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C. difficile Prevention Partnership Collaborative. Clostridium difficile Management in Healthcare Facilities January 19, 2012. Clostridium difficile Management in Healthcare Facilities. Phenelle Segal, RN CIC Modification of Presentation by Gail Bennett, RN, MSN, CIC.

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c difficile prevention partnership collaborative

C. difficile Prevention Partnership Collaborative

Clostridium difficile Management in Healthcare Facilities

January 19, 2012

clostridium difficile management in healthcare facilities

Clostridium difficile Management in Healthcare Facilities

Phenelle Segal, RN CIC

Modification of Presentation by Gail Bennett, RN, MSN, CIC

clostridium difficile infection cdi objectives
Clostridium difficileInfection (CDI) - Objectives

Describe the changing epidemiology of Clostridium difficile.

State two differences between acute care and long term care in managing patients/residents with C. difficile infection.

List three important strategies for preventing transmission of C. difficile within healthcare facilities.

clostridium difficile infection cdi
Clostridium difficile Infection (CDI)

Antibiotic induced diarrhea

May cause approximately 30% of all cases of healthcare associated diarrhea

Most common cause of acute infectious diarrhea in nursing homes

Disease may be a nuisance or cause life threatening pseudomembranous colitis

Increasing numbers of cases

Cases tripled in US hospitals from 2000 until 2005

Increasing disease severity and mortality

background impact
Hospital-acquired, hospital-onset: 165,000 cases, $1.3 billion in excess costs, and 9,000 deaths annually

Hospital-acquired, post-discharge (up to 4 weeks): 50,000 cases, $0.3 billion in excess costs, and 3,000 deaths annually

Nursing home-onset: 263,000 cases, $2.2 billion in excess costs, and 16,500 deaths annually

Background: Impact

Campbell et al. Infect Control Hosp Epidemiol. 2009:30:523-33. Dubberke et al. Emerg Infect Dis. 2008;14:1031-8.

Dubberke et al. Clin Infect Dis. 2008;46:497-504. Elixhauser et al. HCUP Statistical Brief #50. 2008.

clostridium difficile colonization vs infection
Clostridium difficile Colonization vs Infection
  • Colonization: presence of microorganisms without tissue invasion or damage, therefore no signs or symptoms
  • Colonization rate of C. difficile
    • About 10-25% of hospitalized patients
    • About 4-20% of long term care residents
    • Antibiotic therapy may disrupt normal colonic flora in colonized patients and C. difficile proliferates, producing toxins and symptomatic disease
  • Infection: presence of microorganisms with tissue invasion and damage, therefore signs or symptoms
background epidemiology risk factors
Background: EpidemiologyRisk Factors

Antimicrobial exposure

Acquisition of C. difficile

Advanced age

Underlying illness


Tube feeds

? Gastric acid suppression

Main modifiable risk


antibiotics most often associated with clostridium difficile
Antibiotics most often associated with Clostridium difficile
  • Ampicillin
  • Amoxicillin
  • Cephalosporins
  • Clindamycin
  • Fluoroquinolones
testing for clostridium difficile
Testing for Clostridium difficile
  • Toxin testing
    • Quick – same day
  • Stool culture
    • Takes 48-96 hours
  • Testing for C. difficile should be done on unformed (liquid) stool only unless ileus is suspected
treatment options
Treatment Options
  • Discontinue antibiotics if possible
  • Fluid and electrolyte replacement
  • Do not use antimotility agents (e.g. opiates)
  • Metronidazole (Flagyl) 250 mg QID or 500 mg TID for 10-14 days
  • Vancomycin 125 mg QID for 7-10 days - used if resident does not respond to or cannot take Flagyl; may be used first if severe disease
  • New drug: Dificid (Fidaxomicin) – 200 mg bid for 10 days
  • Experimental fecal transplant (enemas)
recurrent clostridium difficile infection
Recurrent Clostridium difficile infection

