Control of Clostridium difficile

Agent: Clostridium difficile is a spore-forming, gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. These cause colon dysfunction and cell death.

Clostridium difficile infection may manifest as◦ Mild diarrhea◦ Pseudomembranous colitis (PMC) ◦ Toxic megacolon ◦ Perforations of the colon ◦ Sepsis ◦ Death

C. difficile Infection

Gram stain of C. difficile

From Public Health Image Library

Watery diarrhea, often foul-smelling Fever Loss of appetite Nausea Abdominal pain/tenderness

Symptoms of C. difficile

C. difficile is shed in feces, even after symptoms resolve

Any surface, device, or material (e.g., toilets, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the spores.

Clostridium difficile spores can survive for long periods (months to years) on surfaces.

Spores are transferred to patients primarily by the hands of healthcare personnel who have touched a contaminated surface or item.

Transmission of C. difficile

Pathogenesis

Image: http://www.cdiff-support.co.uk/about.htm

Increasing incidence and severity Recent outbreaks of severe disease caused by

epidemic strain of C. difficile (BI/NAP1/027)with increased virulence, antibiotic resistance

Persons at greatest risk◦ Advanced age◦ Severe underlying disease◦ Immunosuppression◦ GI surgery or manipulation

More disease reported in “low-risk” persons◦ Healthy persons in community, peripartum women

UTMB has treated patients with the new epidemic strain

Changing Epidemiology of C. difficile

Historically uncommon, now epidemic More resistant to fluoroquinolones Carries extra toxin known as binary toxin There is an 18-base pair deletion in the

regulatory gene (tcdC) responsible for toxin production. This strain produces 16 times as much toxin A and 23 times as much toxin B in vitro.

More severe disease, higher mortality, more frequent relapses

Strain BI/NAP1/027

Implement Extended Contact Precautions for patients with watery diarrhea not explained by non-infectious conditions.

For patients isolated on basis of symptoms: isolation can be discontinued if test is negative

If the laboratory test for C. difficile is positive, patient must remain isolated for duration of hospitalization.

If a test is positive, do not order a later test as a “test of cure” or to discontinue isolation.

Use soap and water for hand hygiene. Alcohol is not effective on spores. Use of gloves does not negate need for hand hygiene!

Precautions to Prevent Transmission

You will be wearing a gown and gloves to enter the room.

If you are performing a procedure that may splatter respiratory secretions to your face, you will need facial protection-a face shield or goggles and a mask.

Always Follow Standard Precautions

Gown first Mask or respirator Goggles or face shield Gloves Combination of PPE is not the same for all

types of precautions. Extended Contact Precautions requires the use of a gown and gloves.

Source: CDC

Sequence for Donning PPE

Note: clean hands before donning PPE.

How to Don a Gown

Select appropriate type and size

Opening is in the back Secure at neck and waist If gown is too small, use

two gowns◦Gown 1 ties in front◦Gown 2 ties in back

Source: CDC

Don gloves last Select proper type and size Insert hands into gloves Extend gloves over cuffs of isolation gown

How to Don Gloves

Keep gloved hands away from faceAvoid touching or adjusting other PPE

Remove gloves if they become torn; perform hand hygiene before donning new gloves

Limit surfaces and items touched.Source: CDC

Safe Use of Gloves

Contaminated-outside front◦ Areas of PPE that have or are likely to have

contact with body sites, materials, or environmental sources where the infectious organism may reside

Clean-inside of gown, outside back of gown, ties on head (mask) and back (gown)◦ Areas of PPE that are not likely to have been in

contact with the infectious organismSource: CDC

“Contaminated” and “Clean” Areas of PPE

1. Gloves 2. Face shield or goggles (if worn).

Avoid touching front of goggles or shield to remove.

3. Gown4. Mask or respirator (if worn). Avoid

touching the front of the mask-use ties or elastic to remove.

Source: CDC

Sequence for Removing PPE

Grab outside edge near wrist Peel away from hand, turning

first glove inside-out. Hold in opposite gloved hand.

How to Remove Gloves-Slide 1

Slide ungloved finger under wrist of remaining glove.

Peel off from inside, creating a bag for both gloves.

Discard Clean hands

How to Remove Gloves-Slide 2

How to Remove an Isolation Gown

•Unfasten ties•Peel gown away from neck and shoulder•Turn contaminated outside away from inside•Fold or roll into a bundle•DiscardSource CDC

Clean your hands after PPE removal If your hands become visibly contaminated

during the process of PPE removal, wash hands before to continuing to remove PPE.

For Extended Contact Precautions:◦ You may use alcohol hand sanitizer BEFORE

patient contact.◦ You must use CHG soap and water AFTER contact

For all other types of isolation, either hand sanitizer or CHG soap is effective both before and after patient contact.

Perform Hand Hygiene

Most hospital-grade disinfectants are not effective against C. difficile

If the surface can tolerate bleach (sodium hypochlorite) use a 1:10 solution, which can be purchased pre-diluted or made fresh (1 part bleach, 9 parts water).

If the surface does not tolerate bleach , a thorough physical cleaning is necessary.

Environment and Equipment

Because patients may be moved and their equipment may accompany them, supervisors for Environmental Services and Clinical Equipment Services will be notified of new cases of C. difficile.

If you enter a room with equipment, you will see the Extended Contact Precautions sign.

If you are scheduling a patient for procedures/ tests off the unit or transferring the patient to another unit, be sure to include information about isolation during the scheduling process and as a part of the handoff.

Communication failure = opportunity for transmission.

Equipment: how will I know when to use bleach ?

As a general rule, the room of patient in Extended Contact Precautions will be available as soon as Environmental Services has finished cleaning and disinfecting the environment.

In some cases, cultures will be taken before and after the terminal clean as a quality control measure. Healthcare Epidemiology will coordinate with the appropriate Environmental Services supervisor/staff member. The room may be released as soon as cultures are collected.

Room Availability After Discharge