Clostridium difficile infection (CDI)

Thanks to Dr. Fidelma Fitzpatrick (HSE Clinical Lead for the Prevention of Healthcare-associated Infection) for her guest post on CDI

Clostridium difficile infection (CDI) results in a wide spectrum of illness ranging from mild diarrhoea to severe colitis. CDI is associated with older age, receiving healthcare and antibiotic use.  CDI principally affects hospitalised patients, though recently has become an important cause of diarrhoea in long term care facilities and in the community. Patients/residents with CDI experience considerable morbidity and are more likely to require additional healthcare interventions (e.g., isolation, additional therapies and procedures). CDI can also cause recurrent infection in up to 50% patients/residents depending on their underlying risk factors for infection and the strain of C. difficile causing the infection.

How can CDI be prevented?

CDI is prevented by a combination of clear governance structures: active CDI surveillance, timely laboratory diagnosis of CDI, antimicrobial stewardship, adherence to appropriate infection prevention and control measures and timely management of patients/residents with CDI as outlined in national guidelines.

·         Standard Precautions should be used at all times by all healthcare staff when caring for patients/residents. Standard Precautions are a group of infection prevention and control practices and measures that apply to all patients/residents at all times regardless of suspected, confirmed or presumed infectious status, in any setting in which healthcare is delivered.  When Standard Precautions are consistently implemented, the risk of transmission of infectious agents to healthcare workers and patients/residents is minimised. 

·         All healthcare facilities should have an active antimicrobial stewardship programme as outlined in national guidelines.  This should include local antimicrobial prescribing guidelines to include a restrictive antimicrobial list and efforts to minimise the frequency, duration and number of antimicrobial agents prescribed

How is C. difficile spread and why should I not use alcohol hand rub for hand hygiene when caring for patients with CDI?

C. difficile can be transmitted from patient-to-patient, via contaminated hands, or via environmental (including healthcare equipment) contamination. C. difficile is also a spore-forming organism, a property which makes it more resistant to standard disinfectants and facilitates its persistence in the environment, often for several months.

·         When caring for patients/residents with CDI alcohol hand rub should not be used as C. difficile spores are known to be highly resist ant to killing by alcohol. The physical action of rubbing and rinsing is the only way to remove spores from hands (i.e., hand washing).  

Are additional precautions required if CDI is confirmed?

Yes. Contact Precautions should be used in addition to Standard Precautions for the care of all patients/residents with CDI in all healthcare facilities as outlined in national guidelines.

What should I do if I suspect my patient/resident has CDI?

The following mnemonic protocol (SIGHT) provides a useful framework when managing suspected potentially infectious diarrhoea:

S	Suspect that a case may be infective where there is no clear alternative cause for diarrheoa
I	Isolate the patient if in a healthcare facility (e.g., hospital, nursing home). Consult with the infection prevention and control team where available while determining the cause of the diarrhoea
G	Gloves and aprons must be used for all contacts with the patient and their environment. Instruct the patient and carers/family members in hand hygiene and when they need to use personal protective equipment
H	Hand washing with soap and water  should be carried out after each contact with the patient and the patient’s environment
T	Test the stool for C. difficile toxin, by sending a specimen immediately.  If the patient is unwell/unstable, contact the consultant microbiologists/ID physician for advice.

What information is available in Ireland on C. difficile?

The Health Protection Surveillance Centre (HPSC) has published weekly reports of CDI cases since May 2008.  In addition, quarterly reports are published that contain additional information on where patients acquired their infection (healthcare facility or community).  CDI is more co mmon in older patients/residents, approx 1.5% have severe infection and in 2012 while the majority of patients present with symptoms of CDI in healthcare facilities (hospitals or long term care facilities), 30% of all patients with CDI had onset of their symptoms in the community.

Further information on:

·         CDI in Ireland (including national guidelines, information leaflets, audit tools, weekly CDI report) http://www.hpsc.ie/hpsc/A-Z/Gastroenteric/Clostridiumdifficile/  

·         Hand Hygiene: http://www.hse.ie/eng/services/healthpromotion/handhygiene/

·         Healthcare-associated Infections: http://www.hse.ie/eng/services/healthpromotion/healthcareassinfection/

·         National antimicrobial stewardship guidelines; http://www.hpsc.ie/hpsc/A-Z/Microbiol ogyAntimicrobialResistance/InfectionControlandHAI/Guidelines/File,4116,en.pdf