Clostridium difficile (C. difficile) is a Gram positive, spore-forming, anaerobic bacillus that causes infectious diarrhea by producing two toxins - toxin A (an enterotoxin) and toxin B (a cytotoxin).Footnote 1 C. difficile is the most frequent cause of healthcare-associated infectious diarrhea in Canadian hospitalsFootnote 2Footnote 3 and is the most common cause of acute infectious diarrheal illness in long-term care facilities.Footnote 4Footnote 5 Show
The reported incidence of healthcare-associated C. difficile infection in Canada has risen over the last decade and is associated with increased morbidity and mortality.Footnote 6 C. difficile infection can have a variety of manifestations from uncomplicated diarrhea to life-threatening pseudomembranous colitis,Footnote 3 bowel perforation and sepsis.Footnote 7 Residents in long-term care facilities are at greater risk because of advanced age, the frequent need for hospitalization,Footnote 8Footnote 9 the presence of underlying diseases/comorbidities, recurrent exposures to antimicrobial agents,Footnote 8 and receipt of chemotherapy and immunosuppressive agents.Footnote 3 Incident rates of C. difficile infection for those aged 65 and older may be 10 times higher than in younger adults.Footnote 8 C. difficile is easily transmitted within healthcare settings, commonly causing outbreaks in hospitalsFootnote 10 and long-term care facilities,Footnote 11 and is associated with an increase in C. difficile infection-related morbidity and mortality in Canada.Footnote 12 There has been an almost four-fold increase in the C. difficile infection attributable mortality rate in Canadian hospitals from 1997 to 2005 (1.5% of cases to 5.7%, respectively, p<.001).Footnote 12 There are multiple reasons behind the increase in C. difficile infection and C. difficile infection-related mortality rates in Canada but an important contributor has been the spread of a more virulent strain, often referred to as North American pulsed field (NAP) type 1.Footnote 13 The primary mode of transmission for C. difficile within healthcare settings, including long-term care facilities, is by person-to-person spread through the fecal-oral route.Footnote 9 The hands of healthcare workers, transiently contaminated with C. difficile spores, along with environmental contamination play an important role in the transmission of C. difficile in healthcare settings.Footnote 14-Footnote 16 Compared to other healthcare-associated bacterial pathogens, environmental contamination around a C. difficile infection resident is thought to be a relatively more significant factor in cross-transmission to others. This is because C. difficile, being a spore-forming microorganism, persists in the environment longer and resists routine disinfection processes more than non-spore forming bacteria. The incidence of C. difficile infection within a long-term care facility is variable. Those responsible for infection prevention and control within a facility should be aware of C. difficile infection epidemiology within their organization and gauge their response accordingly.Footnote 17 Consistent and correct application of infection prevention and control measures has proven effective in reducing the incidence of healthcare-associated C. difficile infection.Footnote 10Footnote 18 As C. difficile infection is strongly associated with previous antibiotic use, antimicrobial stewardship is believed to have a role in preventing and terminating C. difficile infection outbreaks.Footnote 12Footnote 19 While this guidance document is focused on infection prevention and control measures to prevent C. difficile infection in long-term care facilities, it should be acknowledged that the prevention of C. difficile infection also requires appropriate use of antimicrobial therapy (i.e., antimicrobial stewardship). Infection control professionals or delegates should advocate for both effective infection prevention and control and antimicrobial stewardship programs as important strategies to prevent C. difficile infection within their organizations. Recommended Infection Prevention and Control MeasuresThe following guidance is based primarily on recommendations in the Public Health Agency of Canada's Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care Settings guideline,Footnote 20 except where indicated. In addition to routine practices, residents suspected or confirmed to have C. difficile infection in long-term care facilities should be placed on Contact Precautions. A point-of-care risk assessment approach (Appendix A) should be used to guide decisions regarding when to apply contact precautions. The following topics are addressed in more detail below: 1. Organizational ControlsA major role of all healthcare organizations, including long-term care facilities, is to minimize the risk of exposure to and transmission of infections within healthcare settings. This can be achieved by having policies, procedures and programs specifically for the prevention of C. difficile infection based on the following engineering and administrative measures. a) Engineering Measures
b) Administrative Measures
