Clostridium Difficile Infectious
Diarrhea
(CDI)
Infection Prevention Learning Module
Prepared by Infection Prevention and Control Services
Vancouver Island Health Authority
Infectious Diarrhea
There 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 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
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 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.
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 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
Surveillance
Incidence of CDAD infections has been on
the rise in Canadian Acute Care facilities
C.difficile NRGH
12
10.2
Number of cases/1000 admissions
10
9.8
8
7.8
7.1
6
5.9
National Average
4
2
0
1996-1997
2003-2004
2004-2005
2005-2006
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 Strategies
1.
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 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
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)
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.
Reduction Strategies
5.
Environmental Management
•
2 STEP cleaning and disinfection
•
•
•
•
Housekeeping to use Accelerated Hydrogen Peroxide (AHPVirox) 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 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 !)
Reduction Strategies
7.
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 & Records
1. 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
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
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 your
feedback
NOSOCOMIAL CDAD CASES
CDAD REDUCTION STRATEGIES
NRGH 2005/06
16
14
14
Target: 7.9
cases/1000 adm.
12
10
*
8
8
7
6
**
8
7
6
4
*
8
8
8
6
National Average 1997 Prevalence 5.9
2
***
1
0
*Education Blitz
Early recognition &
intervention
1
2
3
4
5
6
7
8
Cleaning
PERIOD FISCAL YEAR**Enhanced
Virox & Bleach
9
2
1
10
11
12
*** Commodes
13
References
• VIHA Infection Control Manual, pp. 2 – 14, 2 – 21
and 2 – 28
• Shea Position Paper, Clostridium DifficileAssociated 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