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 Canada and other developed countries.Footnote 2Footnote 3 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 4 C. difficile infection can have a variety of manifestations from uncomplicated diarrhea to life-threatening pseudomembranous colitis,Footnote 3 bowel perforation and sepsis.Footnote 5 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 4 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 6 The primary mode of transmission for C. difficile within healthcare facilities is by person-to-person spread through the fecal-oral route.Footnote 7 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 8Footnote 10 Compared to other healthcare-associated bacterial pathogens, environmental contamination around a C. difficile infection patient 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 degree to which C. difficile infection is endemic within a healthcare 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 11 Consistent and correct application of infection prevention and control measures has proven effective in reducing the incidence of healthcare-associated C. difficile infection.Footnote 12Footnote 13 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 14Footnote 15 While this guidance document is focused on infection prevention and control measures to prevent C. difficile infection in acute care settings, 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 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 Infections 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 16 except where indicated. In addition to routine practices, patients suspected or confirmed to have C. difficile infection in acute care settings 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 in this document: 1. Organizational ControlsA major role of all healthcare organizations 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. Triage - Emergency Departments and Acute Assessment SettingsPatients with an acute diarrheal illness should be placed into a single examining room with a dedicated toilet or commode whenever possible and as soon as possible. 3. Assessment
4. Surveillance
5. Laboratory Testing/Reporting
6. Contact Precautions
7. Personnel Restrictions
8. Hand Hygiene
9. Patient Placement and Accommodation
10. Patient Flow/Activities
11. Personal Protective EquipmentPersonal protective equipment for contact precautions should be provided outside the room, cubicle or designated bedspace (or when available, in the anteroom) of the patient suspected or confirmed to have C. difficile infection. Healthcare workers, families and visitors should use the following personal protective equipment for patients suspected or confirmed to have C. difficile infection:
The same personal protective equipment should not be worn for more than one patient. Personal protective equipment should be changed and hand hygiene should be performed between contacts with each patient in the same room. 12. Management of Fecal Matter
13. Cleaning and Disinfection of Non-critical Patient Care Equipment
14. Environmental Cleaning
15. Handling Linen, Dishes, Cutlery
16. Duration of Precautions
17. Handling Deceased Bodies
18. Education of Healthcare Workers, Patients, Families, Visitors
19. Visitor Management
20. Discharge PlanningIn preparing patients with C. difficile infection or recovering from C. difficile infection for discharge, the patients should be provided with information/education about the following:
21. Outbreak Management
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
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