Prevention and Management of Clostridium Difficile (C. Diff.) Associated Disease

 

AIM(S) OF GUIDELINE

  • To ensure prompt identification and management of patients with C. Diff Associated Disease (CDAD).
  • To prevent spread of CDAD to other patients
  • To meet HPSC / HPA guidelines on surveillance, management and diagnosis of CDAD.

SCOPE OF GUIDELINE

This guideline applies to:

  • All staff working in the health service
  • All patients who are at risk of developing C Diff. associated disease.
  • All patients confirmed to have C. Diff. associated disease.

DEFINITIONS

Isolation of a patient indicates that the patient be nursed in a single room with contact precautions at all times.
C. Diff associated disease (CDAD) is defined as any patient who has one or more of the following:

  • Diarrhoeal stools * or toxic megacolon, with laboratory confirmed toxin A/toxin B in stools
  • Pseudomembranous colitis
  • Specimen with histopathology of c.difficile

* Diarrhoea is defined as 3 or more loose/watery bowel movements (which are unusual or different for the patient) in a 24 hr period

Severe CDAD is defined as any patient who meets the following criteria:

  • Admission to ITU for treatment of CDAD or it’s complications
  • Surgery (Colectomy) for toxic megacolon, perforation or refractory colitis due secondary to CDAD
  • Death within 30 days after diagnosis if CDAD is considered the primary or a contributory cause.
  • Recurrent CDAD is defined as a patient with an episode of CDAD that occurs within 8 weeks of the onset of a previous episode.
  • Healthcare associated CDAD is defined as a case with either
  • Onset at least 48 hrs following admission

Or

  • Onset within 4 weeks of discharge from a healthcare facility
  • Community Associated CDAD is a patient with either
  • Onset within 48hrs of admission with no healthcare admission in previous 12 weeks
  • Onset in community following d/c more than 12 weeks ago

Unknown case CDAD is defined as a case who is discharged between 4-12 weeks before onset of symptoms

RESPONSIBILITIES

  • It is the responsibility of all staff working in the hospital to ensure they are aware of and follow these guidelines.
  • It is the responsibility of the laboratory to correlate the core data set for CDAD and to report newly diagnosed cases via the mandatory surveillance system
  • It is responsibility of the infection control nurse to investigate and correlate data related to CDAD as part of routine surveillance of Nosocomial infections. The data set from the HPSC should be utilized.

LABORATORY DIAGNOSIS OF CDAD

Specimen Selection for Lab Diagnosis

  • All patients suspected of gastrointestinal infection to be tested for C.Difficile
  • Diarrhoeal stool (defined as stool that takes shape of the container)
  • Testing of asymptomatic patients not recommended
  • Patients not to be retested when on treatment
  • Performing a “test of cure” or clearance is not recommended

Laboratory Diagnosis of CDAD

  • Freshly taken specimen required
  • Specimens for transportation refrigerated at 4°C
  • Lab method to detect both toxin A and Toxin B
  • Clinician involved in patient care to be informed immediately of all positive C.difficile toxin results
  • C.difficile typing
  • In outbreak setting specimens referred to reference lab

MANAGEMENT OF PATIENTS WITH SUSPECTED CDAD

Patient Placement

  • Prompt isolation of all patients with 3 or more bouts of unexplained watery diarrhoea
  • Standard and Enteric Precautions, in a single room with clinical hand washing sink and ensuite facilities.
  • Isolation with Contact Precautions may be discontinued when the patient has had at least 48 hours without diarrhoea and has had a formed or normal stool for that patient.
  • MANAGEMENT OF CONFIRMED CASES OF CDAD

    Treatment of CDAD

    • Asymptomatic carriers of C.diff not treated
    • Antiperistaltic agents should be avoided
    • First line therapy
    • Causative antibiotic stopped if possible
    • Or antibiotics with lower risk prescribed
    • Oral metronidazole 400mgs TDS x 10 days
    • If metronidazole intolerance or contraindication oral vancomycin may be used in consultation with microbiologist.
    • Novel & emerging therapies for CDAD
    • Little evidence to support use of probiotics to prevent CDAD

    Education of patient

    • Patients with CDAD and their visitors should be provided with a CDAD patient information leaflet outlining the infection control precautions required

    Patient movement and transfer

    • Movement and transport of the CDAD patient should be limited to essential purposes only
    • Prior to patient transfer, transport personnel (e.g., porters) and the receiving department/healthcare facility must be informed of the need for Enteric Precautions.
    • Prior to accepting a patient with CDAD, it is the responsibility of the receiving facility to ensure compliance with single room, clinical hand washing sink, ensuite facilities and Contact Precautions. The receiving ward/department, bed manager must be notified
    • Transport equipment (stretcher, bed, wheelchair) used for the transfer should be cleaned and disinfected with approved disinfectant before use with another patient.