Rates of recurrence

  • 20% after 1st episode
  • 45% after 1st recurrence
  • 65% after two or more recurrences
tiered approach to clostridium difficile infection cdi transmission prevention
Tiered Approach to Clostridium difficile Infection (CDI) Transmission Prevention
  • Basic/Core/Routine Approach: C. difficile transmission prevention activities during routine infection prevention and control responses
  • Enhanced/Supplemental/Heightened Approach: C. difficile transmission prevention activities during heightened infection prevention and control responses
    • Evidence of
      • ongoing transmission of C. difficile
      • an increase in CDI rates and/or
      • evidence of change in the pathogenesis of CDI (increased morbidity/mortality among CDI patients)

despite routine preventive measures

  • Note: many facilities choose to use the enhanced/supplemental approach all of the time.
infection prevention strategies
Infection Prevention Strategies

Hand hygiene

Contact precautions

Identification of cases

Environmental disinfection

Appropriate use of antibiotics

For basic measures, may use alcohol handrubs with C. difficile – OR use soap and water

Perform hand hygiene

before contact with the patient/resident

after removing gloves

after contact with the environment

Hand Hygiene for Clostridium difficile

hand hygiene soap vs alcohol gel
Hand Hygiene – Soap vs. Alcohol gel
  • Alcohol not effective in eradicating C. difficile spores
  • However, one hospital study found that from 2000-2003, despite increasing use of alcohol hand rub, there was no concomitant increase in CDI rates
  • Discouraging alcohol gel use may undermine overall hand hygiene program with untoward consequences for HAIs in general

Boyce et al. Infect Control Hosp Epidemiol 2006;27:479-83.

cdc adds
CDC adds:
  • Because alcohol does not kill Clostridium difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs.
  • However, early experimental data suggest that, even using soap and water, the removal of C. difficile spores is more challenging than the removal or inactivation of other common pathogens.
For enhanced measures, do not use alcohol handrubs with the CDI patient/resident – use soap and water

Washing away the spores may be the optimal way to perform hand hygiene when transmission of C. difficile is occurring

Many facilities choose to use the enhanced strategy all of the time

Hand Hygiene for Clostridium difficile (continued)

infection prevention strategies19
Infection Prevention Strategies

Hand hygiene

Contact precautions

Identification of cases

Environmental disinfection

Appropriate use of antibiotics

contact precautions
Contact Precautions

Designed to reduce the risk of transmission of microorganisms by direct or indirect contact

Direct contact

skin-to-skin contact

physical transfer (turning patients/residents, bathing patients, other patient/resident care activities)

Indirect contact

Contaminated objects



High touch surfaces

contact precautions21
Patient or Resident placement

Private room preferred

2nd option: Cohorting with other patient/resident with C. difficile

3rd option: In LTCFs, consider infectiousness and resident-specific risk factors to determine rooming with a low risk roommate and socializing outside the room






Patient care equipment dedicated to single patient/resident if possible. If not, disinfect equipment prior to leaving the room.

Contact Precautions
tiered approach for contact precautions basic
Tiered Approach for Contact Precautions: Basic
  • Contact Precautions - gloves and gowns to enter room or cubicle
  • Do not re-use gowns
  • Supplies outside the room
tiered approach for contact precautions basic continued
Tiered Approach for Contact Precautions: Basic (continued)
  • In semi-private room, keep cubicle curtain drawn to limit movement between cubicles and as a reminder of precautions
contact precautions basic continued
Contact Precautions: Basic (Continued)
  • Use dedicated equipment; if not feasible – decontaminate prior to use on another patient/resident
  • Maintain adequate supplies for contact precautions
  • Do not isolate asymptomatic carriers
contact precautions basic continued25
Contact Precautions: Basic (Continued)
  • May discontinue precautions when diarrhea ceases (may consider 48 hours without loose stool)
  • Do not do a toxin “for cure” once diarrhea has stopped
  • Lab should not accept stool for toxin if the stool is formed

From the Horse’s Mouth:

CDC’s Web Site

After treatment, repeat C. difficile testing is not recommended if the patient’s symptoms have resolved, as patients may remain colonized.


tiered approach for contact precautions enhanced
Tiered Approach for Contact Precautions: Enhanced

May consider alternative signage to ensure staff awareness

Evaluate current system for patient/resident placement

Consider contact precautions for all patients/residents that develop diarrhea until CDI is ruled out

Increase monitoring of isolation precautions and hand hygiene

Extend use of contact precautions even when diarrhea stops



The Inanimate Environment Can Facilitate Transmission

Xrepresents VRE culture positive sites

~ Contaminated surfaces increase cross-transmission ~

Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

infection prevention strategies31
Infection Prevention Strategies

Hand hygiene

Contact precautions

Identification of cases

Environmental disinfection

Appropriate use of antibiotics

identification of cases
Identification of Cases

Colonization or asymptomatic fecal carriage of C. difficile

  • May be common in healthcare facilities
  • Do we care?

