Clostridium Difficile Infectious Diarrhea

(CDI)Infection Prevention Learning Module Prepared by Infection Prevention and Control Services

Vancouver Island Health Authority

Infectious DiarrheaThere are many pathogens responsible for causing diarrhea illness in humans. Of concern to health care facilities are:

• Norovirus• E coli 0157:H7• Rotavirus• Clostridium difficile

The most contagious of these is Norovirus but the one most likely to cause serious and long lasting disease in hospitalized patients is C. difficile !

Clostridium DifficileClostridium difficile is a gram positive

spore forming bacillus that lives in the intestinal tract of healthy people

C. Difficile is also found in soil, water and animal feces

Clostridium Difficile• People can become colonized with C.

difficile and have no symptoms• Antibiotics given for other infection

destroy normal flora of the gut and allow over growth of this bacteria

• C. difficile produces toxin which attacks the lining of the intestinal tract leading to malabsorption of fluids and nutrients

Clostridium DifficileSymptoms of CDAD can include:

– watery diarrhea (more than 3 loose stools within a 24hr period)

– fever – loss of appetite – nausea – abdominal pain/tenderness

Diarrhea can lead to serious complications, including dehydration, loss of bowel tissue function, toxic megacolon and death.

Clostridium Difficile Associated Diarrhea

(CDAD)People at greatest risk for infection have:

– other illnesses and/or are elderly (eg. immunocompromised), or

– conditions requiring use of broad spectrum antibiotics (eg. Clindamycin, Cephalosporins, Fluoroquinolones (Gatifloxacin))

The risk of becoming colonized when in hospital is higher than

25% - WHY?

People are exposed to C. difficile Contaminated Environmental

Surfaces/fomites

People are exposedWhen:

– Patients not recognized as having CDI contaminate the environmental surfaces and

– These surfaces are inadequately cleaned and disinfection with a chemical capable of killing the spores

– Contaminated hands or clothing transfer the bacteria from ill patients to others within their care

SurveillanceIncidence of CDAD infections has been on the rise in Canadian Acute Care facilities C.difficile NRGH

7.8

10.29.8

7.1

0

2

4

6

8

10

12

1996-1997 2003-2004 2004-2005 2005-2006

Num

ber o

f cas

es/1

000

adm

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ons

National Average5.9

Surveillance• The average determined in the 1997

national surveillance was 5.9 cases per 1000 admissions

• Disease tracking across the country suggests that infections are on the rise. Outbreaks have occurred throughout VIHA in recent years

• Each case of CDAD represents 7 to 15 additional days of hospital stay

Infection Reduction Strategies

The following strategies have been shown to reduce the incidence of healthcare associated C. difficile colitis infections (CDI)

Reduction Strategies1. Early Recognition

• Suspect CDI in anyone who is admitted with or develops diarrhea of undetermined cause

• People can develop symptoms from 2 or 3 days to 1 month after exposure to the bacteria

Reduction Strategies2. Patient Placement• Manage in a private room • If no private room available, admit to semi-

private andPatient/resident to use dedicated commode or toilet

Reduction Strategies3. Laboratory Confirmation• Send first available stool for C. difficile toxin

studies using regular dry C & S container• Information on requisition – note any recent

antibiotic administered

Results: Toxin Positive = infection Toxin Negative with diarrhea + lab comment referred for Cytotoxin

studies = probable Infection Cytotoxin positive = Infection Toxin Negative & Cytotoxin negative = diarrhea NYD (continue

precautions until Diagnosis made or diarrhea resolved x 3 days)

Reduction Strategies4. Infection Control Interventions• Contact precautions signage on curtain OR at

foot of bed if in the semiprivate room• Place patient name on dedicated commode/

wheelchair• Wear gown and gloves for personal care• Wash hands with soap & water as alcohol

hand sanitizers do not penetrate the spore shell.

Reduction Strategies5. Environmental Management

• 2 STEP cleaning and disinfection• Housekeeping to use Accelerated Hydrogen Peroxide (AHP-

Virox) to disinfect bed space contact surfaces twice daily• Terminal disinfection with AHP twice upon discharge

• Minimal supplies and equipment are taken into room and dedicate these to the room/patient whenever possible

• All care & assessment equipment to be cleaned & disinfected by nurses when removed from room using Accelerated Hydrogen Peroxide (Virox)

Reduction Strategies6.Personal Care• Bed pans/commode pots must be cleaned and

disinfected • using the mechanical washer disinfector or • rinsed emptied toilet of private room or soiled utility

hopper if patient in semiprivate and them cleaned with AHP before reuse

• Change the wash basin daily and following peri care

• Handle soiled linen with care & directly into the tote (Do not throw soiled linen on floor !)

Reduction Strategies7. Patient & Visitor education

• Visitors who will provide personal care are to wear gown and gloves

• Instruction on hand-washing with soap & water• All patients confirmed to have CDI to receive a

copy of the “Patient Information Pamphlet”

Patients may be out of room for ambulation provided:

• They are not incontinent of stool presently• They wear a clean hospital issue robe• They wash their hands with soap and water prior to leaving

the room

Patient Information Pamphlet

CLOSTRIDIUM DIFFICILE (C. difficile)

Questions and Answers for Patients and

Family Members

PATIENT INFORMATION PAMPHLET

Notification & Records1. Notify person responsible for Infection Control

• Note any recent past admission to hospital, reason for this admission and type of antibiotic

2. Transcribe relevant information and Infection Control precautions in Kardex

3. Notify Most Responsible Physician (MRP) of clinical signs & suspicions

4. Notify any receiving or diagnostic department & porters while diarrhea is present

Treatment & Patient Disposition

Toxin +• Will require either Metronidazole or Vancomycin oral

therapyToxin –

• If diarrhea persists, on the third day resend specimen for C. diff Toxin and contact the physician. The physician may treat.

• If diarrhea resolves while you wait the three days then the patient may be colonized or has diarrhea provoked by another pathogen or physiological cause

Treatment & Patient Disposition

• Once appropriate treatment is started, patient can be cohorted with another CDAD patient also receiving treatment

• Infection Control measures can be discontinued once patient has no diarrhea for 3 days and stools are documented as being formed

• 2 STEP Terminal cleaning and disinfection of bed and room must be done before the precautions are discontinued

– This is accomplished by placing the patient on a clean stretcher or in a clean Broda Chair while the room is being cleaned

– Once this is done and all dedicated equipment is disinfected, then the precautions are discontinued… alert Infection Control that this has occurred

Feedback• Rates of CDI for your facility and ward

will be published and circulated quarterly or at defined intervals by Infection Prevention & Control

• We invite yourfeedback

CDAD REDUCTION STRATEGIESNRGH 2005/06

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1 2 3 4 5 6 7 8 9 10 11 12 13PERIOD FISCAL YEAR

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Target: 7.9 cases/1000 adm.

***

*Education Blitz Early recognition & intervention **Enhanced Cleaning

Virox & Bleach

*

*** Commodes

***National Average 1997 Prevalence 5.9

References• VIHA Infection Control Manual, pp. 2 – 14, 2 – 21

and 2 – 28• Shea Position Paper, Clostridium Difficile-

Associated Diarrhea & Colitis, Infection Control & Hospital Epidemiology, Vol 16, No. 8, pp. 459 – 477

• Infectious Diseases & Microbiology, December 2004, Vol 3, Issue 10

• http://www.phac-aspc.gc.ca/c-difficile/index.html

New references needed! - dc