Clostridium difficile
Management in Healthcare
Facilities
Gail Bennett, RN, MSN, CIC
1
Clostridium difficile
Infection (CDI) Objectives



Describe the changing epidemiology of Clostridium
difficile.
State two differences between acute care and long
term care in managing patients/residents with C.
difficile infection.
List three important strategies for preventing
transmission of C. difficile within healthcare facilities.
2
Primary References for
Presentation




APIC Guide to the Elimination of Clostridium difficile Infections
in Healthcare Settings
CDC, Clostridium difficile Infections Toolkit
Clinical Practice Guidelines for Clostridium difficile Infection in
Adults: 2010 Update by the Society for Healthcare Epidemiology
of America (SHEA) and the Infectious Diseases Society of
America (IDSA)
Note: these documents were developed prior to approval of EPA
registered disinfectants with kill claims against spores.
Therefore they still recommend use of a bleach product for
disinfection.
3
http://www.apic.org/Content/NavigationMenu/PracticeGuidance/
APICEliminationGuides/C.diff_Elimination_guide_logo.pdf
Clostridium difficile
Infection (CDI)





Antibiotic induced diarrhea
May cause approximately 30% of all cases of
healthcare associated diarrhea
Most common cause of acute infectious
diarrhea in nursing homes
Disease may be a nuisance or cause life
threatening pseudomembranous colitis
Increasing numbers of cases


Cases tripled in US hospitals from 2000 until 2005
Increasing disease severity and mortality
5
Background: Impact
• Hospital-acquired, hospitalonset: 165,000 cases, $1.3
billion in excess costs, and
9,000 deaths annually
• Hospital-acquired, postdischarge (up to 4 weeks):
50,000 cases, $0.3 billion in
excess costs, and 3,000
deaths annually
• Nursing home-onset: 263,000
cases, $2.2 billion in excess
costs, and 16,500 deaths
annually
Campbell et al. Infect Control Hosp Epidemiol. 2009:30:523-33.
Dubberke et al. Emerg Infect Dis. 2008;14:1031-8.
Dubberke et al. Clin Infect Dis. 2008;46:497-504.
Elixhauser et al. HCUP Statistical Brief #50. 2008.
Clostridium difficile
Colonization vs Infection


Colonization: presence of microorganisms without
tissue invasion or damage, therefore no signs or
symptoms
Colonization rate of C. difficile




About 10-25% of hospitalized patients
About 4-20% of long term care residents
Antibiotic therapy may disrupt normal colonic flora in
colonized patients and C. difficile proliferates, producing
toxins and symptomatic disease
Infection: presence of microorganisms with tissue
invasion and damage, therefore signs or symptoms
7
Background: Epidemiology
Risk Factors







Antimicrobial exposure
Acquisition of C. difficile
Advanced age
Underlying illness
Immunosuppression
Tube feeds
? Gastric acid suppression
Main modifiable risk
factors
8
Antibiotics most often
associated with
Clostridium difficile





Ampicillin
Amoxicillin
Cephalosporins
Clindamycin
Fluoroquinolones
9
New Toxic Strain



A new BINAP strain (B1/NAP1/027) is
circulating in the U.S., Europe, and
Canada that is more toxic
Produces large quantities of Toxins A
and B
More severe disease, higher mortality
10
Testing for Clostridium
difficile

Toxin testing


Stool culture


Quick – same day
Takes 48-96 hours
Testing for C. difficile should be done
on unformed (liquid) stool only unless
ileus is suspected
11
Testing for CDI by the
Lab - Summary






Culture and toxin neutralization not practical in most
laboratories (but gold standard)
EIA for toxins A and/or B is easy to do, but not very
sensitive (giving false negatives)
GDH tells you C. difficile is present, but doesn’t tell you if
it is toxin-producing
GDH+ plus EIA+ = toxigenic C. difficile, but still have
sensitivity problem related to EIA
PCR more sensitive and as specific, and it identifies A&B
toxin gene
Slide courtesy of: Alfred DeMaria, Public Health Department, Massachusetts
12
Treatments: Non-specific