C. difficile infection

  • Acute diarrhea
cdi collaborative definition
CDI Collaborative Definition
  • A case of C. difficile is defined as a case with the symptom of diarrhea without other known etiology
  • The stool sample will yield a positive result for laboratory assay for C. difficile toxin A and/or B
  • For this collaborative, CDI is limited to lab confirmed cases
  • Will track healthcare associated CDI
cdi collaborative definition of healthcare associated
CDI Collaborative Definition of Healthcare Associated
  • This collaborative will track laboratory confirmed cases of Health Care Facility C. difficile.
  • A laboratory confirmed case of C. difficile is defined as a patient with diarrhea characterized by unformed stool, without other known etiology, and associated with a positive laboratory assay for C. difficile toxin A and/or B on the stool.
  • Count each case of CDI only once
  • Recurrent CDI: Episode of CDI that occurs eight weeks or less after the onset of a previous episode, provided the symptoms from the prior episode resolved.
definition continued
Definition (continued)


  • A patient classified as having a case of healthcare facility associated C. difficileattributable to YOUR facility is defined as a patient who develops diarrhea on or after the 4th day of admission.
  • OR
  • A patient classified as having any symptoms that develop on or before the 4th day after your discharge to another healthcare facility.
  • OR
  • A patient discharged to home with lab confirmed C.diff.within 28 days from the day of discharge and no intervening admissions. (Day of discharge counts as day 1) Also counts if C.diff is identified on readmission to your facility within that 28 day period.
definition continued36
Definition (continued)


  • A patient classified as having a case of healthcare facility associated C. difficileattributable to another health care facility is defined as a patient who develops diarrhea before the 4th day of admission
    • after transfer from another health care facility OR:
    • within 28 days of discharge from another health care facility
48 hours example
48 hours - example
  • Admission = day 1 – Monday
  • Day 2- Tuesday
  • Day 3- Wednesday
  • Day 4- Thursday at 12:01 a.m. is the cutoff. After Thursday at 12:01, it counts for your facility. Prior to that time, it is considered “community acquired” which includes any location other than your facility.
  • Exception – home care – 28 days
facility healthcare associated cdi rate
Facility Healthcare Associated CDI Rate
  • # of HA CDI cases divided by patient/resident days X 10,000 = ___ HA CDI per 10,000 patient/resident days


  • 3 cases HA CDI divided by 3,585 patient/resident days = .0008368 X 10,000 =8.368 or 8.4 cases of HA CDI per 10,000 patient/resident days
identification of cases40
Identification of Cases

Basic Strategy:

With cases of diarrhea, consider C. difficile

Take a detailed history for risk factors

Norovirus, dietary changes, medications, and other things may also be causes of diarrhea

Notify physician

Watch for dehydration

identification of cases41
Identification of Cases

Enhanced Strategy:

Automatic contact precautions for all patients/residents with orders for C. difficile labs AND for all patients/residents with a known history of CDI

Consider allowing nurses to initiate the lab order and contact precautions

Consider universal glove usage on units that have a high incidence/rate of CDI

infection prevention strategies42
Infection Prevention Strategies
  • Contact precautions
  • Hand hygiene
  • Identification of cases
  • Environmental disinfection
  • Appropriate use of antibiotics
environmental survival and contamination
Environmental Survival and Contamination
  • Vegetative form survives for only 15 minutes on dry surfaces in room air
    • May remain viable up to 6 hours on moist surfaces
  • Spores are highly resistant to drying, heat, and chemical and physical agents
    • Can exist for five months on hard surfaces
  • One study (McFarland et al, 1989) found spores in:
    • 49% of rooms occupied with CDI
    • 29% in rooms of asymptomatic carriers
environmental survival and contamination continued
Environmental Survival and Contamination (continued)
  • Heaviest contamination on floors and in bathrooms but ALL surfaces have the ability to be contaminated
  • Spores have been isolated from the air and aerosol dissemination may, in part, account for widespread environmental contamination
  • The frequency of positive personnel hand culture has been strongly correlated with the intensity of environmental contamination
evidence of the role of environmental transmission
Evidence of the role of environmental transmission
  • Frequency of C. difficile acquisition has been linked with the level of environmental contamination
  • Patients admitted to a room previously occupied by a patient with C. difficile have a higher risk for C. difficile acquisition
  • Improved room disinfection has led to decreased rates of C. difficile infection
  • Monitor environmental cleaning
environmental disinfection tiered approach

