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. New references needed! - dc
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
New references needed! - dc