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Infection Prevention, and Control Guidelines for Primary Care Physicians

• Back to Table of Contents
  
  

Patient Management of Clostridium Difficile

• Clostridium Difficile Fact Sheet for Patients

Introduction:

Clostridium difficile associated diarrhea (CDAD) has been a known cause of health care associated diarrhea for approximately 30 years, it can be acquired in the hospital as well as in community settings. Spread of C. difficile occurs due to inadequate hand hygiene and environmental cleaning; therefore, proper control is achieved through consistent hand hygiene and thorough cleaning of the patient environment. The use of evidence-based practices to prevent transmission of C. difficile will not only protect clients but will reduce associated costs to the health care system.

Policy Statement:

Family Health Teams are committed to prevent and control the transmission of C. difficile in the community and through appropriate management of clients with C. difficile.  Clients should not be refused care because of colonization or infection with C. difficile and associated disease. Routine practices are fundamental to the prevention of transmission of any microorganism and must be utilized by all health care providers at all times. These practices include hand hygiene and use of protective barriers. In addition to routine practices, additional precautions specific to C. difficile management are required.

Definitions:

Colonization – The presence and growth of a microorganism in or on a body with growth and multiplication but without tissue invasion or cellular injury. The patient will be asymptomatic.

Infection – The entry and multiplication of an infectious agent in the tissues of the host. Asymptomatic or sub-clinical infection is an infectious process running a course similar to that of clinical disease but below the threshold of clinical symptoms. Symptomatic or clinical infection is one resulting in clinical signs and symptoms (disease).

Best Practices:

1. Acknowledge risk factors for C. difficile

Factors that increase an individual’s risk for acquiring C. difficile include:

• A history of antibiotic usage

• Bowel surgery
  
  
• Chemotherapy
  
  
• Prolonged hospitalization
  
  
• Increased age
  
  
• Serious underlying illness or debilitation

2. Laboratory Testing for C. difficile Cytotoxin

• Diagnosis and testing is the sole responsibility of the client’s physician

• Stool sample collection should occur as soon as possible after the onset of symptoms
  
  
• Testing for C. difficile cytotoxin should not be carried out on formed stools
  
  
• Collect the loose stool and then transfer into a clean, dry specimen container     (does not have to be sterile)
  
  
• Specimens for C. difficile must always be loose/watery enough that they conform to the shape of the container
  
  
• Do not fill the container more that 2/3 full. This sample may emit enough gas to pop the top off. Fasten the lid securely.
  
  
• Label your container correctly and complete the requisition with all required information including a description of current or recent antibiotic use
  
  
• Transport your specimen to the laboratory as soon as possible. If this cannot be done right away, refrigerate your specimen. (The toxin degrades at room temperature and may be undetectable within 2 hrs after collection).
  
  
• When collecting any specimens related to diarrhea symptoms be sure to use gloves and gown for your protection as well as your patients
  
  
• C. difficile cytotoxin should not be done in children under the age of one year, as it is normal flora in this age group and testing for C. difficile should not be carried out on formed stools
  
  
• Cultures for C. difficile are not routinely done
  
  
• Repeat cytotoxin testing as a test of cure is not indicated. Cytotoxin may persist in stool for weeks and therefore is not helpful in determining duration of treatment or the discontinuation of infection control precautions.
  
  
• Testing for C. difficile cytotoxin may be repeated if symptoms do not resolve despite treatment or to diagnose a relapse of C. difficile following a period of absence of symptoms

3. Communication

• When there is suspicion or diagnosis of C. difficile, a staff member of Family Health Teams are obligated to share this information with those in the circle of care (e.g. contracted care providers) and to take appropriate measures to prevent the transmission of infection.