Use EPA approved germicide for routine disinfection during non-outbreak situations

Ensure staff training and contact time

Disinfect shared items between patients/residents


Use 10% sodium hypochlorite (bleach) for disinfecting room and equipment (or use EPA registered sporicidal agent)

In outbreak, consider bleach solution for cleaning all rooms

Use bleach wipes as an adjunct to cleaning

Environmental Disinfection: Tiered Approach
  • Commonly used disinfectants are not sporicidal
    • Some may actually encourage sporulation (the changing of the organism to the spore state)
  • Sporicidal disinfectants:
    • Chlorine-based disinfectants
    • High-concentration, vaporized hydrogen peroxide
    • Recently approved EPA registered disinfectants that kill C. diff spores
  • Chlorine-based disinfectants - disadvantages:
    • Can be corrosive to equipment or surfaces over time
    • Can cause respiratory or other health problems in workers using them
    • May cause bleaching/fading
    • Reconstituted product needs to be made fresh daily
  • APIC states use of chlorine-based disinfectants should be limited to outbreak situations and when high rates of CDI have been documented
    • In these situations (outbreaks and/or high rates), chlorine-based products have demonstrated benefit when used with other control measures
pre mixed hypochlorite solution advantages and disadvantages
Pre-mixed Hypochlorite Solution: Advantages and Disadvantages
  • Advantages:
    • Commercially available solutions include detergent base
    • Cleaning as well as disinfection
    • Eliminates dilution errors
  • Disadvantages of pre-mixed solutions:
    • Solutions expire over time
    • May be hard to store
    • May be more costly
bleach and water mixing your own solution
Bleach and water: mixing your own solution
  • Cleaning and disinfection is a two-step process (must clean first, then disinfect)
  • Contact time of ten minutes required for disinfection (Rutala, 2008)
    • Thorough wetting of the surface, allowed to air dry
  • Note: pre-mixed EPA registered hypochlorite solutions provide cleaning and disinfection in one step
floor decontamination
Floor decontamination
  • Consider cleaning the C. difficile room as the last room of the day
  • Alternately, if not using microfiber mops, change the bucket, solution, and mop head after cleaning the C. difficile room and before cleaning another room
  • All cleaning equipment and supplies should be decontaminated prior to use on another room
germicidal wipes
Germicidal Wipes
  • If wipes are used:
    • The wipe must wet the surface being disinfected for the correct contact time as noted on label
    • Use the right wipes for the right type of job
    • The user should:
      • Know the contact time for the germicide used
      • Know the ability of the wipe to maintain contact time for the task for it will be used
      • Be involved in selection of the right type of wipes
    • Staff must be trained to use the wipes appropriately
monitoring environmental cleaning
Monitoring Environmental Cleaning
  • Consistency with recommended cleaning and disinfection procedures should be routinely monitored.
    • Include all surfaces and items near the patient
  • Staff performing cleaning should use checklists
    • Confirm that each critical area has been cleaned and disinfected
    • Each item must be checked off as it is completed
  • No need for routine environmental sampling for Clostridium difficile
  • If there is ongoing transmission:
    • May indicate non-compliance
    • Thorough cleaning and disinfection of the environment must be done
environmental services training
Environmental Services Training
  • Because of the high turnover of staff, educate personnel on proper cleaning technique frequently.
  • Ensure that education is provided in the personnel’s native language.
infection control strategies
Infection Control Strategies

Contact precautions

Hand hygiene

Identification of cases

Environmental disinfection

Appropriate use of antibiotics

antimicrobial stewardship definition
Antimicrobial Stewardship: definition
  • Antimicrobial (or antibiotic) stewardship programs are interventions designed to ensure that hospitalized patients receive the right antibiotic, at the right dose, at the right time, and for the right duration (CDC definition)
methods to improve antimicrobial use
Methods to Improve Antimicrobial Use
  • Prescriber education
  • Standardized antimicrobial order forms
  • Formulary restrictions
  • Prior approval to start/continue
methods to improve antimicrobial use61
Methods to Improve Antimicrobial Use
  • Pharmacy substitution or switch
  • Multidisciplinary drug utilization evaluation (DUE)
  • Provider/unit performance feedback
  • Computerized decision support/on-line ordering
cdc fast facts
CDC Fast Facts

Antibiotic overuse contributes to the growing problems of Clostridium difficile infection and antibiotic resistance in healthcare facilities.

