Clostridium Difficile Infectious Diarrhea

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Clostridium Difficile Infectious Diarrhea

• (CDI)
• Infection Prevention Learning Module
• Prepared by Infection Prevention and Control
  Services
• Vancouver Island Health Authority

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Infectious Diarrhea

• There are many pathogens responsible for causing
  diarrhea illness in humans. Of concern to health
  care facilities are
• Norovirus
• E coli 0157H7
• 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 !

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Clostridium Difficile

• Clostridium 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

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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

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Clostridium Difficile

• Symptoms 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.

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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))

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The risk of becoming colonized when in hospital
is higher than 25 - WHY?

• People are exposed to C. difficile Contaminated
  Environmental Surfaces/fomites

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People are exposed

• When
• 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

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Surveillance

• Incidence of CDAD infections has been on the
  rise in Canadian Acute Care facilities

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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

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Infection Reduction Strategies

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

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Reduction Strategies

• 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

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Reduction Strategies

• 2. Patient Placement
• Manage in a private room
• If no private room available, admit to
  semi-private and
• Patient/resident to use dedicated commode or
  toilet

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Reduction Strategies

• 3. 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)

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Reduction Strategies

• 4. 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.

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Reduction Strategies

• 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)

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Reduction Strategies

• 6.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 !)

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Reduction Strategies

• 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

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Patient Information Pamphlet
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Notification Records

• Notify person responsible for Infection Control
• Note any recent past admission to hospital,
  reason for this admission and type of antibiotic
• Transcribe relevant information and Infection
  Control precautions in Kardex
• Notify Most Responsible Physician (MRP) of
  clinical signs suspicions
• Notify any receiving or diagnostic department
  porters while diarrhea is present

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Treatment Patient Disposition

• Toxin
• Will require either Metronidazole or Vancomycin
  oral therapy
• Toxin
• 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

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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

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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 your
• feedback

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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