ipcc guidelines section 10 1 - hse.ie · responsibility for review infection prevention and control...

Guidelines on Infection Prevention & Control 2012 CDAD HSE South (Cork & Kerry) of 16 Community & Disability Services.

SECTION 10.1

CLOSTRIDIUM DIFFICILE ASSOCIATED DIARRHOEA

(CDAD)

• CDAD What is it? • Treatment of the Resident/Client with CDAD • Further Screening Considerations • Treatment of Recurrences of CDAD • Transfer of a Resident/Client to a Healthcare Facility • Infection Prevention and Control Precautions for the

resident/client with CDAD in the Healthcare Facility • Management of an Outbreak of CDAD • Infection Prevention and Control Precautions for the

Clients with CDAD in their Home • Appendix 10.1.1 CDAD Care Plan • Appendix 10.1.2 Infection Prevention and Control Stool

Chart • Appendix 10.1.3 Patient Information Leaflet

Developed by Máire Flynn, Niamh Mc Donnell, Patricia Coughlan, Liz Forde In conjunction with Consultant Microbiologists Cork and Kerry. Date developed August 2012 Approved by Cork and Kerry Infection Prevention and Control Committee

Kerry Infection Prevention and Control Committee Reference number IPCG 10. 1/ 2012 Revision number 0 Revision date 2015 or sooner if new evidence becomes available Responsibility for review

Infection Prevention and Control Nurses

HSE InfectionPreventionBody_36054 30/08/2012 13:19 Page 135


CDAD What is it? Clostridium difficile (C. difficile) is a spore-forming, anaerobic bacteria resistant to heat, drying and air which is present in the intestinal tract of some residents/clients. It can produce a toxin which can give rise to diarrhoea, the severity of which can vary from person to person. The production of this toxin is usually associated with antibiotic therapy particularly third generation cephalosporins. C. difficile-associated disease (CDAD) presents as diarrhoea, abdominal cramps, fever and leucocytosis. In some severe cases a pseudo-membranous colitis may develop which can be life-threatening. Notifiable Disease Note: Clostridium difficile associated disease (CDAD) is a notifiable disease specified on the Infectious Disease regulation schedule of notifiable diseases. (HPSC 2012) Medical practitioners and diagnostic laboratories are required to notify the Medical Officer of Health (Dept of Public Health) of cases of CDAD.

Clinical Features

• Commonest infectious cause of diarrhoea among hospital residents/clients. • Prone to cause significant outbreaks. • Stool cultures - positive in approximately <5% asymptomatic adults • Over 20% colonisation detected in hospitalised patients • C.difficle infection is not confined to acute hospitals and is increasingly common in

both community and community healthcare residential settings. Recordings to June 2011 show 215 of all cases were associated with the community, an increase from 13% in 2009, while 12.5% were associated with residential settings, an increase of 9% in 2009 (HPSC 2012).

• Colonised residents/clients may contribute to transmission but are not at increased risk of developing symptomatic disease.

The following are the groups most at risk: • Current or recent antibiotic use (up to 10 weeks). Antibiotics reduce the normal

bowel flora and allow C. difficile to flourish. • Advanced age • Hospitalisation • Contact with resident/client with confirmed C. difficile associated diarrhoea. Presentation

• Diarrhoea which may be explosive watery/mucousy foul-smelling &/or • Abdominal pain • Fever • CDAD recurs in 8-50% of residents/clients and if a resident/client has 2 or more

episodes of CDAD, the risk of additional reoccurrence increases to 50-65%.



Diagnosis/Laboratory testing Diarrhoea is defined as three or more loose/watery bowel movements (which are unusual or different for the resident/client) in a 24 hour period and there is no other recognized aetiology for the diarrhoea (e.g. laxative use). (HPSC 2008) Note: Diarrhoeal specimens are defined as those that take up the shape of their container. Only liquid samples will be tested for C. difficile.

Please Refer to the Bristol stool Chart in stool chart. Appendix 10.1.2

C. difficile and culture & sensitivity may be requested on the one form. Norovirus testing can also be requested on the same form if indicated. For optimal laboratory investigation, freshly taken faecal specimens should be sent directly to the lab. If there is a delay in specimen transportation, specimens should be refrigerated at 4°C in a designated specimen refrigerator. One study reports complete inactivation of C. difficile toxin in 20% of stool specimens sent through the post (Brazier, 1998).

