Practice No.
444
Version 1
Reference: 10/06 HCC AS 31/00
HCC AS 20/06
Page 1 of 3 New
February 2009
Marsden Manual of Clinical
Nursing Procedures
1. WHAT IS C. DIFFICILE AND IS IT IMPORTANT IN THE COMMUNITY?
1.1
1.2
1.3
1.4
1.5
1.6
C.difficile (c. diff) is an abbreviation of Clostridium difficile, the major cause of antibioticassociated diarrhoea and colitis, an infection of the intestines. It is part of the Clostridium family of bacteria, which includes bacteria that cause tetanus, botulism, and gas gangrene. It is an anaerobic bacterium (i.e. it does not grow in the presence of oxygen) and produces spores that can survive for a long time in the environment. ‘Difficile’ because when initially identified it was very difficult to culture in the laboratory.
Although C. difficile was first described in the 1930s, it was not identified as the cause of diarrhoea and colitis following antibiotic therapy until the late 1970s. Lab tests have identified over 100 different types of C.difficile
. Since January 2004, C.difficile has been part of the mandatory surveillance programme for healthcare associated infections. All residential homes should maintain a log of cases and more than two cases must be reported to the Health
Protection Agency.
The usual habitat of C. difficile is the large intestine, where there is very little oxygen. It can be found in low numbers in a small proportion (less than 5%) of the healthy adult population, where it is kept in check by the normal, 'good' bacterial population of the intestine. It is common in the intestines of babies and infants, but does not cause disease in immature bodies because its toxins (poisons) do not damage their immature intestinal cells.
The infection is confirmed by diarrhoeal faeces being tested for the presence of the C. difficile toxins. This is the main diagnostic test and gives a result within a few hours. The most prevalent type of C. difficile identified in the UK in March 2008 was Type 027 which produces much more of the toxins than most other types because a mutation has knocked out the gene that normally restricts toxin production. It causes a greater proportion of severe disease and appears to have a higher mortality. It also seems to be very capable of spreading between individuals. 1
C. difficile can cause diarrhoea, ranging from a mild disturbance to a very severe illness with ulceration and bleeding from the colon (colitis) and, at worst, perforation of the intestine leading to peritonitis. Generally, it is only able to do this when the normal, healthy intestinal bacteria have been killed by antibiotics. When C difficile is not held back by the normal bacteria, it multiplies in the intestine and produces two toxins (A and B) that damage the cells lining the intestine. The result is diarrhoea. It most commonly, but not exclusively, affects elderly individuals with other serious underlying diseases and can be fatal.
Because of the way in which C.difficile
develops, the people who are most at risk of infection are those who have been treated with broad spectrum antibiotics (those that affect a wide range of bacteria, including intestinal bacteria). Although some people can be healthy carriers
1 Brazier J S Raybould, R Patel, B. Duckworth, G. Pearson, A., Charlett, A., Duerden, B I 4 , the HPA Regional Microbiology
Network 2 DISTRIBUTION AND ANTIMICROBIAL SUSCEPTIBILITY PATTERNS OF CLOSTRIDIUM DIFFICILE PCR
RIBOTYPES IN ENGLISH HOSPITALS , 2007-08 Eurosurveillance, Volume 13 , Issue 41, 09 October 2008

1.7 of C.difficile
, in most cases the disease develops after cross-infection from another infected person, either through direct person to person contact, via healthcare staff, or in a contaminated environment. This is why most infections occur in hospitals and nursing homes, but they can also occur in primary care settings.
A individuals who has C.difficile diarrhoea excretes large numbers of the spores in their liquid faeces. These can contaminate the general environment around the individual ’s bed (including surfaces, keypads, equipment), the toilet areas, sluices, commodes, bedpan washers, etc.
The spores can survive for a long time and be a source of hand-to-mouth infection for others.
If these others have also been given antibiotics, they are at risk of C. difficile infection .
2.
2.1
2.2
2.3
ADMISSION OF A C. DIFFICILE CARRIER TO A RESIDENTIAL ESTABLISHMENT
If it is known that a potential or new resident is a C. difficile carrier the following people should be informed :