2. Assessment
3. Surveillance
4. Laboratory Testing/Reporting
5. Contact Precautions
6. Personnel Restrictions
7. Hand Hygiene
8. Resident Placement and Accommodation
9. Resident Flow/Activities
10. Personal Protective EquipmentPersonal protective equipment for contact precautions should be provided outside the room or designated bedspace of the resident suspected or confirmed to have C. difficile infection. Healthcare workers, families and visitors should use the following personal protective equipment for residents suspected or confirmed to have C. difficile infection and include the following:
11. Management of Fecal Matter
12. Cleaning and Disinfection of Non-critical Resident Equipment
13. Environmental Cleaning
14. Handling Linen, Dishes, Cutlery
15. Duration of Precautions
16. Handling Deceased Bodies
17. Education of Healthcare Workers, Residents, Families, Visitors
18. Visitor Management
19. Outbreak Management
Footnote a Long-term care facility - A facility or unit that includes a variety of activities, types and levels of skilled nursing care for individuals requiring 24-hour surveillance, assistance, rehabilitation, restorative and/or medical care in a group setting that does not fall under the definition of acute care. These facilities/units are called by a variety of names including chronic, continuing, complex, residential, rehabilitation, or convalescence care and nursing homes.Footnote 20 Return to footnote a referrer Footnote bHealthcare workers - Individuals who provide health care or support services, such as nurses, physicians, dentists, nurse practitioners, paramedics and sometimes emergency first responders, allied health professionals, unregulated healthcare providers, clinical instructors and students, volunteers and housekeeping staff. Healthcare workers have varying degrees of responsibility related to the health care they provide, depending on their level of education and their specific job/responsibilities.Footnote 20 Return to footnote b referrer Footnote cA thorough evaluation on the efficacy of bedpan disinfector systems for use on patient units should be done prior to procurement with a continuous quality improvement process in place for monitoring and evaluating performance.Footnote 27Footnote 28 Return to footnote c referrer An operational definition is suggested by some experts to continue contact precautions for at least 48 hours after diarrhea has resolved as relapse of diarrhea is common. However, there is currently no data to support isolation of asymptomatic patients.Footnote 26 Return to footnote d referrer Footnote 1 Poxton IR, McCoubrey JM, Blair G. The pathogenicity of Clostridium difficile. Clin Microbiol Infect 2001;7:421-427. Return to footnote 1 referrer Footnote 2Dubberke ER, Butler AM, Yokoe DS et al. Multicenter study of surveillance for hospital-onset Clostridium difficile infection by the use of ICD-9-CM diagnosis codes. Infect Control Hosp Epidemiol 2010;21:262-268. Return to footnote 2 referrer Footnote 3Poutanen S, Simor AE. Clostridium difficile-associated diarrhea in adults. CMAJ 2004;171:51-58. Return to footnote 3 referrer Footnote 4Simor AE, Yake SL, Tsimidis K. Infection due to Clostridium difficile among elderly residents of a long-term-care facility. Clin Infect Dis 1993;17:672-678. Return to footnote 4 referrer Footnote 5Sims RV, Hauser RH, Adewale AO, et al. Acute gastroenteritis in three community-based nursing homes. J. Gerontol 1995;50A:M252-M256. Return to footnote 5 referrer Footnote 6Gravel D. Miller M, Simor A, et al. Health care-associated Clostridium difficile infection in adults admitted to acute care hospitals in Canada: A Canadian nosocomial infection surveillance program study. Clin Infect Dis 2009;48:568-576. Return to footnote 6 referrer Footnote 7Miller MA, Meagan H. Ofner-Agostini M, et al. Morbidity, Mortality, and healthcare burden of nosocomial Clostridium difficile-associated diarrhea in Canadian hospitals. Infect Control Hosp Epidemiol 2002;23:137-140. Return to footnote 7 referrer Footnote 8Simor AE. Diagnosis, management and prevention of Clostridium difficile infection in long-term care facilities: A review. JAGS 2010;58:1556-1564. Return to footnote 8 referrer Footnote 9Cohen SH, Gerding DN, Johnson S, et al. 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). Available from: http://www.jstor.org/stable/10.1086/651706. Accessed July 7, 2011. Return to footnote 9 referrer Footnote 10Muto CA, Pokrywka M, Shutt K, et al. A large outbreak of Clostridium difficile-associated disease with an unexpected proportion of deaths and colectomies at a teaching hospital following increased fluoroquinolone use. Infect Control Hosp Epidemiol 2005;26:273-280. Return to footnote 10 referrer Footnote 11Gaynes R, Rimland D, Killum E, et al. Outbreak of Clostridium difficile infection in a long-term care facility: Association with gatifloxacin use. Clin Infect Dis 2004;38:640-645. Return to footnote 11 referrer Footnote 12Pepin J, Saheb N, Coulombe MA, et al. Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: A cohort study during an epidemic in Quebec. Clin Infect Dis 2005;41:1254-1260. Return to footnote 12 referrer Footnote 13Miller M, Gravel D, Mulvey M, et al. Health care-associated Clostridium difficile infection in Canada: Patient age and infecting strain type are highly predictive of severe outcome and mortality. Clin Infect Dis 2010;50:194-201. Return to footnote 13 referrer Footnote 14Johnson S, Gerding DN, Olson MM, et al. Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission. Am J Med 1990;88:137-140. Return to footnote 14 referrer Footnote 15Gerding D, Johnson S, Peterson L, Mulligan M, Silva JJ. Clostridium difficile-associated diarrhea and colitis. Infect Control Hosp Epidemiol 1995;16:459-477. Return to footnote 15 referrer Footnote 16Johnson S, Gerding DN. Clostridium difficile-associated diarrhea. Clin Infect Dis 1998;26:1027-1036. Return to footnote 16 referrer Footnote 17Siegel JD, Rhinehart E, Jackson M. Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention. Management of multidrug-resistant organisms in healthcare settings, 2006. Available from: http://www.cdc.gov/hicpac/mdro/mdro_0.html. Accessed on July 28, 2011. Return to footnote 17 referrer Footnote 18Kuijper EJ, Coignard B, Tull P. Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect 2006;12(Suppl 6):2-18. Return to footnote 18 referrer Footnote 19Valiquette L, Cossette B, Garant MP, et al. Impact of a reduction in the use of high-risk antibiotics on the course of an epidemic of Clostridium difficile-associated disease caused by the hypervirulent NAP1/027 strain. Clin Infect Dis 2007;45(Suppl 2):S112-121. Return to footnote 19 referrer Footnote 20Public Health Agency of Canada, Routine Practices and Additional Precautions for Preventing the Transmission of Infection in HealthCare Settings. Revised 2012. PHAC release pending. Return to footnote 20 referrer Footnote 21McDonald LC, Coignard B, Dubberke E, et al. Recommendations for surveillance of Clostridium difficile-associated disease. Infect Control Hosp Epidemiol 2007;28(2):140-145. Return to footnote 21 referrer Footnote 22Public Health Agency of Canada. Case Definitions for Communicable Diseases under National Surveillance - 2009 CCDR Volume 35s2, November 2009. Available at: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/09vol35/35s2/index-eng.php Return to footnote 22 referrer Footnote 23Public Health Agency of Canada and Canadian Patient Safety Institute. Case Definition and Minimum Data Set for the Surveillance of Clostridium difficile Infection (CDI) in Acute Care Hospitals across Canada. December 2008. Return to footnote 23 referrer Footnote 24Vanpouke H, DeBaere T, Claevs G, et al. Evaluation of six commercial assays for the rapid detection of Clostridium difficile toxin and/or antigen in stool specimens. Clin Microbiol Infect. 2001 Feb;7(2):55-64. Return to footnote 24 referrer Footnote 25Public Health Agency of Canada, Hand Hygiene Practices in HealthCare Settings. 2012. PHAC release pending. Return to footnote 25 referrer Footnote 26Dubberke E, Gerding N, Classen D, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29:S81-S92. Return to footnote 26 referrer Footnote 27Bryce E, Lamsdale A. Forrester L, et al. Bedpan washer disinfectors: An in-use evaluation of cleaning and disinfection. Am J Infect Control 2011;39:566-570. Return to footnote 27 referrer Footnote 28Alfa MJ, Olson H, and Buelow-Smith L. Simulated-use testing of bedpan and urinal washer disinfectors: Evaluation of Clostridium difficile spore survival and cleaning efficacy. Am J Infect Control 2008;36:5-11. Return to footnote 28 referrer
Prior to any patient/resident/client interaction, all healthcare workers have a responsibility to always assess the infectious risk posed to themselves and to other patients/residents/clients, families, visitors, and healthcare workers. This risk assessment is based on professional judgment about the clinical situation and up-to-date information on how the specific healthcare organization has designed and implemented engineering and administrative controls, along with the availability and use of personal protective equipment. The point-of-care risk assessment is an activity performed by the healthcare worker before every patient/resident/client interaction, to:
The point-of-care risk assessment is not a new concept, but one that is already performed regularly by healthcare workers many times a day for their safety and the safety of patients/residents/clients and others in the healthcare environment. For example, when a healthcare worker assesses a patient/resident/client and the situation to determine the possibility of blood or body fluid exposure or chooses appropriate personal protective equipment to care for a patient/resident/client with an infectious disease, these actions are both activities of a point-of-care risk assessment. References:Appendix A Footnote 1 Public Health Agency of Canada. Prevention and Control of Influenza during a Pandemic for All Healthcare Settings. Annex F of The Canadian Pandemic Influenza Plan for the Health Sector. Available at: www.phac-aspc.gc.ca/cpip-pclcpi/index-eng.php. Return to appendix a footnote 1 referrer
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