Control of Clostridium difficile

is a sporeforming, gram-positive anaerobic bacillus
that produces two exotoxins: toxin A and
toxin B. These cause colon dysfunction and
cell death.
infection may manifest as
Mild diarrhea
Pseudomembranous colitis (PMC)
Toxic megacolon
Perforations of the colon
Gram stain of C. difficile
From Public Health Image Library
Watery diarrhea, often foul-smelling
Loss of appetite
Abdominal pain/tenderness
is shed in feces, even after symptoms
Any surface, device, or material (e.g., toilets,
bathing tubs, and electronic rectal thermometers)
that becomes contaminated with feces may serve
as a reservoir for the spores.
spores can survive for long
periods (months to years) on surfaces.
Spores are transferred to patients primarily by the
hands of healthcare personnel who have touched a
contaminated surface or item.
Increasing incidence and severity
Recent outbreaks of severe disease caused by
epidemic strain of
(BI/NAP1/027)with increased virulence,
antibiotic resistance
Persons at greatest risk
More disease reported in “low-risk” persons
UTMB has treated patients with the new
epidemic strain
Advanced age
Severe underlying disease
GI surgery or manipulation
◦ Healthy persons in community, peripartum women
Historically uncommon, now epidemic
More resistant to fluoroquinolones
Carries extra toxin known as binary toxin
There is an 18-base pair deletion in the
regulatory gene (tcdC) responsible for toxin
production. This strain produces 16 times as
much toxin A and 23 times as much toxin B
in vitro.
More severe disease, higher mortality, more
frequent relapses
patients with watery diarrhea not explained by
non-infectious conditions.
For patients isolated on basis of symptoms:
isolation can be discontinued if test is negative
If the laboratory test for
is positive,
patient must remain isolated for duration of
If a test is positive, do not order a later test as a
“test of cure” or to discontinue isolation.
You will be wearing a gown and gloves to
enter the room.
If you are performing a procedure that may
splatter respiratory secretions to your face,
you will need facial protection-a face shield
or goggles and a mask.
Gown first
Mask or respirator
Goggles or face shield
Combination of PPE is not the same for all
types of precautions. Extended Contact
Precautions requires the use of a gown and
Source: CDC
Note: clean hands before donning PPE.
Select appropriate type
and size
Opening is in the back
Secure at neck and waist
If gown is too small, use
two gowns
◦ Gown 1 ties in front
◦ Gown 2 ties in back
Source: CDC
Don gloves last
Select proper type and size
Insert hands into gloves
Extend gloves over cuffs of isolation gown
 Keep
gloved hands away from
 Avoid touching or adjusting other
 Remove gloves if they become
torn; perform hand hygiene
before donning new gloves
 Limit surfaces and items touched.
Source: CDC
Contaminated-outside front
◦ Areas of PPE that have or are likely to have contact
with body sites, materials, or environmental sources
where the infectious organism may reside
Clean-inside of gown, outside back of gown,
ties on head (mask) and back (gown)
◦ Areas of PPE that are not likely to have been in
contact with the infectious organism
Source: CDC
Face shield or goggles (if worn).
Avoid touching front of goggles or
shield to remove.
Mask or respirator (if worn). Avoid
touching the front of the maskuse ties or elastic to remove.
Source: CDC
Grab outside edge near wrist
Peel away from hand, turning
first glove inside-out.
Hold in opposite gloved hand.
Slide ungloved finger
under wrist of
remaining glove.
Peel off from inside,
creating a bag for both
Clean hands
•Unfasten ties
•Peel gown away from neck and shoulder
•Turn contaminated outside away from inside
•Fold or roll into a bundle
Source CDC
Clean your hands after PPE removal
If your hands become visibly contaminated
during the process of PPE removal, wash
hands before to continuing to remove PPE.
For Extended Contact Precautions:
◦ You may use alcohol hand sanitizer BEFORE patient
◦ You must use CHG soap and water AFTER contact
For all other types of isolation, either hand
sanitizer or CHG soap is effective both before
and after patient contact.
Most hospital-grade disinfectants are not
effective against
If the surface can tolerate
hypochlorite) use a
, which can
be purchased pre-diluted or made fresh (1
part bleach, 9 parts water).
If the surface does not tolerate
thorough physical cleaning is necessary.
Because patients may be moved and their
equipment may accompany them, supervisors for
Environmental Services and Clinical Equipment
Services will be notified of new cases of
If you enter a room with equipment, you will see
If you are scheduling a patient for procedures/
tests off the unit or transferring the patient to
another unit, be sure to include information
about isolation during the scheduling process
and as a part of the handoff.
As a general rule, the room of patient in
will be
available as soon as Environmental Services
has finished cleaning and disinfecting the
In some cases, cultures will be taken before
and after the terminal clean as a quality
control measure. Healthcare Epidemiology
will coordinate with the appropriate
Environmental Services supervisor/staff
member. The room may be released as soon
as cultures are collected.