If a sample sent for C. difficile is returned negative and there is high clinical suspicion of CDAD, the microbiology laboratory should be consulted and a repeat sample may be sent. A ‘test of cure’ or clearance of C.difficle on stool specimens after treatment for CDAD is not recommended. How is it Spread? C. difficile can be transmitted from person to person via contaminated hands (healthcare workers and residents/clients), or via environmental contamination including inadequately cleaned healthcare equipment e.g. commodes, bedrails. Treatment of the Resident/Client with CDAD

Once a positive diagnosis of CDAD has been obtained and the resident/client has diarrhoea, the following is recommended:

! Discontinue current antibiotic therapy if possible. In mild cases, this may resolve symptoms and no further treatment may be necessary.

! If antibiotic therapy is still clinically indicated, antibiotics with a lower propensity to induce CDAD should be substituted.

! Liaise with Consultant Microbiologist for advice regarding suitable antibiotic use. ! Avoid the use of third generation cephalosporins. ! Commence resident/client on Metronidazole 400mg orally TDS for 10 days. ! Anti-diarrhoeal agents should be avoided. ! Maintain adequate hydration to ensure that fluid and electrolyte balance are

maintained. The mean time for diarrhoea resolution has been shown to be 3-4 days but most residents/clients show some improvement of symptoms in 1-2 days of starting treatment (HPSC, 2008).



Further Screening Considerations

• Specimens should not be obtained while the resident/client is on treatment. • Screening after treatment is not required – the absence of diarrhoea for 48 hours

and a formed or normal stool for that person indicates resolution of CDAD. • Asymptomatic carriers of C. difficile should not be treated. Treatment of colonised

residents/clients with antibiotics is not advised – residents/clients without diarrhoea & normal hygiene standards are an unlikely source of cross-infection.

Treatment of Recurrences of CDAD • Following discharge if the resident/client develops diarrhoea they should be advised

to contact their general practitioner or to follow the advice given by the discharging hospital.

• If the resident/client continues to have diarrhoea following treatment particularly with a high white cell count, the GP may consult with the Consultant Microbiologist for advice.

• CDAD has a high relapse rate and particularly if broad spectrum oral antibiotic therapy is initiated e.g. for a Respiratory Tract Infection or Urinary Tract Infection. If there is need for such therapy liaise with the Consultant Microbiologist for advice as it may be necessary for the resident/client to receive oral Metronidazole in combination with the other antibiotic therapy.

Healthcare workers (HCW) As the majority of HCW have few risk factors for CDAD, and cases in HCW are rare despite the large potential for exposure to C. difficile, the risk of HCWs acquiring CDAD is thought to be low. While a small number of cases in HCWs on antibiotics have been reported, adherence to infection prevention and control precautions and good standards of personal hygiene will minimise the risk to HCWs. Transfer of a Resident/Client to a Health Care Facility Prior to the transfer of the resident/client, inform the healthcare facility of the resident’s/client’s history of CDAD When a resident is suspected to have CDAD or when accepting a transfer of a resident with CDAD contact your local Infection Prevention and Control Nurse for advice. The following criteria must be considered by the accepting healthcare facility. • The healthcare facility that has been asked to admit the resident/client should only

accept a resident/client that is currently being treated for CDAD if ! The resident/client has had no diarrhoea for at least 48 hrs and ! Has had a formed or normal stool for that person

• Prior to accepting a resident/client with CDAD, it is the responsibility of the receiving facility to ensure compliance with single room, clinical hand washing sink, en-suite facilities and Contact Precautions. The receiving ward/department and Director of Service must be notified

• Clearance of C.difficle after treatment for CDAD is not required before transfer.



Communication Good communication is essential, prior to discharging residents/clients with CDAD or a history of CDAD from acute hospitals to other healthcare facilities or home. This facilitates • Appropriate precautions to be put in place to prevent cross-infection and • Appropriate antibiotic prescribing, if required, to prevent CDAD recurrence. Being informed of a residents/clients CDAD history will assist the GP/medical officer to: • Prescribe an antibiotic with a lower propensity to CDAD recurrence if repeated

antibiotic treatment is required. • Be alert to suspect a recurrence of CDAD, if a client develops diarrhoea following

discharge. Infection Prevention and Control Precautions for Residents/Clients

with CDAD in a Healthcare Facility In the residential setting, the following precautions are advised when caring for a resident/client who is symptomatic with CDAD. • Implement CDAD care plan for residents/clients: precautions for caring for

residents/clients with suspected/known Clostridium difficile associated disease Appendix 10.1.1 and

• Implement Infection Prevention and Control Stool Chart Appendix 10.1.2 • Contact your infection prevention and control nurse for advice. Placement: • Standard and Contact Precautions are recommended for all residents/clients that

are known or are suspected to have CDAD. • Prompt isolation in a single room with clinical hand washing sink and ensuite

facilities. • If ensuite facilities are not available it is essential that residents/clients have a

dedicated toilet or commode and are not permitted to use the general toilet in the area.

