IPC 3.1 Clostridioides Difficile

Contents

arrow 1.0 Introduction
arrow 2.0 Mode of transmission
arrow 2.1 Risk factors
arrow 2.2 Signs and symptoms - clinical indications
arrow 2.3 Screening
arrow 3.0 Treatment guidance
arrow 4.0 Infection prevention and control principles
arrow 4.1 Isolation
arrow 4.2 Hand hygiene
arrow 4.3 Personal protective equipment
arrow 4.4 Equipment
arrow 4.5 Environmental cleaning
arrow 4.6 Linen
arrow 4.7 Body fluids
arrow 4.8 Occupational exposure
arrow 5.0 Surveillance
arrow 6.0 Outbreaks
arrow Appendix 1
arrow References / Source documents
arrow Record of changes

 

1.0 Introduction

Organism

Clostridioides difficile (C. difficile) is a bacterium which can be part of the normal gut flora in some healthy individuals. When excreted by an infected individual (in diarrhoeal faeces), the environment can become heavily contaminated with spores which can survive out with the body for long periods of time. Spores can be detected in the environment surrounding the patient. 

The main symptom of C. difficile Infection (CDI) is diarrhoea (see definition below); however, clinical disease comprises a range of toxin mediated symptoms such as abdominal cramps, fever, raised white blood cell levels, acute renal failure and in severe cases pseudomembranous colitis, toxic megacolon and peritonitis which can lead to death.

 

Incubation period

No specific period.

 

Period of communicability

The patient must be nursed in isolation, if this cannot be achieved to complete a risk assessment with Infection Prevention Control Team (IPC), until they have been asymptomatic for at least 72 hours and usual bowel pattern has returned.

 

Individuals at risk

All age groups can be affected. Clinical teams to identify patients who are high risk of developing C. difficile and require additional monitoring regarding antimicrobial stewardship.

 

Notifiable disease

No.

 

Informing IPC team

Inform the IPC team, details can be found on the Infection Prevention and Control Team (IPC) (The page is available from the 'Infection Prevention and Control Team (IPC)' page on the Connect site) page if you suspect or a patient has confirmed C. difficile.

 

2.0 Mode of transmission

Routes of transmission are:

  • Direct spread from patient to patient (faecal oral route)
  • Direct spread through contaminated hands
  • Indirect spread from the infected patient to the surroundings and from the contaminated environment to the patient

 

2.1 Risk factors

High risk factors include the following:

  • PreviousC. difficile infection or carrier
  • Frequent prescribing of antibiotics
  • Surgery of gastrointestinal tract or abdominal surgery
  • Hospitalisation
  • Living in extended care facilities, colon problems (e.g. colorectal cancer, irritable bowel syndrome)
  • Weakened immune system
  • Organ transplant patients taking immunosuppressive drugs
  • Older age (65 and older)
  • Proton pump inhibitors

 

2.2 Signs and symptoms - clinical indications

Common symptoms of aC. difficile infection include:

  • Diarrhoea
  • high temperature
  • loss of appetite
  • feeling sick
  • stomach ache

C. difficile associated diarrhoea is defined as one or more episode of loose stools, defined as Bristol Stool Chart types 5-7 that are not attributable to any other cause (including medicines) in a 24-hour period or more frequently than is normal for the individual. Note: The frequent passing of formed stools is not diarrhoea.

 

2.3 Screening

IPC 4.1 Obtaining a clinical sample

Faecal samples should be liquid or semi formed (take the shape of the container). Formed stools are unsuitable for investigation forC. difficile,Public Health England, 2020:

UK Standards for Microbiology Investigations - Gastroenteritis

C. difficile should be managed as a diagnosis in its own right, and clinicians should apply the following mnemonic protocol (SIGHT) when managing suspected potentially infectious diarrhoea, Public Health England and Department of Health and Social Care, 2009, updated 2019.

 

S

Suspect that a case may be infective where there is no clear alternative cause for diarrhoea.

I

Isolate the patient and consult with the Infection Prevention and Control Team.

G

Gloves and aprons must be used for all contacts with the patient and their environment.

H

Handwashing with soap and water should be carried out before and after each contact with the patient, and the patient’s environment.

T

Test the stool for toxin by sending a specimen immediately.

Any patient that has a previous history ofC.difficle should be highlighted in the patient’s notes. If there is a reoccurrence of symptoms within 28 days of a previous positiveC.difficile diagnosis, isolate patientBUT do not send a stool sample. Inform the IPC team and obtain microbiologist advice regarding treatment. If more than 28 days and diarrhoea is present, isolate the patient and stool sample to be sent. Inform the IPC team.

 

Negative Result - GDH negative and Toxin negative.

Isolate patient if type 5-7 on the Bristol stool chart until asymptomatic for at least 48 hours and usual bowel pattern has returned.

 

Positive Result but not toxin producing - GDH* positive and Toxin negative.

Isolate the patient until asymptomatic for at least 72 hours and usual bowel pattern has returned. Microbiological advice to be sought regarding possible treatment. IR1 to be completed.

 

Positive Result - GDH* positive and Toxin Positive.