Discontinue antibiotics if possible
Fluid and electrolyte replacement
Do not use antimotility agents
(e.g. opiates)
13
Specific Treatment for
Clostridium difficile




Metronidazole (Flagyl) 250 mg QID or 500 mg TID
for 10-14 days
Vancomycin 125 mg QID for 7-10 days - used if
resident does not respond to or cannot take Flagyl;
may be used first if severe disease
 No reports of Metronidazole or Vancomycin
resistance following treatment
New drug: Dificid (Fidaxomicin) – 200 mg bid for 10
days
Experimental fecal transplant (enemas)
14
Recurrent Clostridium
difficile infection
Rates of recurrence



20% after 1st episode
45% after 1st recurrence
65% after two or more recurrences
15
C. difficile in Acute vs.
Non-acute Settings
16
Tiered Approach to Managing
C. difficile


Includes a basic and an enhanced approach
A tiered approach is presented by

Association for Professionals in Infection Control and Epidemiology
(APIC)



Society for Healthcare Epidemiology of America (SHEA) and
Infectious Diseases Society of America( IDSA)



Elimination Guide for C. difficile
“Routine and heightened” approaches
Clinical Practice Guideline
No tiered approach but categorizes recommendations by “strength of
the recommendation”
Centers for Disease Control (CDC)



Recommendations to Prevent Spread of C. difficile
Toolkit
“Core and supplemental” approaches
17
Tiered Approach to Clostridium
difficile Infection (CDI)
Transmission Prevention


Basic/Core/Routine Approach: C. difficile transmission
prevention activities during routine infection prevention and
control responses
Enhanced/Supplemental/Heightened Approach: C. difficile
transmission prevention activities during heightened infection
prevention and control responses
 Evidence of



ongoing transmission of C. difficile
an increase in CDI rates and/or
evidence of change in the pathogenesis of CDI (increased
morbidity/mortality among CDI patients)
despite routine preventive measures

Note: many facilities choose to use the enhanced/supplemental
approach all of the time.
18
Why Would Enhanced
Strategies be Needed?

What we are currently doing is failing!!
19
Infection Prevention
Strategies





Hand hygiene
Contact precautions
Identification of cases
Environmental disinfection
Appropriate use of antibiotics
20
Hand Hygiene for Clostridium
difficile


For basic measures,
may use alcohol
handrubs with C.
difficile – OR use soap
and water
Perform hand hygiene



before contact with
the patient/resident
after removing gloves
after contact with the
environment
21
Hand Hygiene – Soap vs. Alcohol gel



Alcohol not effective in eradicating C. difficile
spores
However, one hospital study found that from
2000-2003, despite increasing use of alcohol
hand rub, there was no concomitant increase
in CDI rates
Discouraging alcohol gel use may undermine
overall hand hygiene program with untoward
consequences for HAIs in general
Boyce et al. Infect Control Hosp Epidemiol 2006;27:479-83.
CDC adds:


Because alcohol does not kill Clostridium
difficile spores, use of soap and water is more
efficacious than alcohol-based hand rubs.
However, early experimental data suggest
that, even using soap and water, the removal
of C. difficile spores is more challenging than
the removal or inactivation of other common
pathogens.
23
Hand Hygiene for Clostridium
difficile (continued)



For enhanced measures, do not
use alcohol handrubs with the CDI
patient/resident – use soap and
water
Washing away the spores may be
the optimal way to perform hand
hygiene when transmission of C.
difficile is occurring
Many facilities choose to use the
enhanced strategy all of the time
24
CDC Guideline for Hand Hygiene in
Healthcare Settings
(MMWR 2002, vol.51, no. RR16)
25
Conversation and
Questions



What has worked for you?
If you have alcohol handrubs mounted
in each room, how do you prevent its
use with C. diff?
Questions?
Infection Prevention
Strategies





Hand hygiene
Contact precautions
Identification of cases
Environmental disinfection
Appropriate use of antibiotics
27
Contact Precautions



Designed to reduce the risk of transmission of
microorganisms by direct or indirect contact
Direct contact
 skin-to-skin contact
 physical transfer (turning patients/residents,
bathing patients, other patient/resident care
activities)
Indirect contact
 Contaminated objects



