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.

The incidence of healthcare associated C. difficile infection (CDI) has increased in Florida as it has across the country. It has become one of the greatest challenges of local infection control programs. The Florida Department of Health along with the Northeast Florida Association for Professionals in Infection control and a local physician champion, have begun a regional CDI prevention collaborative in the metropolitan Jacksonville area. The collaborative includes both acute and long term care facilities from Duval, Baker, Clay, Nassau, and St. Johns Counties. The measures that will be used to prevent CDI will include hand hygiene, environmental cleaning, barrier precautions and antibiotic stewardship. The specific interventions to be deployed will be determined by the participants.

CDI Evidence-Based Prevention Strategies

CDC Core Prevention Strategies:

Hand hygiene in compliance with the Centers for Disease Control and Prevention (CDC) and the World Health Organization.
Rapidly report and implement isolation for patients with positive CDI lab results.
Implement contact precautions for duration of diarrhea.
Properly clean and disinfect equipment and the patient-care environment.
Educate healthcare personnel, housekeeping, administration, patients, and families by providing information on prevention, as well as signs and symptoms of CDI.

Supplemental Prevention Strategies:

Extend use of contact precautions beyond duration of diarrhea (e.g. 48 hours).
Presumptive isolation for symptomatic patients pending confirmation of CDI/presumtive isolation for patients with > 3 unformed stools within 24 hours.
Implement soap and water for hand hygiene before exiting the room of a patient with CDI.
Use a sporicidal or hypochlorite cleaning agent for environmental cleaning.

* Implementation of additional prevention strategies is advised when rates rise, transmission occurs, or outbreaks appear despite strict adherence to core prevention strategies. If your facility CDI rate is > 5 cases per 10,000 patient days, then it will be considered endemic and additional interventions should be considered.

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.

Evaluate and optimize test-ordering practices and diagnostic methods.
Restrict testing to unformed stool only unless ileus due to C. Difficile is suspected.
Limit testing on patients at risk for CDI with > 3 unformed stools within 24 hours.
If you have a negative test, repeat testing during the same episode of diarrhea is of limited value and should be avoided.
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.

Jacksonville Regional CDI Prevention Collaborative Supporting Documents

CDI Case Definition and Prevention Strategies

CDI Data Collection Form SNF-NH

CDI Data Collection Protocol SNF-NH
CDI Laboratory Testing

FDOH NHSN User Group Data Use Agreement

Jacksonville CDI Nursing Home Pre-assessment

Metro Jacksonville Collaborative Commitment Form

Metro Jacksonville Collaborative Timeline

Optional CDI Tools

Antimicrobial Stewardship Resource Tool

CDC Antimicrobial Stewardship Program Gap Analysis Worksheet

CDI Analysis in NHSN