Isolate the patient until asymptomatic for at least 72 hours and usual bowel pattern has returned. Clinician to review medications (laxatives, Proton Pump Inhibitors and antibiotics). IR1 to be completed.

*Glutamate dehydrogenase (GDH) is an enzyme present in the cell wall of the C. difficile bacterium. Toxins may be released by certain strains ofC. difficile.

 

3.0 Treatment guidance

Treatment ofC. difficile in children and young people under 18

As per the recent NICE guidelines (2021), treatment should be provided or guided by a specialist (microbiologist, paediatric infectious diseases, paediatric gastroenterologist). Oral antibiotics should be offered, with the choice of agent based on adult treatment recommendations with reference to licenced indications for children and adolescents.

 

Treating suspected or confirmed C. difficile infection for adults

For adults, offer an oral antibiotic to treat suspected or confirmed C. difficile infection. Refer to local Integrated Care Board (ICB) antimicrobial guidelines for the management ofC. difficile via this link via the Antimicrobial Stewardship and Guidelines (The page is available from the 'Antimicrobial Stewardship and Guidelines' page on the Connect site).

Treatment should be commenced promptly as advised by the prescribing clinician and where appropriate discussion with microbiologist.

All patients with ongoing diarrhoea are at risk of deterioration. Continually review patients with a multidisciplinary approach and document for signs of dehydration, physical observations, and non-response to treatment.

 

4.0 Infection prevention and control principles

 

4.1 Isolation 

The door should remain closed. If this is not possible, a risk assessment must be included in the nursing notes e.g. patient at risk of falls. Dedicated toilet facilities are required. The patient must be nursed in isolation, until they have been asymptomatic for at least 72 hours and usual bowel pattern has returned.

Visiting protocol to be discussed with the IPC team.

 

4.2 Hand hygiene

Alcohol Based Hand Rub (ABHR) cannot be used to decontaminate hands as they are ineffective against enteric microorganisms.

 

4.3 Personal protective equipment

Plastic aprons and disposable gloves should be worn when in direct contact with the patient or the patient’s immediate environment.

To follow droplet precautions if patients are vomiting (eye protection and fluid repellent face masks).

 

4.4 Equipment

Shared or reusable equipment to be cleaned with an approved chlorine releasing agent or sporicidal wipes (red Clinell wipes).

 

4.5 Environmental cleaning

To be cleaned using an approved chlorine releasing agent or sporicidal wipes (red Clinell wipes). Ensure the domestic team are informed for enhanced daily cleaning using approved disinfectant. Deep clean, including curtain change to be undertaken once the patient has been 72 hours without symptoms and usual stool pattern has returned.

 

4.6 Linen

 

4.7 Body fluids

 

4.8 Occupational exposure

Contact occupational health.

 

5.0 Surveillance 

To contact the IPC Team.

 

6.0 Outbreaks 

Contact the IPC Team for further advice and support immediately, if there are two or more new cases in a 28-day period on a ward. This will be confirmed as an outbreak if two or more cases caused by the same strain related to time and place Clostridium difficile infection: How to deal with the problem (publishing.service.gov.uk) Department of Health 2008.

 

Appendix 1

 

References / Source documents

 

Record of changes 

 

Version

Date

Expert writer

Status (New, Edited)

Comments and details of changes being made

2

September 2013

P Strazds

Edited

Changes throughout the document in line with new guidelines

3

June 2014

P Strazds

Edited

Changes throughout the document

4

September 2017

P Strazds

Edited

Changes to section 5.3, 8.1.1, 8.3.2, change of authors and additional reference

5

December 2020

B. Amadi

Edited

Changes throughout the document in line with new guidelines.

Addition of Trust policies and procedures.

Changes to Section 1.2, 5.1, 5.3, 7.12, 7.13, 8.1, 10.1, 14.0, 15.0, 19.0.

Changes to Appendix 1 and Appendix 3.

Addition of Appendix 2.

Change of treatment section to refer to Nottinghamshire Area Prescribing Committee.Clostridium Difficile and relevant local guidelines.

Name change ofClostridium difficile to Clostridioides difficilethroughout the document.

Transfer to new Trust Policy template.

5

April 2021

L West

Edited

Reference number changed to 07.12

 

6

February 2022

B. Amadi

Edited

Changes to Section 8.0 and 9.0

Addition of Appendix 3 and 4

7

October 2022

B Amadi

Edited

Item 3.6 - addition of high-risk.

Item 8.0 - Creation of new section for Treatment of CDI in children and young people under 18 and change of wording to text.

Change of stool chary (update).

Addition of Antimicrobial Stewardship and Guidelines to Appendix 4.

7

October 2022 

I Brakenridge

Edited

Changes to aspects of the layout of policy to align with the approved Trust template including numbering of items. Minor corrections to typing errors and updating of related policies. 

7

November 2022

I Brakenridge

Edited

Communications received from Infection Prevention Control Nurse indicating that the policy had undergone a “full review”. Request for review date to be revised. Review date changed from December 2023 to December 2025.

8

March 2024

IPC Team

Edited

Policy reviewed by the IPC Team, edited and revised into new template format. Updated references from the library team.

 

 

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