Clostridioides (Clostridium) difficile Infection Prevention

Implementation of CDI surveillance

• Surveillance programs are an important measure used to detect and prevent outbreak of C. difficile within health care facilities. Surveillance programs should fit the needs of your facility while incorporating:
  • Early and accurate recognition of CDI patients
  • Standardized definitions:
    • Healthcare Facility-Onset (HO): specimen collected >3 days after admission to the facility (on or after day 4)
    • Community-Onset Healthcare Facility-Associated (CO-HCFA): infection in a patient discharged from the facility ≤4 weeks prior to specimen collection date
    • Community-Onset (CO): specimen collected ≤3 days after admission to the facility (days 1, 2, or 3 of admission)
  • At minimum, conduct surveillance for health care facility-onset CDI in all inpatient health care facilities to detect outbreaks and monitor patient safety

Isolation precautions

• Implement Contact Precautions for all CDI patients; consider pre-emptively  placing symptomatic patients on Contact Precautions until laboratory results are available
• Communicate precautions status to direct care-givers and other key staff (e.g., environmental services, dietary, PT/OT, etc.)
• Use disposable or dedicated patient care equipment whenever possible. If not possible, clean and disinfect patient equipment immediately after every use
• Discontinue precautions when diarrhea has resolved (i.e., patient has <3 unformed stools in a 24 hour period)
  • Some experts recommend continuing Contact Precautions for 48 hours after the resolution of diarrhea due to continued C. diff shedding, environmental contamination and patient skin colonization
  • You may also consider continuing Contact Precautions through completion of CDI antibiotic therapy
  • In facilities with high rates of CDI, consider continuing Contact Precautions until discharge
  • In long-term care facilities, consider continuing Contact Precautions for a minimum of 48 hours after resolution of diarrhea
    • Consider extending Contact Precautions for residents that are incontinent and require considerable assistance with activities of daily living

Rooming

• Place patients in a private room
• Cohort patients if private room is not available
  • Patients with discordant status of infection or colonization are not cohorted.
  • Place spatial separation (minimum 3 feet) between beds; may use privacy curtain or place tape on floor for visual queue.
• Patients should not leave their room unless medically necessary
  • Receiving units should be made aware of CDI status and wear appropriate PPE

Contact Precautions

• Use gloves and gown when entering patients’ rooms and during patient care
  • Remove PPE and perform hand hygiene when exiting the room
• Change gloves and gowns and perform hand hygiene when moving from one patient to another when patients are cohorted, and before leaving patient room

Hand Hygiene

• Follow CDC or WHO recommendations for hand hygiene
• Perform hand hygiene before entering the room and donning gloves and gown. Perform hand hygiene (soap and water preferred) before exiting the patient room; alcohol-based hand rub is used if soap and water are not available
• Alcohol-based hand rubs can be used for routine hand hygiene when caring for other patients
• Safe from CDI Roadmap and Toolkit
  More information on Isolation/Contact precautions

Environmental cleaning and disinfection

• CDI patient rooms and patient care equipment must be cleaned prior to disinfection
• Rooms should be cleaned and disinfected starting with cleanest areas and ending with the dirtiest (e.g., bathroom cleaned last) and from high areas to low areas
• Use a hospital-grade cleaner and Environmental Protection Agency (EPA)-registered sporicidal disinfectant in accordance with label instructions
  • US Environmental Protection Agency Office of Pesticide Programs: LIST K: EPA’s Registered Antimicrobial Products Effective against Clostridium difficile Spores
    List of EPA registered products effective against Clostridioides (Clostridium) difficile spores.
• Daily cleaning and disinfecting should include (but are not limited to):
  • High touch areas (e.g., door knobs, light switches, call buttons, and bed rails)
  • Horizontal surfaces, including the floor
  • Walls
  • Bathroom (always end with the toilet)
• Terminal/discharge cleaning and disinfection should include daily cleaning areas plus:
  • Bed frame
  • Mattress
  • Bed linens, pillows
• Safe from CDI Roadmap and Toolkit
  More information on cleaning and disinfection

Antimicrobial Stewardship

• Appropriate antibiotic use is a key component of CDI prevention
• Programs should incorporate a process that monitors and evaluates antimicrobial use and provides feedback to prescribers and facility leadership.
  • Antimicrobial Resistance and Stewardship
    MDH antimicrobial resistance and stewardship website.
  • Acute Care Antibiotic Stewardship Program Resource List

For Long Term Care Facilities

• Infection prevention and control practices in long term care and home health settings are similar to those practices taken in acute care settings.
  
  
• Algorithms for Prevention and Management of Clostridium difficile Infections in Long-term Care Facilities (PDF)
  MDH guidance for Clostridioides (Clostridium) difficile prevention and control including: early recognition and testing, Contact Precautions, room placement, identifying roommates, environmental cleaning and disinfection, and social and activity precautions.

Refer to Contact Precautions, but also consider:

• Consider continuing Contact Precautions for a minimum of 48 hours after resolution of diarrhea
  • Consider extending Contact Precautions for residents that are incontinent and require considerable assistance with activities of daily living
• After resolution of symptoms, assure clean, dry incontinence products and hand hygiene is performed prior to  resident leaving their room or participating in group activities
  
  
• Occupational and physical therapy with active C. difficile diarrhea
  • For incontinent residents, all therapy and rehabilitation treatments and activities should be provided in the resident’s room if feasible and if resident safety or well-being would not be jeopardized
    • Clean and disinfect equipment after use and before use by another resident
  • Therapists, technicians, and all other personnel must follow Contact Precautions, wear appropriate PPE and perform hand hygiene accordingly
  • If therapy cannot be provided in the residents room, CDI residents should be scheduled  for the last sessions of the day and equipment should be cleaned and disinfected after each use
• Social activities
  • Continent residents, or residents whose diarrhea can be contained with incontinence products AND who can perform hand hygiene and follow instructions can be allowed to use common areas and participate in group activities
  • Be sure the resident has clean clothing, dry incontinence products, and performs hand hygiene prior to leaving room
  • Immediately clean and disinfect any inadvertent diarrheal accidents