Clostridioides Difficile (previously known as Clostridium Difficile); Guideline for the prevention of transmission in adults and children >2 years with Clostridioides difficile Infection (CDI)

• Summary of guideline
• Background
• Provision of training
• Appendix 1 - Investigations & diagnosis
• Appendix 2 - Investigations & diagnosis
• Appendix 3 - Management to prevent transmission
• Appendix 4 - Removal from source isolation
• Appendix 5 - Recurrences of clostridium difficile diarrhoea and transfer
• Appendix 6 - Algorithm for stool sampling in patients in critical care units (Level 2 & 3 areas)
• Glossary of terms

Summary of guideline

Actions required to prevent transmission of Clostridioides difficile (C. difficile) in patients with suspected or confirmed infection. This guideline must be used in conjunction with LTHT Isolation Guideline.
For clinical management of cases of suspected or confirmed CDI see Clostridium difficile Infection in adults (> 16 years of age)

Aims
To prevent and or control the transmission of C. difficile to patients, visitors, staff and students within LTHT

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Background

C. difficile is a Gram-positive spore forming bacterium that can be a cause of infectious diarrhoea acquired in the healthcare setting. Some patients are colonized by C. difficile and can be either asymptomatic or symptomatic

CDI causes serious illness particularly in the elderly, the debilitated and patients who are immunosuppressed and/or have had antibiotic treatment and is easily transmitted between individuals in a care setting.

C. difficile can cause outbreaks in hospitals, and in the community care setting where vulnerable patients are grouped (for example community intermediate care facilities and nursing care facilities).

When patients present with diarrhoea, the possibility that it may have an infectious cause should be considered. Patients with suspected potentially infectious diarrhoea should be isolated.( Isolation Guideline and Diagnosis and management of Clostridium difficile infection in adults (>16 years of age)

Investigation & Diagnosis- see APPENDIX 1 & 2

Management: To prevent transmission- see APPENDIX 3

Removal from Source Isolation - see APPENDIX 4

Recurrences of C. difficile diarrhoea are common, occurring in at least 20% of cases & Transfer - See APPENDIX 5

Algorithm for stool sampling in patients in Critical Care Units (Level 2 & 3 areas) - see APPENDIX 6

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Provision of training

Essential training in the management of patients with suspected or confirmed C. difficile infection is a Trust priority and is required as a minimum to be completed on a three yearly basis for all clinical staff working in clinical areas within LTHT.
The training can be accessed as a power point presentation through the Trust intranet site under Infection Control.
Source Isolation competency assessment is required as a minimum to be completed on a three yearly basis for all clinical staff working in clinical areas within LTHT. The supporting documentation can be found through the Trust intranet site under Infection Control. Infection Prevention and Control — LTH Web

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Glossary of Terms

Isolation; this term is used to describe single room accommodation
Cohort Isolation; is a defined area which can be sealed off from other communal clinical areas
CDI; C.difficile infection this means the patients is toxin positive
CD toxin positive; C. difficile toxin positive which means if the patient is symptomatic they have C. difficile infection
GDH positive; Glutamate dehydrogenase positive which means there is presence of the
C. difficile organism

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Appendix 1 - Investigations & diagnosis

Symptoms include diarrhoea (type 5-7 Bristol Stool Chart), with no clear alternative cause for the diarrhoea, requires a risk assessment by Senior Medical and Nursing staff risk assessment.

If C. difficile is suspected sample should be sent, marked for C. difficile testing (which includes a two stage diagnostic test, Glutamate dehydrogenase (GDH) and Toxin).

If in doubt about the need to test, please seek advice from a senior colleague, microbiologist or member of the IPC Team. In a patient in whom persistent diarrhoea (e.g. lasting for >48 hrs) was previously attributed to a cause other than C. difficile, Senior Medical and Nursing staff should request a stool specimen be sent for C. difficile testing as C. difficile can co-exist with other causes of diarrhoea.

If a sample is tested the patient should be placed in Source Isolation (Isolation Guideline) while awaiting the result.

Stool samples should not be sent for C. difficile testing in patients who do not have diarrhoea.

Patients with GDH-positive toxin-negative stools will be further tested using C. difficile toxin gene PCR. This will determine if the strain of C. difficile present is capable of producing toxin.

If the toxin gene PCR test is POSITIVE then the patient should remain source-isolated and terminal cleaning of their side room should take place as outlined for confirmed CDI patients (see ‘Removal from Source Isolation’ below). There is NO requirement to treat these patients for CDI (e.g. with Vancomycin).

If the toxin gene PCR test is NEGATIVE then the patient does not require source isolation (unless there is an alternative infective cause of their diarrhoea) and an Amber terminal clean of the side room once vacated is what is required (see ‘Removal from Source Isolation’ below).

Stool samples should not be sent for C. difficile testing routinely in patients whose diarrhoea immediately follows administration of a laxative/enema (see appendix 2 for sampling algorithm).

Further Sampling - It is not necessary to send repeat specimens to aid in the decision to remove a patient from source isolation.