The resident/client or their family should be provided with the information leaflet for CDAD. Please refer to Appendix 10.1.3. Client Movement and Transfer: The transfer of clients between healthcare facilities has been implicated in the spread of CDAD. • The movement and transport of the resident/client with CDAD should be limited to

essential purposes only. • If the transport or movement is necessary, staff should ensure that Contact

Precautions are maintained to minimise the risk of transmission to other residents/clients and the contamination of environmental surfaces or equipment.

• Prior to resident/client transfer to another healthcare facility, ! The receiving healthcare facility should be informed of the residents/clients

CDAD status/history.



! Transport personnel (e.g., porters, emergency medical technician) and the

receiving healthcare facility should be informed of the need of Contact Precautions.

! Contaminated aprons/gowns and gloves should be removed and disposed and hand hygiene performed prior to transporting residents/clients. Apron/gown and gloves should be donned to handle the resident/client at the transport destination.

! Transport equipment (stretcher, bed, wheelchair) used for the transfer should be cleaned and disinfected immediately after use, i.e. before use with another resident/client.

Hand Hygiene Hand hygiene is the single most important infection control measure: • Thorough hand washing with liquid soap and water using the correct technique

followed by drying with paper towels is essential for healthcare workers. If a non antimicrobial soap is used, after drying, an alcohol hand rub should be applied to the hands (SARI, 2005; HPSC 2008).

• Alcohol hand rubs alone are not effective against C. difficile spores. • Residents/Clients should be advised to or be assisted to wash their hands

thoroughly with soap and warm water and dry them with paper towel after using the bathroom and before eating.

Personal Protective Equipment e.g. gloves and aprons: • Disposable gloves and aprons should be worn on entry to isolation/single room,

during resident/client care activities or contact with the clients’ equipment or immediate environment likely to result in contamination of staff hands and clothing.

• Gowns may be necessary as healthcare workers clothing have been shown to be contaminated with C difficile. The wearing of gowns depends on the nature of resident/client interaction including anticipated degree of contact with infectious material.

• Personal protective equipment is single use; discard immediately after episode of care. Perform hand hygiene after removal of personal protective clothing. Hands should not touch potentially contaminated environmental surfaces or items in the resident/client room to prevent cross infection.

Laundry

• All laundry must be placed in alginate bags or water soluble bags (refer to laundry section).

• Change bed linen and towels daily. Waste

• Soiled incontinence wear must be disposed of as healthcare risk waste i.e. yellow bag into a hands free bin. Non contaminated waste should be disposed of as healthcare non risk waste as normal.



Cleaning • Environment

The residents/clients’ immediate environment should be cleaned and then disinfected paying particular attention to hand contact surfaces. C. difficile has been linked with a high level of contamination and a prolonged ability to survive in the environment. Therefore, daily cleaning of surfaces i.e. toilets, sinks, bed table, lockers etc with neutral detergent and water followed by disinfection with a chlorine based solution of 1,000ppm available chlorine is essential or using the approved one step product combined cleaner/disinfectant e.g. Chlor-clean. Following disinfection, rinse and allow to dry. Disposable cloths should be used for cleaning areas soiled with diarrhoea and discarded after use. Special attention should be given to surfaces frequently touched by hands including bed side rails, telephone, call bells, light switches, door handles etc. Disinfection can be achieved through the use of

• 50mls of Milton 2 % in a litre of cold water or

• 100mls of Milton 1 % in a litre of cold water

• The approved one step product combined cleaner /disinfectant Chlor-clean should be made up as per manufacturer’s instructions in its own dispenser using one tablet to one litre of cold water and two tablets to 2 litres of cold water.

• Rinse and dry after using disinfectants.

• Equipment: • If a commode is being used careful cleaning and disinfection should be carried

out paying particular attention to commode arms and the underside of commodes as this is likely to be faecally contaminated. Commode pans/bedpans must be placed into the bedpan washer complete with contents.

• Bedpan washers must have yearly scheduled maintenance and validation records.

• All equipment should be cleaned at least daily with detergent and water. i.e., beds, bed rails, bed tables, commodes, and then disinfected with a chlorine based solution of 1,000ppm available chlorine, e.g. Milton solution or using one step product combined cleaner/disinfectant e.g. chlor-clean.

