Clostridium Difficile Infectious Diarrhea

1. Clostridium Difficile Infectious Diarrhea (CDI) Infection Prevention Learning Module Prepared by Infection Prevention and Control Services Vancouver Island Health Authority

2. 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 !

3. 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

4. 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

5. 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.

6. 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))

7. The risk of becoming colonized when in hospital is higher than 25% - WHY? People are exposed to C. difficile Contaminated Environmental Surfaces/fomites

8. 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

9. Surveillance Incidence of CDAD infections has been on the rise in Canadian Acute Care facilities

10. 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

11. Infection Reduction Strategies The following strategies have been shown to reduce the incidence of healthcare associated C. difficile colitis infections (CDI)

12. Reduction Strategies • 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

13. 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

14. 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)

16. 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.

17. Reduction Strategies • Environmental Management • 2 STEP cleaning and disinfection • Housekeeping to use Accelerated Hydrogen Peroxide (AHP-Virox) 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)

18. 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 !)

19. Reduction Strategies • 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

20. Patient Information Pamphlet

21. Notification & Records • Notify person responsible for Infection Control • Note any recent past admission to hospital, reason for this admission and type of antibiotic • Transcribe relevant information and Infection Control precautions in Kardex • Notify Most Responsible Physician (MRP) of clinical signs & suspicions • Notify any receiving or diagnostic department & porters while diarrhea is present

22. 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

23. 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

24. 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

25. References • VIHA Infection Control Manual, pp. 2 – 14, 2 – 21 and 2 – 28 • Shea Position Paper,Clostridium Difficile-Associated 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