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Appendix 2 - Investigations & diagnosis

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Appendix 3 - Management to prevent transmission

Apply the SIGHT protocol when managing suspected potentially infectious diarrhoea: A simple grading system for the recommendations is given in Table 1. A grade A, B or C appears in brackets after each recommendation

Clinicians (doctors and nurses) should apply the following mnemonic protocol
(SIGHT) when managing suspected potentially infectious diarrhoea:

• All patients requires source isolation for diarrhoea (type 5-7 Bristol stool chart ), with no clear alternative cause for the diarrhoea.
• All patients with suspected or confirmed CDI must be source isolated within two hours of onset of symptoms (LTHT Isolation guidelines) in a single room with an en-suite toilet. If an en-suite toilet is not available, a commode for sole use of the isolated patient should be kept in the isolation room for the duration of the patient’s stay or a designated toilet identified.
• Once the presence of the C. difficile organism in the patient’s stool has been confirmed by a GDH positive result (the first stage of the CDI diagnostic test) an explanation to patient and relatives/next of kin is essential as they will be source isolated pending the toxin result. Should CDI be confirmed by a positive toxin result a further explanation to patient and relatives/next of kin is essential. It is also important to maintain the patient’s dignity and confidentiality at all times.
• In areas where a dedicated CDI isolation facility exists, patients with confirmed CDI should be transferred to this facility as soon as possible.
• Patient’s belongings should not be taken into source isolation where possible and should be returned home, as any items taken into the room will be subjected to chlorine releasing agents as part of source isolation cleaning to prevent transmission and may become damaged. Any items taken into source isolation which are not suitable for cleaning with chlorine should be disposed of at the end of source isolation. An explanation should be given to the patient and their next kin to allow an informed decision to be made.
• If a single room is not available a discussion should take place with the IPCT to establish the actions required to reduce the risk of transmission. Contact details are provided on the Trust intranet page. The IPCT may suggest a cohort of confirmed CDI patients within the speciality.
• The nursing care standard when patients require source isolation must be adhered to and the source isolation care plan must be commenced (Print Unit Order Number WUN 1010, WUN 1008).
• Appropriate door signage must be used (contact Trust Building Manager if new or replacement signage is required)
• All antibiotics that are clearly not required should be stopped, as should other drugs that might cause diarrhoea.
• Review acid suppressing medications, in particular proton pump inhibitors may be a risk factor for CDI, especially in patients who experience recurrence of CDI.
• A severity assessment MUST be carried out in all patients with suspected or confirmed CDI by the medical team. Diagnosis and management of Clostridium difficile infection (CDI) in adults (>16 years of age)
• Do not wait for laboratory confirmation before starting therapy; if suspicion is high, use severity/recurrence to guide therapy. Diagnosis and management of Clostridium difficile infection (CDI) in adults (>16 years of age)
• Hand washing with soap and water after every contact with the patient/ patients’ environment. NB – Do not use sanitizer, as it has minimal effect on C. difficile spores.
• All areas used to care for patients with CDI must be cleaned with a chlorine releasing agent with a minimum of 1000ppm available chlorine on a twice daily basis( (see LTHT Isolation guidelines)
• Ensure patients understand the importance of washing their hands with soap and water especially after going to the toilet and before eating. Provide facilities to assist bed bound patients and those with delirium/dementia who are unable to remain in isolation to wash their hands frequently.
• If a patient is re-admitted then an assessment of the patient’s bowel history should be undertaken to establish if isolation is required.
• Patients who have CDI should still receive appropriate rehabilitation and treatment as part of their care pathway. This will need to be provided within the isolation facility where possible. If the rehabilitation facilities are off the ward the patient should be the last to use these facilities and the area and equipment should be cleaned with a chlorine releasing agent with a minimum of 1000ppm available chlorine as soon as the patient leaves.
• Patients in isolation require frequent contact with staff and relatives to promote mental wellbeing and improve the patient experience. Ensure you have a system in place to make regular contact and spend time with patients in isolation.
• Where a decision is taken to commence an end of life care plan the IPCT should be involved to help the clinical team reduce the risk of transmission whilst meeting the requirements of the patient and relatives.

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Appendix 4 - Removal from source isolation

• All CD toxin positive patients should remain in source isolation for the duration of that inpatient episode where the CD toxin positive result was identified.
• All patients who are GDH positive, toxin negative, PCR-positive should remain in source isolation for the duration of that inpatient episode.
• All patients who are GDH positive, toxin negative, PCR-negative do not need to remain source-isolated unless there is a confirmed/suspected alternative infective cause for their symptoms
• When a CDI positive or GDH positive, toxin negative, PCR-positive patient is transferred or discharged the vacated isolation room must be decontaminated with Hydrogen Peroxide Vaporisation (HPV) prior to the next patient .This can be accessed through CARPs.
• When a GDH positive, toxin negative, PCR negative patient is transferred or discharged the vacated isolation room must be cleaned with a chlorine releasing agent with a minimum of 1000ppm available chlorine and curtains changed. (see Isolation Guidelines)

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Appendix 5 - Recurrences of C. difficile diarrhoea and transfer

• At least 20% of cases of CDI will relapse.
• If the patient has had a positive C. difficile toxin result ensure they have had a full appropriate course of antibiotics; please refer to Clostridium difficile Infection in adults (> 16 years of age)
• If the patient is still symptomatic after treatment is complete, continue to take precautions and liaise with IPCT, who will advise as to whether a repeat specimen is required and on the management of the patient.
• If the patient is C. difficile negative and symptoms continue wait 7 days before sending a repeat sample, unless symptoms change worsen or are severe.
• If clinically concerned about the patient please discuss with the Consultant Microbiologist.

Transfer

• The movement and transfer of infected patients should be kept to a minimum, where possible. If patients need to attend other departments for essential investigations they should be placed last on the list and the receiving department must be informed verbally of the patient’s infectious status. An Infection Control Transfer Form Transfer and Handover of Care Procedure) must be completed.
• If a patient is transferred before the diagnostic test result is available the bed space/isolation room must be cleaned with a chlorine releasing agent with a minimum of 1000ppm available chlorine and the curtains changed. (See Isolation Guideline). If the result comes back CD toxin positive the vacated isolation room/bay must be decontaminated using Hydrogen Peroxide Vaporisation (HPV).

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Appendix 6 - Algorithm for stool sampling in patients on the critical care units (Level 2 and 3 areas)