Equipment
Linens
High touch surfaces
28
Contact Precautions
Patient or Resident placement

Private room preferred

2nd option: Cohorting with other patient/resident with C.
difficile


3rd option: In LTCFs, consider infectiousness and residentspecific risk factors to determine rooming with a low risk
roommate and socializing outside the room
 Consider:
 Clean
 Contained
 Cooperative
 Cognitive
Patient care equipment dedicated to single patient/resident if
possible. If not, disinfect equipment prior to leaving the room.
29
Tiered Approach for
Contact Precautions: Basic



Contact Precautions - gloves and gowns
to enter room or cubicle
Do not re-use gowns
Supplies outside the room
30
Tiered Approach for
Contact Precautions: Basic
(continued)

In semi-private
room, keep cubicle
curtain drawn to
limit movement
between cubicles
and as a reminder of
precautions
31
Contact Precautions:
Basic (Continued)



Use dedicated equipment; if not
feasible – decontaminate prior to use
on another patient/resident
Maintain adequate supplies for contact
precautions
Do not isolate asymptomatic carriers
32
Contact Precautions:
Basic (Continued)



May discontinue precautions when
diarrhea ceases (may consider 48 hours
without loose stool)
Do not do a toxin “for cure” once
diarrhea has stopped
Lab should not accept stool for toxin if
the stool is formed
33
From the Horse’s Mouth:
CDC’s Web Site
After treatment, repeat C. difficile testing is not
recommended if the patient’s symptoms have
resolved, as patients may remain colonized.
http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html
34
Tiered Approach for Contact
Precautions: Enhanced





May consider alternative signage to ensure staff
awareness
Evaluate current system for patient/resident
placement
Consider contact precautions for all patients/residents
that develop diarrhea until CDI is ruled out
Increase monitoring of isolation precautions and
hand hygiene
Extend use of contact precautions even when
diarrhea stops
35
Why contact precautions for
C. difficile??

Environmental contamination
36
The Inanimate Environment Can
Facilitate Transmission
X represents VRE culture positive sites
~ Contaminated surfaces increase cross-transmission ~
Abstract: The Risk of Hand and Glove Contamination after Contact with a
VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.
37
38
Signage for Precautions
39
Infection Prevention
Strategies





Hand hygiene
Contact precautions
Identification of cases
Environmental disinfection
Appropriate use of antibiotics
40
Identification of Cases
Colonization or asymptomatic fecal
carriage of C. difficile


May be common in healthcare facilities
Do we care?
C. difficile infection

Acute diarrhea
41
CDI Collaborative
Definition (see separate handout)




A case of C. difficile is defined as a case with the
symptom of diarrhea without other known etiology
The stool sample will yield a positive result for
laboratory assay for C. difficile toxin A and/or B
For this collaborative, CDI is limited to lab confirmed
cases
Will track healthcare associated CDI
42
CDI Collaborative Definition of
Healthcare Associated




This collaborative will track laboratory confirmed
cases of Health Care Facility C. difficile.
A laboratory confirmed case of C. difficile is defined
as a patient with diarrhea characterized by unformed
stool, without other known etiology, and associated
with a positive laboratory assay for C. difficile toxin A
and/or B on the stool.
Count each case of CDI only once
Episode of CDI that occurs eight weeks or less after the
onset of a previous episode, provided the symptoms
from the prior episode resolved.
43
Definition (continued)
HAI-CDI (INDEX FACILITY)
 A patient classified as having a case of healthcare facility
associated C. difficile attributable to YOUR facility is defined
as a patient who develops diarrhea on or after the 4th day of
admission.

OR

A patient classified as having any symptoms that develop on or
before the 4th day after your discharge to another
healthcare facility.

