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CLOSTRIDIUM DIFFICILE POLICY Prepared by:

Kirklees Infection Control Team

Responsible Area: Approval Information:

Public Health Date Approved: COMMITTEE:-

Lead Director:

Dr Judith Hooper

Infection Control 15 August 2007 PEC

Version No. Approved:

One

Review Date:

July 2009

Reference to Standards for Better Health Domain

Department of Health 2004 Standards for Better Health First domain Safety

Core/Development standard

Developmental Standard D1 C4b, C4c, C4e

Performance indicators

1. To reduce incidence of cross infection

History of Document Version 1


CONTENTS Section No.

Page No’s 1

1.

Introduction

2.

Associated Policies and Procedures

1

3.

Clinical Features

1

4.

Diagnosis

1

5.

Transmission

1

6. 7.

Infection Control Measures Treatment

2 2

8.

Surveillance

2

9.

Prevention

2

10.

Transfer/Discharge of Patients

3

11.

References

4

NICE Guidance Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgement. However, NICE Guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian or carer.

Approval Committee: Version No: Date Approved:


1.

Introduction Clostridium difficile is an anaerobic, Gram positive spore forming bacilli. These spores are resistant to exposure to air, drying, heat and survive in the environment. Following antibiotic therapy the intestinal flora is altered which allows the C. difficile bacteria to proliferate. The bacteria produces a toxin that irritates the colon and causes what is commonly known as antibiotic associated diarrhoea, which can lead to pseudomembranous colitis (PMC). The source may be the patient themselves (endogenous) if they are a carrier or acquired from the environment (exogenous). Groups of patients at Risk

2.

• • • • • •

Aged over 65 years Severity of underlying disease Non surgical gastro intestinal procedures Presence of nasogastric tube Anti-Ulcer medication Intensive care patients

Duration of antibiotic course

Administration of multiple antibiotics

Associated Policies and Procedures Records Management Universal Precautions Incident Reporting Hand Decontamination Waste Management Guideline

3.

Clinical Features Clinical features are:

4.

Usually associated with the use of antibiotics

Can be asymptomatic

Minor to moderate explosive watery foul smelling diarrhoea (green appearance)

Abdominal pain/tenderness

Fever, loss of appetite, nausea

Can lead to pseudo-membranous colitis and perforation of the bowel. Sepsis. Death

Diagnosis The diagnosis is confirmed through investigation of faecal specimens to detect the toxin produced by C. difficile bacteria. Once the diagnosis is confirmed no further specimens are required unless another cause of the diarrhoea is suspected. Faecal specimens should be taken and tested within 18 hours of onset of symptoms.

5.

Transmission Routes of transmission are: •

Direct spread from patient to patient by the faecal-oral route

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6.

Direct spread through the hands of health care workers

Indirect spread from the patient to the environment and from the environment to the patient

The organism and its spores maybe transmitted by aerosol

Infection Control Measures •

All infected patients must be nursed in a side room or initiate cohort nursing

Non-sterile disposable powder-free gloves and plastic aprons should be worn when caring for affected patients

Hands must be thoroughly washed and dried with hot water and soap before and after patient contact. (The use of alcohol hand rub must not be used as an alternative. They can be used following a hand wash). Spores in the diarrhoea are not destroyed by the alcohol.

Patients should be encouraged to wash their hands after using the toilet and before meals

Dispose of all items as infectious waste

All equipment that has come into contact with the patient, including medical equipment should be cleaned and disinfected in accordance with the decontamination policy

Enhanced environmental cleaning - twice daily using chlorine based disinfectant – Chlor Clean.

Patients bedding and cotton duvets must be placed in water soluble bags and outer bag for infected linen. Personal clothing can be washed at the highest temperature possible in the washing machine but NOT with other patients clothing

Any doubts arising from infection control procedures contact the infection control team.

7.

Treatment •

antibiotics stopped wherever possible

maintain fluids and electrolyte balance

where indicated Metronidazole can be given orally for 10 to 14 days

If Metronidazole is not effective discuss further with microbiologist the use of Vancomycin

There is a risk of relapse of symptoms in about 20%--30% of patients and further courses of these antibiotics maybe required.

8.

Surveillance Early detection of Clostridium Difficile is required for rapid detection and intervention. Clostridium Difficile is a preventable infection. Outbreaks must be reported as a serious untoward incident.

9.

Prevention •

good antibiotic prescribing

adherence to antibiotic policies

appropriate use of antibiotics

short course of antibiotics instead of long courses

use of narrow spectrum antibiotics wherever possible as opposed to broad spectrum

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antibiotics unless there is a good clinical need

10.

ensure stop dates are adhered to

restrict prescription of IV antibiotics

Transfer/discharge of patients Patients with C. difficile infection should not be transferred to other areas without discussion with the infection control team. Visits to other departments should be kept to a minimum. Where visits are absolutely necessary, for investigation and treatment, prior arrangements should be made and the following principles adhered to: • Infected patients should be seen at the end of the working session and only sent for when the department is ready to deal with them. Patients should not be left in waiting areas with other patients • Disposable equipment should be used whenever possible; non-disposable equipment must be thoroughly cleaned and sterilized • Staff should adhere to strict infection control procedures during the investigation or treatment, the use of personal protective equipment. • The patient should return to their care home/ward/home immediately following the procedure • All equipment to be cleaned and decontaminated according to decontamination guidance

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11.

References Department of Health and PHLS (1995) Clostridium Difficle Infection Prevention and Management A report by a Department of Health/Public Health Laboratory Service Joint Working Group Health Protection Agency 2007 A good practice guide to Control Clostridium Difficile. Health Protection Agency London Wilcox M H. et al (1996) Financial Burden of Hospital Acquired Clostridium difficle. Journal of Hospital Infection Vol 34 (23-30) Wilson J. 8th Ed (2000) Clinical Micribiology. An Introduction for Healthcare Professionals. Balliere Tindall, London

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