C. difficile Infection • 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 difficileinfection may manifest as • Mild diarrhea • Pseudomembranous colitis (PMC) • Toxic megacolon • Perforations of the colon • Sepsis • Death Gram stain of C. difficile From Public Health Image Library
Symptoms of C. difficile • Watery diarrhea, often foul-smelling • Fever • Loss of appetite • Nausea • Abdominal pain/tenderness
Transmission of C. difficile • C. difficileis 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 difficilespores 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.
Pathogenesis Image: http://www.cdiff-support.co.uk/about.htm
Changing Epidemiology of C. difficile • 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
Strain BI/NAP1/027 • 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 invitro. • More severe disease, higher mortality, more frequent relapses
Precautions to Prevent Transmission • 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!
Always Follow Standard Precautions • 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.
Sequence for Donning PPE • 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 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
How to Don Gloves • Don gloves last • Select proper type and size • Insert hands into gloves • Extend gloves over cuffs of isolation gown
Safe Use of Gloves • Keep gloved hands away from face • Avoid 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
“Contaminated” and “Clean” Areas of PPE • 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 organism Source: CDC
Sequence for Removing PPE • Gloves • Face shield or goggles (if worn). Avoid touching front of goggles or shield to remove. • Gown • Mask or respirator (if worn). Avoid touching the front of the mask-use ties or elastic to remove. Source: CDC
How to Remove Gloves-Slide 1 • Grab outside edge near wrist • Peel away from hand, turning first glove inside-out. • Hold in opposite gloved hand.
How to Remove Gloves-Slide 2 • Slide ungloved finger under wrist of remaining glove. • Peel off from inside, creating a bag for both gloves. • Discard • Clean hands
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 • Discard • Source CDC
Perform Hand Hygiene • 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 othertypes of isolation, either hand sanitizer or CHG soap is effective both before and after patient contact.
Environment and Equipment • 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.
Equipment: how will I know when to use bleach? • 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.
Room Availability After Discharge • 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.