• Use disposable resident/client equipment where possible or ensure dedicated equipment for that person.

• No additional measures are required for cutlery/crockery.

Discontinuation of Contact Precautions: Single room placement with Contact Precautions may be discontinued when:

• The resident/client has had at least 48 hrs without diarrhoea and • Has had a formed or normal stool for that resident/client.

Thus the absence of diarrhea for 48 hours and having had a normal or formed stool for that person indicates the resolution of CDAD.



Cleaning Following Discontinuation of Contact Precautions • All privacy and window curtains must be removed and sent for laundering. • All disposable items including paper towels and toilet paper must be discarded. • All sterile and non-sterile supplies in the residents/clients environment which

cannot be reprocessed must be discarded. Clean the environment and all resident/client care equipment with a neutral detergent and disinfect with a chlorine releasing solution of 1,000ppm available chlorine, e.g. Milton/Klorosept solution or using a one step product – combined cleaner/disinfectant e.g. chlor-clean. Following disinfection, rinse and allow to dry. On resolution of CDAD symptoms or on the client discharge/transfer, cleaning and disinfection of the environment must occur as described above. Particular attention should be paid to any surface soiled with faecal matter and hand contact surfaces including door handles, taps, remote controls, hand rails, light switches, call bells etc. Treatment of Recurrences of CDAD • If the resident/client develops diarrhoea at any stage recommence Contact

Precautions as described. • If the resident/client continues to have diarrhoea following treatment, consult with

the Consultant Microbiologist for advice. Education of Visitors • Residents/Clients with CDAD and their visitors/carer’s should be given information

on preventing transmission of CDAD outlining the range and need for appropriate infection prevention and control precautions. (See Appendix 10.1.3 CDAD Information Leaflet)

• Visitors should be alerted to check with ward nursing staff regarding hand hygiene and other requirements before and after visiting a resident/client with CDAD.

• Visitors will not need to wear gloves and aprons unless they are assisting with personal care.

• Visitors should not visit other residents/clients after visiting a person with CDAD. • Visitors should not use the resident/client’s bathroom.



Management of an Outbreak of CDAD An outbreak is defined as the occurrence of two or more epidemiologically linked CDAD cases over a defined period. Where an outbreak is suspected the residents GP/doctor is required to notify the Medical Officer of Health at the Department of Public Health (See Useful Contacts for contact details) The decision to convene an outbreak control team (OCT) should be made by the CEO/ General Manager or Area Manager on the advice of the

• Consultant Microbiologist • Medical Officer of Health.

Guidance on the membership, functions and role and responsibilities of the OCT members is outlined in the document ‘Surveillance, Diagnosis and Management of Clostridium difficile-associated disease in Ireland’ from Health Protection Surveillance Centre (2008). The OCT is chaired by the CEO/ General Manager or PCCC Area Manager.

Infection Prevention and Control Precautions for Clients with CDAD in their Home

The client or their family should be provided with the information leaflet for CDAD. Please refer to Appendix 10.1.3. The need for the following precautions depends on the persons’ CDAD symptoms, the level of care required and their ability to maintain their own personal hygiene. In the home setting, the following precautions are advised when caring for a person who is symptomatic with CDAD Hand Hygiene is the single most important infection control measure: • Thorough hand washing with liquid soap using the correct technique followed by

drying with paper towels is essential for healthcare workers. • Alcohol hand rubs alone are not effective against C. difficile spores. • Carer’s, including family should be advised to wash their hands thoroughly, when

they are involved in personal care. • Clients should be advised to wash their hands thoroughly with soap and warm

water and dry them after using the bathroom, before preparing food and before eating. While symptomatic it is recommended that the client uses their own separate towel for hand drying.

Personal Protective Equipment e.g. gloves and aprons: • Disposable gloves and aprons should be worn by healthcare workers when

attending to a client who has diarrhoea. These should be removed and disposed of immediately after the episode of care. Hand washing must be then carried out as described above.



Laundry • While a client continues to have diarrhoea it is advisable that bed linen and towels

are changed daily. All laundry including bedding, towels and nightwear are washed separately in the hottest wash cycle suitable for the material of the item.

• Soiled laundry should be machine-washed separately from other washing on the hottest wash cycle suitable for linen and clothing. A cold pre-wash cycle is advised for soiled clothing prior to a hot wash. Hand washing/rinsing of soiled laundry clothing is not advised.

