Page updated 5th March 2007
5.0. Patient Management
The number and presentation of C. difficile cases will influence the management of C. difficile infection. Monitoring of C. difficile cases by the Infection Control Team (ICT) with epidemiological investigation will result in initiation of 3 categories of management:
- Sporadic cases (hospital or community acquired)
- Localised cluster of cases (2 or more cases of hospital acquired C. difficile in a defined area i.e. ward per week where cross infection is suspected).These may occur sporadically without indicating an outbreak.
- Outbreak - site-specific C. difficile expected levels exceeded for 2 weeks or more than 3 cases of hospital acquired infection per week for 2 consecutive weeks in a defined area.
5.1 Sporadic cases
Following identification of C. difficile infection the following infection control measures must be implemented:
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Immediate isolation of the patient in a single room. An en-suite bathroom is preferable. Patients who do not have access to en-suite facilities must have a commode dedicated for their use.
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Patients who require being moved from a bay to a side room for isolation following confirmation of C. difficile infection must have the previous bed space thoroughly cleaned with a 5% solution of hypochlorite detergent (1000 ppm available chorine e.g. Actichlor plus), and the curtains changed prior to occupation by the next patient. The bathroom or toilet which they used will also require a thorough clean if patients have used the toilet whilst symptomatic.
- Patients should be provided with an information leaflet on C. difficile.
ON ENTERING: .
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Staff must wear aprons and gloves.
- Use alcohol gel.
ON LEAVING:
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All staff leaving the patients' room dispose of apron and gloves in a yellow sack.
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The use of alcohol hand disinfectant is not advised, as these are not effective in killing C . difficile spores.
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Patient transfers to other wards must be kept to a minimum in order to prevent potential spread of infection. Should the patient require transfer for clinical reasons, the receiving ward must be informed of the patient's infectious status to enable side room accommodation to be identified. The transfer of symptomatic patients to another hospital or facility should be avoided if possible. If it is nessessary, infection control staff should be informed and the receiving hospital should be infomed both verbally and in the written handover.
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A stool chart must be implemented and updated following every bowel action. Stools charts should record daily if a patient does not have their bowels open in order to prevent patients becoming constipated.
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The patient may be removed from isolation for C. difficile infection when a 'symptom free status' has been achieved. This is normally regarded to be 48-72 hours free of diarrhoea or of normal formed stools. Patients with underlying bowel disorders who did not have semi-formed 'normal' stools prior to infection should be assessed by the ICT on an individual patient basis following two courses of antibiotic therapy. (Toxin tests are not used as a "test of cure".)
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The GP must be notified of the patients C. difficile episode at discharge.
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No special precautions are required for deceased patients.
5.2. Clinical patient management
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Appropriate fluid and electrolyte replacement is a vital component of general treatment.
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STOP ANTIBIOTICS if possible.
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If the patient is very ill, or the antibiotics cannot be stopped or the diarrhoea does not settle within 48 hours of stopping antibiotics.
- 1st choice Metronidazole 400mg tds orally for 7-10 days.
- 2nd choice Vancomycin 125mg qds orally for 7-10 days.
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Patients who experience prolonged C. difficile diarrhoea (>4 weeks) should be managed with advice from a consultant microbiologist.
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Repeat faeces specimens for C. difficile toxin testing are not necessary within 1 month of diagnosis.
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Patients who develop diarrhoea following a period of being symptom free may have been re-infected or relapsed. These patients must be isolated immediately and a faeces specimen sent for C. difficile toxin testing if more than one month since the previous toxin positive result.
5.3. Localised cluster of cases
The ICT will inform the relevant clinical Team if a potential cluster of hospital acquired C. difficile infection has been detected. ICT to review cases involved, including ward moves and exposure to other cases. (see Outbreak Management)
In addition to guidance provided for 'sporadic cases', the following measures will be implemented:
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ICT to inform Director Infection Prevention and Control (DIPC), chief nurse, relevant divisional clinical leads, senior nurses in addition to ward sister. This information will be cascaded to appropriate trust personnel according to location and requirements.
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Instigation of enhanced patient monitoring within the affected area by ICT to identify potential further cases, with daily reporting of situation to DIPC and chief Nurse.
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Control of staff deployment to other areas to ensure adequate staffing levels are present and to prevent transmission of C. difficile.
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Enhanced promotion of hand hygiene to raise awareness locally, with particular emphasis on the use of soap and water.
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Restriction of patient transfers and admissions to/from affected area (ward/bay) for 48 hours to prevent 'seeding' of infection to other areas.
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Patients in the affected area who develop diarrhoea/loose stools must have faeces specimens sent for C . difficile toxin testing. All patients in the affected area must have stool charts implemented.
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Typing of C. difficile isolates to be requested
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Staff working on the ward must change their uniforms on a daily basis. Sufficient supplies of uniforms must be available.
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Additional cleaning should be arranged using 5% hypochlorite solution e.g. Actichlor plus. This should focus on the near patient environment and particularly toilet areas. The domestic supervisor should be included in discussions about enhanced cleaning to ensure continuity.
5.4. Outbreaks
The identification of more than 3 cases per week of hospital acquired infection, for 2 consecutive weeks in a defined area will initiate specific actions by the ICT and DIPC in order to manage a potential outbreak of C. difficile .
In addition to guidance provided for localised clusters, the following additional measures will be implemented:
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ICT and DIPC and Chief Nurse should consider the need to form an outbreak committee. Chief Executive to be informed of decision.
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Potential outbreak to be reported to HPA and SHA by ICT with completion of Serious Untoward Incident (SUI) forms (Healthcare Associated SUI form to be submitted to HPA by ICT, trust SUI form to be submitted to SHA).
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Restriction on admissions to and transfer from all affected area(s).
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Resolution of the cluster/outbreak will be confirmed by the ICT. Following confirmation, the affected area will undergo a 'terminal' clean of the whole ward environment, including all patient equipment with a 5% solution of hypochlorite detergent. A full curtain change is required.
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Patients may not be admitted to the ward until the 'terminal' clean is completed and the nurse in charge is happy with the standard of cleanliness.
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Audit of outbreak management to be undertaken by the ICT utilising the Dept of Health Saving Lives High Impact Intervention no 6 - C . difficile. Results of the audit to be submitted to the Risk Management Committee.
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