Clinical Considerations for Patients with Active Clostridium difficile Infection
Submitted by Donna Boyer, RN, WCC
Written by Donna Boyer,RN,WCC and James McShane,BA,RN.
There are many patients with active Clostridium difficile (C. difficile) infection who require a low air surface as part of their plan of care for wound management.
Low air loss surfaces are an important intervention in the prevention and treatment of pressure ulcers. These support surfaces are utilized in acute care, sub-acute rehabilitation and long term care settings.1,2,3
At the core of low air loss (LAL) technology is a relatively high volume, low pressure continuous air blower. The mattress surface contains small holes that allow air from the blower to escape at a controlled rate. The rate of air flow can be varied to provide individualized pressure re-distribution. The majority of LAL surfaces generate greater than 100 liters of air flow per minute.
Most LAL surfaces are made with a vapor permeable cover that allows for the diffusion of moisture vapor into the airflow and preventing moisture from contacting the mattress. The loose-fitting, air tight and vapor-permeable cover does not allow free airflow to contact the skin, which could ultimately dehydrate the user. The moisture vapor from the patient passes through the top portion of the cover. Beneath the surface, the vapor interacts with the air flow from the system, therefore reducing the humidity beneath the patient, which evaporates the excess moisture.
However, certain low air loss surfaces do not utilize any type of vapor-permeable cover or use a cover that allows air to freely flow through it. Since air is allowed to interface directly with the patient's body there are several clinical issues to consider. This constant air flow can potentially cause drying of the skin, desiccation of wounds and dressings, dehydration and vasoconstriction; all of which can lead to delayed wound healing. 4,5
Clinicians should be aware that this system has the potential of transmitting particles, such as airborne pathogens, into the air. The widespread dissemination of C. difficile spores in the air, on the environmental surfaces of these patients’ rooms as well as the staff members who enter the room is of particular concern.6
Researchers found from the surfaces around 9 patients with C. difficile infection that 60% had both air and surface environments that were positive for C. difficile. The report states that isolation of infected patients would help reduce the spread of C. difficile to other patients nearby but with airflow, movement by staff and patients, along with air circulation from vents, it could disseminate the c-diff spores into the air even further. The study concluded, “Molecular characterization confirmed an epidemiological link between airborne dispersal, environmental contamination, and C. difficile cases.” 6 There was no mention that any of these patients were on a LAL surface or how the use of LAL may increase the amount of air and surface contamination. Is it possible that C. difficile spores are disseminated at a higher rate and across a greater distance when a patient is on a LAL surface? We propose that this should be a consideration when deciding on the utilization of a LAL surface. As with all care interventions, the risks need to be weighed with the benefits.
It is well accepted that appropriate cleaning of environmental surfaces is vital to control the transmission of C difficile. Of utmost importance is the frequency of cleaning high touch surfaces and the utilization of a sporicidal agent. There are many cleaning agents that are effective in killing vegetative forms of C. difficile, but only chlorine-based disinfectants and high-concentration, vaporized hydrogen peroxide are sporicidal.7
Each manufacturer of a low air loss mattress has specific recommendations for the cleaning of the cover surfaces. Several of the LAL manufacturer’s user manuals indicate to wipe the cover surface with a dilute detergent solution, quaternary cleaner disinfectant or other germicidal detergent solution. Some manufacturer’s have a specific instructions to not use chlorine bleach cleansing products because it may cause damage to the fabric coating of the LAL surface.
Is enhanced environmental cleaning warranted for these patients?
We are suggesting that additional research is warranted to determine the extent of increased environmental spore contamination from a patient with active C. difficile infection on a LAL surface.
- Inman KJ, Sibbald WJ, Rutledge FS, et al. Clinical utility and cost effectiveness of an air suspension bed in the prevention of pressure ulcers. JAMA. 1993; 269:1139–1143.
- Ferrell BA, Osterweil D, Christenson P. A randomized trial of low-air-loss beds for treatment of pressure ulcers. JAMA. 1993; 269(4):494-7.
- Gibbons, Shanks, Kleinhelter, Jones. Eliminating Facility-Acquired Pressure Ulcers at Ascension Health,