The Registered Unit Manager

The Service Manager

The Member of the management team with responsibility for infection control
 The individual’s General Practitioner should be consulted to determine if any other relevant persons should be informed.
Individuals with active C. difficile infections should not be admitted to residential homes until they are clear of the infection.
Individuals with active C.difficile
will not be accepted into the care of the Community Response
Team until they are clear of the infection.
3. CARE OF A SERVICE USER WITH C. DIFFICILE
3.1 All work bases should have a designated member of staff to deal with infection control matters and to ensure that the manager’s responsibilities to provide adequate arrangements for prevention of infections in the home, under the Care Homes Regulations 2001, are fulfilled.
3.2 If C.difficile infection is suspected or an individual on antibiotic therapy develops diarrhoea, the
General Practitioner should be informed and a sample of the diarrhoea should be sent for analysis immediately.
3.3 Staff should practice good hygiene at all times.
Hands should be washed thoroughly with water and bactericidal hand wash, following any physical contact with an infected individual or any items within their vicinity. Do not rely solely on alcohol gel as this does not kill C.difficile spores. The efficiency with which the spores of this infection, which are able to live for long periods in the environment, are able to spread and create cross infections, cannot be overstated.
3.4 Infected residents should be isolated and all staff having contact with them must wear protective clothing, (gloves and aprons). This is particularly important when dealing with bedpans, commodes or cleaning toilets. Where possible it may be appropriate to designate specific staff to undertake the care of an individual with C.difficile
, as healthy individuals, not taking antibiotic therapy are at little risk of infection. This should further minimise the risk of cross infection.
3.5 Care should be taken to provide the infected individual with information regarding the reason for isolation, to avoid creating unnecessary additional stress. Relatives and friends should also receive information and instruction in hygiene precautions and the need to wear protective clothing, to avoid carrying the infection into the community.

3.6 Clear instructions should be posted outside of the resident’s, explaining the need to avoid non essential visitors and how to use the protective clothing. (see guideline 406)
3.6 Environments should be kept clean at all times. Where there are cases of C. difficile infection, all surfaces should be cleaned with a diluted bleach solution as per official guidance for cleaning and following a COSHH risk assessment. When the use of bleach solutions is withdrawn, an alternative sanitizer will be issued. From that time, all surfaces will be cleaned with TECare. This product comes in two parts, a spray bottle of solution and a pack of cleaning wipes. It is effective against all known infections and is already in use at ICES as part of their decontamination process for re-cycled items.
3.7 Where en suite facilities are not available a separate toilet and bathroom should be reserved for the infected person. Communal facilities should not be used in cases of C. difficile infection.
3.8 All bedding and clothing should be collected in a hot water soluble laundry bag and placed in a red laundry bag to indicate it is contaminated linen. At the time of writing, information suggests the following :-

Wash at 40

C using a bleach-based laundry product.
Or

Wash at 60

C or above (using any laundry product, however, this will not necessarily guarantee that 100% of the spores will be destroyed. It is advisable to wash bedding
3.9 and clothing at as high a temperature as possible.
Where possible single use food containers and utensils should be used to enable them to be disposed of as hazardous waste.
3.10 All other materials should be collected in a yellow hazardous waste bag and disposed of by incineration.
3.11 Whilst all of these precautions are of some effect in themselves, they are totally ineffective without effective hand washing by all staff and visitors.
3.12 When the individual has been symptom free for 48 hours, it may be assumed that the infection has been cleared. However, this does not mean that the environment is clear of spores and the room and contents should be thoroughly deep cleaned as directed in the cleaning manual and guideline 406. All disposable items must be incinerated as hazardous waste.
3.13 As a basic rule for management of this infection :-

S = suspect




I = isolate
G = gloves / aprons
H = hand washing
T = test
Ref:
Online http://www.dh.gov.uk/en/Publichealth/Healthprotection/Healthcareacquiredinfection/Healthcareacquiredg eneralinformation/DH_4115800 @ 4/2/2009
Online http://www.clean-safe-care.nhs.uk
@ 4/2/2009
Online http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4115
883 @ 5/2/2009