Improving antibiotic use through stewardship interventions and programs improves patient outcomes, reduces antimicrobial resistance, and saves money.

Interventions to improve antibiotic use can be implemented in any healthcare setting—from the smallest to the largest.

Improving antibiotic use is a medication-safety and patient-safety issue.


antibiotic review for long term care facilities
Antibiotic Review for Long Term Care Facilities

F441: Because of increases in MDROs, review of the use of antibiotics is a vital aspect of the infection prevention and control program.

An area of increased surveyor focus - an area where you need to assess if you are meeting the surveyor guidance

from surveyor guidance
From Surveyor Guidance

42 CFR §483.25(l), F329, Unnecessary Drugs

Determine if the facility has reviewed with the prescriber the rationale for placing the resident on an antibiotic to which the organism seems to be resistant or when the resident remains on antibiotic therapy without adequate monitoring or appropriate indications, or for an excessive duration

antibiotic monitoring and review
Antibiotic Monitoring and Review
  • What most likely exists currently in your program:
    • Comparison of prescribed antibiotics with available susceptibility reports (charge nurse and infection preventionist)
    • Review of antibiotics prescribed to specific residents during regular medication review by consulting pharmacist
  • What may be needed:
    • Antibiotic stewardship program in the facility (CDC recommendation – 2006 MDRO guideline)
    • Broader overview of antibiotic use in your facility with reporting to quality assurance/infection control committee

Right drug - Right dosage - Right monitoring - Feedback of data to MDs

monitoring of practices is crucial
Monitoring of practices is crucial!
  • We must observe to see that our policies and recommended processes are being done and done correctly
  • Educate staff or use other appropriate measures when you see non-compliance
    • She doesn’t know
    • She doesn’t care
    • It won’t work
  • Enforce that all staff must follow the rules for contact precautions and hand hygiene
conversation and questions
Conversation and Questions
  • Thinking about your cleaning processes:
      • What do you think is working well?
      • Where could you use help?
  • Questions?
  • Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)


  • APIC Guide to the Elimination of Clostridium difficile Infections in Healthcare Settings. http://www.apic.org/Content/NavigationMenu/PracticeGuidance/APICEliminationGuides/C.diff_Elimination_guide_logo.pdf
  • SHEA: Clostridium difficile in Long Term Care Facilities for the Elderly http://www.shea-online.org/Assets/files/position_papers/SHEA_Cdiff.pdf
references continued
References (continued)
  • Spotlight on Clostridium difficile Infection: An Educational Resource for Pharmacists
  • David P. Nicolau , PharmD, FCCP, FIDSAhttps://secure.pharmacytimes.com/lessons/200902-02.asp
cdi toolkit cdc
CDI Toolkit – CDC
  • Clostridium difficile (CDI) Infections Toolkit (pdf)http://www.cdc.gov/hai/organisms/cdiff/cdiff_infect.html
  • CDI Toolkit 
    • available in PowerPoint formaton the CDC website
  • Clostridium Difficile Infection (CDI) Baseline Prevention Practices Assessment Tool For States Establishing HAI Prevention Collaboratives Using ARRA Funds Using Recovery Act Funds 
  • http://www.cdc.gov/HAI/recoveryact/stateResources/toolkits.html



Protect patients…protect healthcare personnel…

promote quality healthcare!

Thank you!


if you haven t yet register for regional meetings
If you haven’t yet…Register for Regional Meetings
  • Lowell General Hospital—January 24
  • Baystate Medical Center—January 25
  • Jordan Hospital—January 26
  • UMASS Memorial Medical Center—January 31
  • Register at: https://www.regonline.com/cdifficilepreventioncollaborativeregionalworkshops