Note to learner. In 2016, Clostridium difficile underwent a name change to Clostridioides difficile. Throughout the presentation, we may still refer to Clostridioides difficile by its previous name, Clostridium difficile. However, for the purposes of this learning module, the names will be interchangeable. Preventing Clostridium difficile transmission and infection continues to represent a serious and difficult challenge in infection prevention and residents safety. In this module, you will learn about how C. difficile is spread and best practices for preventing the spread of the germ in your facility. The learning objectives for this module are to describe the epidemiology of C. difficile, describe how C. difficile is spread, describe the control measures for C. difficile. Clostridium difficile is a rod shaped spore forming bacteria that is normally found in the intestines. It causes disease by producing toxins and is transmitted by the fecal-oral route, meaning it has to be ingested. C. difficile infection is one of the most common health care acquired infections that frequently causes life-threatening diarrhea in elderly persons residing in nursing homes. In 2000, a stronger strain of the bacteria emerged, which is more virulent than previous strains. CDC estimates that there are 500,000 infections and 15,000 deaths per year. Infections and deaths due to C. difficile have increased dramatically since 2011, with approximately one-third of the infections occurring in people aged 65 and older. Patients in the hospital with C. difficile infection are more likely to be discharged to a long-term care facility. Recent data shows that 41.5 percent of patients hospitalized with C. difficile are discharged to long-term care facilities. As a result, a significant number of individuals may be carrying C. difficile on admission to a long-term care facility and up to 20 percent may acquire the organism during their stay. As a consequence of the high numbers of residents already admitted to long-term care facilities with C. difficile from the hospital and the subsequent colonization of other residents. The prevalence of C. difficile colonization in nursing homes has been reported to be as high as 46 percent. Now, let's tune back into Gowns and Gloves and see how Elaine reacts to her new diagnosis. Previously on Gowns and Gloves. Has David's Hollywood romance with Minerva inadvertently created complications for his grandmother, Mrs. Houston? How will his love story end? More importantly, will Mrs. Houston receive her own storybook ending? Find out on on Gowns and Gloves. Hello Mrs. Houston, it's your lucky day. Is the last day of your antibiotic treatment. How can I be when I'm in so much pain? My stomach is in pieces. I have the big J. You mean diarrhea? Yes. A lot and often. I'm so sorry. That sounds very uncomfortable. I just feel drained. Good morning, darling. How are you feeling today? Today is the last day of your antibiotic treatment. Unfortunately, Mrs. Houston is not feeling well today. She's had to make frequent trips to the bathroom yesterday and today for about of diarrhea. The big day. What is going on with Elaine? I think you may have another infection, Mrs. Houston. Sometimes people taking antibiotics can be affected by a bad bug called Clostridium difficile. Given the symptoms you told me about, I have a feeling this may be the case. I'll call Dr. Kennedy. You keep drinking your fluids. Cut. That is great stuff. You all are really learning. Clostridium difficile or C. diff, is the most frequent cause of antibiotic associated diarrhea in nursing homes? Yeah. But is there anything my care could have done to prevent this? Unfortunately, C. diff is a side effect of receiving antibiotics. It is more common in persons over the age of 65 and among long-term residents in nursing homes and other health care facilities. Now, the best way for residents to reduce their chances of getting C. diff is to wash hands frequently with soap and water, especially after using the bathroom, before eating and before and after group activities. You should also remind your nurse and others entering your room to wash their hands before and after having contact with you. Back to action. I am sorry, you are feeling badly. Thank you. I'm just disappointed because today we were going to tell [inaudible] our secret. What secret? Let's say, secret recipe. You know the brownies that you and Elaine were talking about? You both have secret family recipes and Elaine was going to share hers with you. Oh how sweet? I'll have to show you mine so we can compare. It was my mother's recipe. When I was little, I never liked birthday cakes, so she used to make me birthday brownies. She said it was a secret family recipe. That's all I ever knew about my mom's family. Secret family recipe for birthday breakfast. At least it's a happy memory. My mom died when I was nine. I know. I mean, great detail though. True. The brownies really are fantastic, but we've got more important things at hand. We need to help you get this diarrhea cleared up. You mean the big D? Yes the big D. I need to make sure that you are clean and comfortable and I'd like to get a stool sample. Mr. Houston, I mean, Dimitre, would you excuse us? Yeah, of course. The major factor contributing to acquisition of C. difficile is systemic antibiotic use. Antibiotic exposure increases the risk of C. difficile infection by at least sixfold within the first 30 days and threefold for three months following exposure. Up to 85 percent of patients with Clostridium difficile infection have antibiotic exposure in the 28 days before infection. Antibiotic use increases the risk for C. difficile disease for the next 60 days. Older age has also been recognized as an important risk factor for C. difficile acquisition and development of severe C. difficile disease. This is likely due to a number of age-related changes to the composition of the fecal flora, blunted immune responses, and reduced gastric acidity. Older adults often also have more than one condition at the same time, which can impact the ability to fight off infections. Recurrent hospitalizations, and increased length of stay in health care also increases the risk for acquiring C. difficile. The microbial flora of the intestines is incredibly diverse, with 200-1000 different species of microorganisms, comprising about 100 trillion bacteria. When this ecosystem is