Clostridium Difficile Infection

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Clostridium Difficile Infection (CDI) Prevention Collaborative

Clostridium difficile (C. difficile) is a spore-forming, Gram-positive anaerobic bacillus that produces 2 exotoxins, toxin A and toxin B, which injure the large intestine, causing diarrhea among infected patients. C. difficile is the most commonly recognized cause of infectious diarrhea in healthcare settings. Clostridium difficile infection (CDI) should be considered when a patient has received antibiotics in the last 12 weeks and has had 3 or more diarrheal stools in a 24-hour period. C. difficile, in its spore form, can survive on surfaces in the healthcare environment for up to five months.

C. difficile is transmitted in the healthcare setting on the hands of healthcare workers, for example by failing to wash hands or change gloves or gowns between patients, or by touching soiled surfaces of rooms and shared devices and then touching patients. According to the Association for Professionals in Infection Control and Epidemiology (APIC) Elimination Guide for Clostridium difficile (2008), many patient care activities provide an opportunity for the transmission of C. difficile. Some examples of these activities are: sharing electronic thermometers used for obtaining rectal temperatures (even though probes are changed and probe covers are used, handles may be contaminated); poor hand hygiene practices; ineffective or inconsistent disinfection of patient care equipment; and ineffective environmental cleaning.

Strategies for Preventing the Spread of CDI

Facilities participating in our CDI collaboratives have had success in preventing the spread of CDI by implementing the following strategies.

1.   Perform hand hygiene.

·    Wash hands with soap and water upon exiting the room of a patient/resident with CDI.

2.   Presumptively isolate symptomatic patients pending confirmation of lab test.

3.   Extend contact precautions for 48 hours beyond the duration of diarrhea.

4.   Monitor compliance with gown and glove use and provide feedback to others.

·    Educate staff as needed when gowns and gloves are not used properly or at the appropriate time and positively recognize staff for proper use of gowns and gloves.

5.   Properly clean and disinfect equipment and patient care environment.

·    Use hypochlorite (bleach) solution or sporicidal cleaning agents. Ensure staff is following the instructions on how to properly use cleaning agent. For example, some cleaning agents   need to remain wet on a surface for 5 minutes in order to have sufficient time to kill the spore.

·    Clean high-touch surfaces, such as call button, bed rails, TV remote daily.

·    Terminally clean room when patient is removed from contact precautions, transferred, or discharged.

·    Evaluate cleaning, provide feedback, and make improvements as needed.

6.   Educate patients, family members, and visitors on how to prevent CDI. Emphasize the importance of performing hand hygiene with soap and water and the proper cleaning of high touch surfaces and the bathroom.

Laboratory Testing

It is important for facilities to educate clinicians on the type of test used at their facility and provide instructions for recommended testing practices for the lab test used. Changes in laboratory tests may impact surveillance data so it is important to note if testing modality changes during the course of the collaborative.

1.   Evaluate and optimize test-ordering practices and diagnostic methods.

2.   Restrict testing to unformed stool only unless ileus due to C. Difficile is suspected.

3.   Limit testing on patients at risk for CDI with > 3 unformed stools within 24 hours.

4.   If you have a negative test, repeat testing during the same episode of diarrhea is of limited value and should be avoided.

5.   If you have a positive test, repeat testing should not be used to guide duration of isolation or treatment.

Please note: Resolution of diarrhea, particularly resolution of diarrhea at the conclusion of using therapeutic agents to treat C. difficile, is the indicator of successful treatment. It is also the end of risk for transmission from that patient to other patients. Patients who have been successfully treated for C. difficile and who have non-diarrheal bowel movements may be found to have a positive test but further treatment will not help them (treatment of an asymptomatic or colonized patient increases their risk of developing CDI in the future) and placing them on special infection control precautions will not benefit other patients, staff or the environment.

Orlando Regional CDI Prevention Collaborative Supporting Documents

Collaborative Overview

Commitment Form: Acute Care and Long-term Acute Care Hospitals

Commitment Form: Nursing Home

Commitment Form: Home Health Agency and Hospice

FDOH NHSN User Group Data Use Agreement

Metro Orlando Collaborative Timeline

Collaborative Meeting Schedule and Topics