, Volume44(Issue Supplement) Page p.e77To-e84 Weber, D. J., Consoli, S. A., & Rutala, W. A. (2016). Occupational health risks associated with the use of germicides in health care. AJIC: American Journal of Infection Control, 44(Supplement), e85-e89. doi: /j.ajic

61 Becker Pre Registration SurveyDo you use sporicidal agents in all declared Cdiff outbreaks in your facility? No 5.62% Not Applicable 25.53% Yes 68.85% In cases when you have to use sporicidal disinfectants, is there ever a delay initiating switch to sporicidal products from non sporicidal? All the time 1.87% Never 37.00% Not applicable' 27.87% Sometimes 28.10% Are there ever gaps that lead to failure to use a sporicidal agent for Cdiff patients 26.00% Not applicable 31.85% 9.60% Why do you dislike using sporicidal disinfectant Cost 3.51% Damage to Equiptment 30.21% Other 21.08% Residue 7.26% Smell 18.27% They Don't Work 1.64%

62 Thank You