Waste • Waste soiled with diarrhoea (e.g. incontinence wear) should be disposed of in a

safe manner (i.e., the waste is sealed to ensure that the bag will not leak or that the outside of the bag will not become contaminated and may need to be double bagged).

Cleaning

• Environment The clients’ immediate environment should be cleaned and then disinfected paying particular attention to hand contact surfaces. C. difficile has been linked with a high level of contamination and a prolonged ability to survive in the environment.

The client’s immediate environment should be cleaned with detergent and water, paying particular attention to hand contact surfaces e.g. bedside table, hand rails and frequent hand contact surfaces in bathroom e.g. sink taps, flush handle, toilet seats. If soiled, following cleaning, those areas should be disinfected.

Disinfection can be achieved through the use of

• 50mls of Milton 2 % in a litre of cold water or

• 100mls of Milton 1 % in a litre of cold water

Household bleach mixed with cold water as instructed on the container can also be used for disinfection.

Rinse and dry after using disinfectants.

Safety Issues when using Chemical Solutions Please note: Chlorine based solutions

• Should not be used on urine spillages • May bleach fabric. • May corrode metal. • Should only be used in well ventilated areas. • Should be used according to instructions on the product • Disposable cloths should be used for cleaning areas soiled with diarrhoea and

discarded after use Equipment: • Commodes if in use must be cleaned after each use in the same manner as above. • All equipment which is touched frequently i.e. lifting aids, walking aids, bedrails etc

should be cleaned at least daily with detergent and water and then disinfected with a chlorine based solution of 1,000ppm available chlorine, e.g. Milton solution. Following disinfection, rinse and allow to dry.



The client should be encouraged and facilitated to maintain a high standard of personal hygiene:

• Personal items such as towels and face cloths should not be shared. • Clients should avoid using the same toilet as everyone else in the home where

possible while they have symptoms of diarrhoea. • If it is not possible for the client to have a separate toilet, after an episode of

diarrhoea, the bathroom must first be cleaned with detergent and water and then disinfected “as mentioned above”. Special attention should be paid to the frequently touched sites (e.g. sink taps, flush handle, toilet seats) and the toilet bowl.

Clients should be reminded to monitor their bowel movements. Discontinuation of Precautions in the Client’s Home A client is no longer considered infectious when:

• The client has had at least 48 hrs without diarrhoea and • Has had a formed or normal stool for that person.

Thus the absence of diarrhoea for 48 hours and having had a formed or normal stool for that person indicates the resolution of CDAD. Cleaning Following Discontinuation of Precautions On resolution of CDAD symptoms cleaning and disinfection of the client’s immediate environment e.g. bedroom and bathroom must occur as described above. Particular attention should be paid to any surface soiled with faecal matter and hand contact surfaces including door handles, taps, remote controls, hand rails, light switches, etc. Prior to initiating environmental cleaning and disinfection it is recommended that bed clothes, duvets, client handling slings etc are laundered at 60° degrees. All disposable items including paper towel and toilet paper must be discarded. References Bettin, K., Clabots, C., Mathie, P., Willard, K. & Gerding, D.N. (1994) Effectiveness of liquid soap Vs Chlorhexidine gluconate for the removal of Clostridium difficile from bare hands and gloved hands Infection Control & Hospital Epidemiology 15; 697-702 Health Protection Surveillance Centre (2008). Surveillance, Diagnosis and Management of Clostridium difficile-associated disease in Ireland. Health Protection Surveillance Centre: Clostridium difficile Sub-Committee Health Protection Surveillance Centre (2012) Case Definitions for Notifiable Diseases. Infectious Diseases (Amendment) Regulation 2011(SI No 452 of 2011 Murchan, S;Burns, K and Fitzpatrick, F (2012) Clostidium Difficle a growing problem in the community Epi-Insight13(1), available on www.hpsc.ie Public Health Laboratory Service (1994). The prevention and management of Clostridium difficile Infection. London: Department of health Strategy for Antimicrobial Resistance in Ireland (2005) Guidelines for Hand Hygiene in Irish Healthcare Settings http://www.hpsc.ie/hpsc/A-Z/Gastroenteric/Handwashing/Guidelines/File,1047,en.pdf



Appendix 10.1.1 CDAD Care Plan

SAMPLE CONTACT IPCN FOR COPIES



Appendix 10.1.2 Infection Prevention & Control Stool Chart




Appendix 10.1.3 CDAD Patient Information Leaflet

SAMPLE LEAFLET CONTACT IPCN FOR COPIES


ipcc guidelines section 10 1 - hse.ie · responsibility for review infection prevention and control...

Documents