OR

A patient discharged to home with lab confirmed C.diff. within
28 days from the day of discharge and no intervening
admissions. (Day of discharge counts as day 1) Also counts if
C.diff is identified on readmission to your facility within that 28
day period.
44
Definition (continued)
HAI-CDI (OTHER FACILITY)
 A patient classified as having a case of
healthcare facility associated C. difficile
attributable to another health care
facility is defined as a patient who develops
diarrhea before the 4th day of admission


after transfer from another health care facility
OR:
within 28 days of discharge from another health
care facility
45
48 hours - example





Admission = day 1 – Monday
Day 2- Tuesday
Day 3- Wednesday
Day 4- Thursday at 12:01 a.m. is the cutoff.
After Thursday at 12:01, it counts for your
facility. Prior to that time, it is considered
“community acquired” which includes any
location other than your facility.
Exception – home care – 28 days
46
Facility Healthcare
Associated CDI Rate

# of HA CDI cases divided by patient/resident
days X 10,000 = ___ HA CDI per 10,000
patient/resident days
Example:
 3 cases HA CDI divided by 3,585
patient/resident days = .0008368 X 10,000
=8.368 or 8.4 cases of HA CDI per 10,000
patient/resident days
47
48
Identification of Cases
Basic Strategy:
 With cases of diarrhea, consider C. difficile




Take a detailed history for risk factors
Norovirus, dietary changes, medications, and
other things may also be causes of diarrhea
Notify physician
Watch for dehydration
49
Identification of Cases
Enhanced Strategy:
 Automatic contact precautions for all
patients/residents with orders for C. difficile
labs AND for all patients/residents with a
known history of CDI
 Consider allowing nurses to initiate the lab
order and contact precautions
50
Conversation and
Questions
How does this show up in your
facility?
 What are you doing? What are
you worried about?
 Questions?

Infection Prevention
Strategies





Contact precautions
Hand hygiene
Identification of cases
Environmental disinfection
Appropriate use of antibiotics
52
Environmental Survival
and Contamination

Vegetative form survives for only 15 minutes on dry
surfaces in room air


Spores are highly resistant to drying, heat, and
chemical and physical agents


Can exist for five months on hard surfaces
One study (McFarland et al, 1989) found spores in:



May remain viable up to 6 hours on moist surfaces
49% of rooms occupied with CDI
29% in rooms of asymptomatic carriers
Heaviest contamination on floors and in bathrooms
53
Environmental Survival and
Contamination (continued)


Spores have been isolated from the air
and aerosol dissemination may, in part,
account for widespread environmental
contamination
The frequency of positive personnel
hand culture has been strongly
correlated with the intensity of
environmental contamination
54
Environmental
Contamination

Examples of items that may become
contaminated:
 Overbed table







Electric thermometers
Blood pressure cuffs
Bedrails
Call buttons
Tube feedings
Flow-control devices
for IVs or tube feedings
Bed sheets


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


Commodes
Toilets
Scales
Telephones
TV controls
Light controls
Window sills
55
Evidence of the role of
environmental transmission



Frequency of C. difficile acquisition has
been linked with the level of
environmental contamination
Patients admitted to a room previously
occupied by a patient with C. difficile
have a higher risk for C. difficile
acquisition
Improved room disinfection has led to
decreased rates of C. difficile infection 56
Environmental Disinfection:
Tiered Approach
Basic:
Use EPA approved
germicide for routine
disinfection during nonoutbreak situations
Ensure staff training and
contact time
Disinfect shared items
between
patients/residents
Monitor environmental
cleaning
Enhanced:
Use 10% sodium
hypochlorite (bleach)
for disinfecting room
and equipment (or use
EPA registered
sporicidal agent)
In outbreak, consider
bleach solution for
cleaning all rooms
Use bleach wipes as an
adjunct to cleaning
Monitor and enforce
adherence for cleaning
Disinfectants


Commonly used disinfectants are not sporicidal
 Some may actually encourage sporulation (the
changing of the organism to the spore state)
Sporicidal disinfectants:
 Chlorine-based disinfectants
 High-concentration, vaporized hydrogen peroxide
 Recently approved EPA registered disinfectants
that kill C. diff spores
58
Disinfectants