4. Prevention and Control Measures

• Appropriate prevention and control measures will reduce the risk of transmission of C. difficile and reduce associated morbidity and mortality

• Upon suspicion of C. difficile in a client at the onset of symptoms, contact precautions in addition to routine practices should be initiated
  
  
• If the client is on antibiotic therapy, it should be discontinued at the onset of symptoms if the client’s condition permits (except metronidazole or vancomycin initiated as treatment for C. difficile)
  
  
• Hand hygiene and routine practices
  
  
• Hand hygiene must be performed by all staff before and after each contact with a patient or contact with environmental surfaces near the patient
  
  
• Patients should be encouraged to perform hand hygiene upon arrival and before leaving
  
  
• Additional Precautions for C. difficile
  
  
• In addition to routine practices, additional precautions are necessary to prevent and control C. difficile
  
  
• Signage indicating the required contact precautions should be posted at the entrance to the client/patient assessment room
  
  
• Patient Placement
  
  
• It is strongly recommended that clients/patients experiencing C. difficile be assessed at the end of the day and be placed in a single room
  
  
• Personal Protective Equipment
  
  
• Gloves must be worn by all persons prior to providing direct care to a patient confirmed or suspected to have C. difficile
  
  
• A long sleeved gown may be worn for direct care depending on the type of interaction with the client and if soiling of clothing is anticipated
  
  
• Gloves and gown must be removed, discarded appropriately and hand hygiene performed immediately on completion of direct care tasks for clients with C. difficile
  
  
• Duration of Contact Precautions
  
  
• After at least 48 hours without symptoms of diarrhea, the precautions may be discontinued. Retesting for C. difficile cytotoxin is not necessary to determine the end of isolation and should not be done.
  
  
• Recurrence of Symptoms
  
  
• Relapse refers to the return of the symptoms of CC. difficile after a symptom-free period. C. difficile cases should be counted as relapse if symptoms recur within 2 months of the last infection
  
  
• Recurrence of C. difficile is common and occurs in approximately 30% of cases. If diarrhea recurs, the client should be immediately placed on Contact precautions, retested for C. difficile cytotoxin and re-initiation of therapy considered as outlined previously.

5. Treatment

Do not treat symptom-free carriers of Clostridium difficile

• Treatment of patients with C. difficile should be initiated based on the individual patient risk factors and symptoms

• Treatment should include:
  
  
• Cessation of antibiotic therapy if possible. If this is not possible, consultation with an infectious disease physician should be considered.
  
  
• Rehydration of the patient
  
  
• Avoidance of antimotility agents such as loperamide
  
  
• Recommended 1st line therapy for mild to moderate C. difficile:
  
  
• Metronidazole 250 mg orally every 6 hours OR 500 mg orally every 8 hours for a minimum of 10 days
  
  
• Recommended 1st line therapy for severe C. difficile:
  
  
• Vancomycin 125 - 250 mg orally every 6 hours for a minimum of 10 days
  
  Severe C. difficile is defined as either the presence of pseudomembranous colitis on endoscopy, or C. difficile infection requiring treatment in an intensive care unit, or the presence of at least two of: age >60 years, temperature >38.5°C, white blood cell count >15,000.
  
  
• Use vancomycin also if:
  
  
• Metronidazole is ineffective
  
  
• The patient is pregnant
  
  
• The patient is allergic to metronidazole
  
  
• True resistance to metronidazole is shown

• Patients with recurrent C. difficile may be retreated with the same agent used to treat the initial episode of C. difficile
  

• Patients with multiple recurrences or refractory disease despite appropriate treatment should have consultation with a physician knowledgeable in the treatment of C. difficile (e.g. Infectious Disease Physician, Gastroenterologist, General
  Surgeon, Medical Microbiologist).
  
  
• Monitor patients throughout the course of treatment for signs and symptoms of complications such as peritonitis, dehydration or electrolyte abnormalities

6. Environmental Cleaning

• Dedicate equipment to a single patient on contact precautions.

• Upon discharge of the patient with C. difficile.  rooms and dedicated equipment must be thoroughly cleaned and then disinfected using a disinfectant
  
  
• Routine health care cleaning practices for laundering linens/laundry are adequate for eliminating clostridium difficile spores

7. Education

• Staff must receive education in the correct and consistent use of routine practices with emphasis on hand hygiene and appropriate use of personal protective equipment

• Staff must have an understanding of C. difficile
  
  
• Patients should receive education regarding C. difficile (refer to Section V a, p 5)

Reference:

PIDAC Best Practices Document for the Management of Clostridium difficile in all health care settings, January 2009