    Hand hygiene and protective clothing

  • Hand washing with soap and water performed before and after all patient and equipment contact and after glove removal
  • The physical action of rubbing and rinsing is the only way to remove spores from hands (Alcohol-based hand rubs do not have reliable sporicidal activity)
  • Encourage patients to wash hands and assist patients with hand washing when necessary
  • In addition to Standard Precautions, gloves and aprons should be worn for contact with the patient and the patient environment
  • Contaminated aprons/gowns and gloves should be removed and disposed of and hand hygiene performed prior to transporting patients.
  • A clean apron and gloves should be worn prior to handle the patient at the transport destination  
  • Environmental and Equipment Decontamination

    • The environment and all patient care equipment should be thoroughly cleaned with an approved hospital disinfectant.
    • Pay special attention to frequently touched sites e.g., bedrails, over bed table, toilets, commodes etc.
    • Immediately clean and disinfect items likely to be faecally contaminated e.g., the under surfaces and hand contact surfaces of commodes. These Items should be cleaned and disinfected after each use.
    • Medical devices (e.g., thermometers, sphygmomanometers, stethoscopes) should be dedicated to a single patient and disposable materials used whenever possible
    • No additional measures are required for cutlery and crockery washed in dishwashers
    • Bedpan/commode utensils should be placed directly into a bedpan washer-disinfector. Bedpan washers must reach a temperature of 80°C for a minimum of 1 minute.
    • Environmental faecal soiling should be cleaned and disinfected immediately
    • In the event of an outbreak, the frequency with which environmental cleaning and disinfection performed should be increased on the affected ward in liaison with ICN
    • Cleaning and disinfection of isolation room should be performed after discharge of the CDAD patient
    • All laundry should be placed into an alginate at the bedside. The sealed bag should be placed immediately into a colour coded (contaminated laundry) red laundry bag
    • All waste soiled with diarrhoea (e.g., incontinence wear and wipes) from a suspected or known CDAD patient should be disposed of as healthcare risk waste in yellow risk waste bags/yellow lidded wheelie bins.

    OUTBREAK MANAGEMENT

    • An outbreak is defined as the occurrence of two or more linked CDAD cases over a defined period agreed locally, taking account of the background rate or where the observed number of CDAD cases exceeds the expected number.
    • The ICN and Infection Control doctor will decide on what constitutes an outbreak and call an urgent meeting of the Infection Control Committee
    • An outbreak team (OCT) consisting of the ICN, ICD, Divisional manager and housekeeping supervisor will be convened
    • Outbreak measures will be considered in liaison with all parties involved.
    • These may include the following measures:
    • Designated staff assigned to the affected unit/ward
    • All infection control measures as listed above should be reinforced.
    • Increased frequency of cleaning on the affected ward.
    • Storage of faecal samples from all infected patients for culture and typing in reference laboratory essential
    • When transmission continues despite the assignment of the above measures and dedicated staff, the unit or facility should be closed to new admissions
    • When transmission continues despite all of the above measures the unit should be vacated for intensive environmental cleaning and disinfection to eliminate all potential environmental reservoirs of C. difficile
    • An outbreak may be declared over by the OCT when there are no new cases and the number of cases has returned to the endemic level.

    SURVEILLANCE OF CDAD

    • The ICN will correlate data related to the surveillance of CDAD.
    • On isolating a new toxin positive sample the laboratory will inform the Microbiologist on call and the ICN/ her deputy.
    • The ICN/deputy will review the patient and complete the reporting form for the microbiologist to sign.
    • Figures for CDAD will be recorded per 10,000 bed days and per 1,000 admissions.
    • Onset of CDAD (setting where symptoms begin) will be recorded for all diagnosed cases.
    • Origin of CDAD (see definitions) will be recorded for all diagnosed cases.

    REFERENCES

    Ayliffe et. al. (2000) “Control of Hospital Infection: a practical handbook”: Chapman and Hall, London.

    Ayliffe, G.A.J. (2001)  “Hospital-acquired Infection: principles and prevention”

    HPSC(2008) “Surveillance, diagnosis and management of clostridium difficile associated disease in Ireland”, HSPC, Dublin.

    Please note - this document is a guide only - national guidance may change at any time due to new research, local needs or updated opinion - we do not take any responsibility for ensuring this information is up to date or reflects best practice.

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