Chlorine-based disinfectants - disadvantages:
 Can be corrosive to equipment or surfaces over time
 Can cause respiratory or other health problems in workers
using them
 May cause bleaching/fading
APIC states use of chlorine-based disinfectants should be limited
to outbreak situations and when high rates of CDI have been
documented
 In these situations (outbreaks and/or high rates), chlorinebased products have demonstrated benefit when used with
other control measures
 In other situations, routine use of chlorine-based products
has not been evaluated
 Physical motion of cleaning + use of routine germicides =
removal and dilution of spore concentration for nonoutbreak situations
59
Disinfectants

10% sodium hypochlorite solution


One part household chlorine bleach mixed
with nine parts water
Must be mixed fresh daily
60
Pre-mixed Hypochlorite Solution:
Advantages and Disadvantages

Advantages:




Commercially available solutions include
detergent base
Cleaning as well as disinfection
Eliminates dilution errors
Disadvantages of pre-mixed solutions:



Solutions expire over time
May be hard to store
May be more costly
61
Bleach and water: mixing
your own solution


Cleaning and disinfection is a two-step
process (must clean first, then disinfect)
Contact time of ten minutes required for
disinfection (Rutala, 2008)


Thorough wetting of the surface, allowed to air
dry
Note: pre-mixed EPA registered hypochlorite
solutions provide cleaning and disinfection in
one step
62
Newer products with EPA registration
against C. difficile spores

Several on the market now
63
Housekeeping Germicidal Agents with
Sporicidal Claims against Clostridium
difficile
64
Floor decontamination



Consider cleaning the C. difficile room
as the last room of the day
Alternately, change the bucket,
solution, and mop head after cleaning
the C. difficile room and before cleaning
another room
All cleaning equipment and supplies
should be decontaminated prior to use
on another room
65
Germicidal Wipes

If wipes are used:



The wipe must wet the surface being disinfected
for the correct contact time as noted on label
Use the right wipes for the right type of job
The user should:




Know the contact time for the germicide used
Know the ability of the wipe to maintain contact
time for the task for it will be used
Be involved in selection of the right type of wipes
Staff must be trained to use the wipes
appropriately
66
Additional thought..

Remember the cubicle curtains when doing
terminal cleaning following C. difficile infection
67
Monitoring
Environmental Cleaning

Consistency with recommended cleaning and disinfection
procedures should be routinely monitored.


Include all surfaces and items near the patient
Staff performing cleaning should use checklists


Confirm that each critical area has been cleaned and
disinfected
Each item must be checked off as it is completed

No need for routine environmental sampling for

If there is ongoing transmission:
Clostridium difficile


May indicate non-compliance
Thorough cleaning and disinfection of the environment
must be done
68
http://www.cdc.gov/HAI/toolkits/Appendices-Evaluating-Environ-Cleaning.html
69
70
APIC Guide
71
72
Approaches to Environmental
Cleaning Monitoring
Basic Program
 Subjective visual
assessment
 Deficiency oriented
 Problem detection
feedback
 Open definition of
correctable
interventions
Enhanced Program
 Objective quantitative
assessment
 Performance oriented
 Ongoing cyclic
monitoring
 Objective performance
feedback
 Goal oriented structured
process improvement
model
73
Environmental Services
Training


Because of the high turnover of staff,
educate personnel on proper cleaning
technique frequently.
Ensure that education is provided in
the personnel’s native language.
74
Infection Control
Strategies





Contact precautions
Hand hygiene
Identification of cases
Environmental disinfection
Appropriate use of antibiotics
75
Appropriate Use of Antibiotics:
just a few thoughts
76
Antimicrobial
Stewardship: definition

Antimicrobial (or antibiotic) stewardship
programs are interventions designed to
ensure that hospitalized patients receive
the right antibiotic, at the right dose, at
the right time, and for the right duration
(CDC definition)
77
 Prescriber education
 Standardized antimicrobial order forms
 Formulary restrictions
 Prior approval to start/continue
78
 Pharmacy substitution or switch
 Multidisciplinary drug utilization
evaluation (DUE)
 Provider/unit performance feedback
 Computerized decision support/on-line
ordering
79
Antimicrobial Stewardship
80
CDC Fast Facts





Antibiotic overuse contributes to the growing
problems of Clostridium difficile infection and
antibiotic resistance in healthcare facilities.
Improving antibiotic use through stewardship
interventions and programs improves patient
outcomes, reduces antimicrobial resistance, and
saves money.
Interventions to improve antibiotic use can be
implemented in any healthcare setting—from the
smallest to the largest.
Improving antibiotic use is a medication-safety and
patient-safety issue.
http://www.cdc.gov/getsmart/healthcare/inpatient-stewardship.html
81
Antibiotic Review for
Long Term Care Facilities
F441: Because of increases in MDROs,
review of the use of antibiotics is a vital
aspect of the infection prevention and
control program.
An area of increased surveyor focus - an
area where you need to assess if you
are meeting the surveyor guidance
82
42 CFR §483.25(l), F329, Unnecessary Drugs
 Determine if the facility has reviewed with
the prescriber the rationale for placing the
resident on an antibiotic to which the
organism seems to be resistant or when the
resident remains on antibiotic therapy
without adequate monitoring or appropriate
indications, or for an excessive duration

83


What most likely exists currently in your program:
 Comparison of prescribed antibiotics with available susceptibility
reports (charge nurse and infection preventionist)
 Review of antibiotics prescribed to specific residents during
regular medication review by consulting pharmacist
What may be needed:
 Antibiotic stewardship program in the facility (CDC
recommendation – 2006 MDRO guideline)
 Broader overview of antibiotic use in your facility with reporting
to quality assurance/infection control committee
Right drug - Right dosage - Right monitoring Feedback of data to MDs
84
Monitoring of practices
is crucial!



We must observe to see that our policies and
recommended processes are being done and done
correctly
Educate staff or use other appropriate measures
when you see non-compliance
 She doesn’t know
 She doesn’t care
 It won’t work
Enforce that all staff must follow the rules for contact
precautions and hand hygiene
85
Be cautious!

If you don’t look, you don’t know!
Conversation and
Questions
Thinking about your cleaning
processes:
 What do you think is
working well?
 Where could you use help?
 Questions?

References

Clinical Practice Guidelines for Clostridium
difficile Infection in Adults: 2010 Update by
the Society for Healthcare Epidemiology of
America (SHEA) and the Infectious Diseases
Society of America (IDSA)
http://azdhs.gov/phs/oids/epi/disease/cdif/documents/Clinical%
20Practice%20Guidelines%20for%20C%20Diff%20Infection%2
0%202010%20update%20by%20SHEA-IDSA.pdf
88
References

APIC Guide to the Elimination of Clostridium
difficile Infections in Healthcare Settings.
http://www.apic.org/Content/NavigationMenu/PracticeGuidance
/APICEliminationGuides/C.diff_Elimination_guide_logo.pdf

SHEA: Clostridium difficile in Long Term Care
Facilities for the Elderly
http://www.sheaonline.org/Assets/files/position_papers/SHEA_Cdiff.pdf
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References (continued)


Spotlight on Clostridium difficile
Infection: An Educational Resource for
Pharmacists
David P. Nicolau , PharmD, FCCP,
FIDSA
https://secure.pharmacytimes.com/lessons/200902-02.asp
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CDI Toolkit – CDC


Clostridium difficile (CDI) Infections
Toolkit (pdf)
CDI Toolkit

http://www.cdc.gov/hai/organisms/cdiff/cdiff_infect.html
available in PowerPoint format
on the CDC website

Clostridium Difficile Infection (CDI) Baseline

http://www.cdc.gov/HAI/recoveryact/stateResources/toolkits.html
Prevention Practices Assessment Tool For States
Establishing HAI Prevention Collaboratives Using
ARRA Funds Using Recovery Act Funds
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Clostridium difficile
Infection (CDI) Objectives



Describe the changing epidemiology of Clostridium
difficile.
State two differences between acute care and long
term care in managing patients/residents with C.
difficile infection.
List three important strategies for preventing
transmission of C. difficile within healthcare facilities.
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Prevention
IS PRIMARY!
Protect patients…protect healthcare personnel…
promote quality healthcare!
Thank you!
gailbennett@icpassociates.com
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