intact, it helps us digest food, produce vitamins, and keep our immune systems in balance. It also provides protection to the intestines from invading microorganisms. This is called colonization resistance. Antibiotic therapy plays a central role in the pathogenesis of C. difficile infection, particularly clindamycin, third-generation cephalosporins, penicillins, and fluoroquinolones. When antibiotics are consumed, the diversity and numbers of microorganisms in the gut is drastically altered and reduces colonization resistance, making colonization and disease with C. difficile more likely. If C. difficile is ingested while the gut flora is suppressed, it can colonize the gut and start producing toxins. If the immune response to the toxins is high, diarrhea will not develop. Conversely, if the immune response to the toxins is low, residents can go on to develop disease. C. difficile resolves when it is treated with antibiotics, allowing the immune system to respond and normal gut flora to re-establish itself. Illness associated with C. difficile infection can range from mild diarrhea to potentially fatal pseudomembranous colitis, toxic megacolon, and death. The typical signs and symptoms of the disease are watery diarrhea with crampy lower abdominal pain, often accompanied by fever, nausea, and anorexia. These symptoms generally last for up to 20 days depending on the severity of the illness. Symptoms of pseudomembranous colitis are generally more severe with diffuse abdominal pain, distension, and the absence of diarrhea, which is due to a paralyzed bowel or toxic megacolon. Toxic megacolon is an enlarged colon that can perforate, leading to peritonitis and death. Back at Sunnyside, let's see how the staff uses infection prevention practices to control the spread of C. diff. Priscilla, haven't seen anything like this. First MRSA, then the flu, and now C. difficile. I don't get it. You and the other nurses are washing your hands, right? As best I can tell, everyone is using proper hand hygiene like they should. I don't think the three Ps are being followed. The triple threat, product, practice, perfection. Well, I could talk about cleaning all day. I was going to go into environmental services if nursing didn't work out. Earth to Vanessa. The C. diff outbreak really concerns me. We need to get everyone cleaning properly and fast. I just learned that Ms. Turner is infected too. Let's cut right there. Priscilla, let me show you this diagram to help explain why she's concerned. It shows how C. diff is spread in health care facilities. You can see here that the two main routes of infection are; by contaminated healthcare workers' hands, or by contaminated environment. If the environmental services staff isn't cleaning well and using bleach to disinfect the rooms of residents with C. diff, then that could lead to other residents getting colonized or infected. Yes, exactly. Environmental cleaning disinfection is critical to fighting the transmission of infection. Action. We need to spearhead this disinfection process. Let's make sure the staff is cleaning well and using a 1:10 bleach solution, to clean shared equipment and rooms occupied by residents with C. diff. Sounds good. I'll make sure that the nursing staff uses good hand hygiene when providing care to the affected residents. Be sure to specify that they must use soap and water, not alcohol-based rubs because only hand hygiene with soap and water will effectively remove the C. diff spores. Action. I'll make sure that the nursing staffs properly washes their hands using soap and water. Yes. We all have to work together to get this fixed and fast. The two major reservoirs for C. difficile in healthcare settings are infected people and environmental surfaces, with symptomatic people comprising the major reservoir. Studies looking at contaminated surfaces in healthcare settings have demonstrated that room contamination with C. difficile spores can reach 75 percent of surfaces in rooms of infected people. They have also found spores in rooms of people who do not have C. difficile, indicating that cross-transmission is occurring. Not surprisingly, bathrooms of infected people are also heavily contaminated with C. difficile spores. If environmental surfaces in the resident rooms and bathrooms are not adequately disinfected with an EPA-registered sporicidal disinfectant, these surfaces can play a role in cross-transmission. C. difficile spores are very hardy in the environment and can survive up to five months on surfaces that are not adequately cleaned and disinfected using an EPA-registered sporicidal agent. There is data to suggest that many surfaces in healthcare environments are not adequately cleaned, which increases the risk for cross-transmission even if the person with C. difficile is no longer in the room. Patients and health care personnel can transmit and acquire C. difficile from contact with contaminated surfaces and infected people. Studies have shown that 25 percent of health care providers' hands are contaminated with C. difficile spores after caring for infected patients. If the provider fails to wear gloves and wash their hands properly with soap and water, this can lead to cross-transmission to other residents or themselves. Now back to Sunnyside to see how Elaine is doing. Mrs. Houston, I told you we have to move you to this room to ensure that the Clostridium difficile does not spread across the entire facility. I'm sure you don't want anyone to experience the discomfort you've been experiencing. I should've let Priscilla help with this time. Well, now Elaine, it won't be so bad to spend a few days here with Miss? Turner. Ms. Turner, I'm Dmitri Houston. I'm Elaine's husband. We've become, well, regulars here at Sunnyside. Regular, I would like to be regular, is it that why they put us in this room? Well, kind of. This is called cohorting. You both have acquired a bad bug called Clostridium difficile, or C diff for short. When we have a bad bug like C diff in the facility, we tried to put residents with the same bad bug together so that we can minimize the transmission of a bug across the entire facility. In other words, they've sent us to Siberia. Why don't you two introduce yourselves? The best laid plans. What do you mean? Can you keep a secret? Of course. I think my granddaughter works here. What do you mean, you think your granddaughter works here? Don't you know? Not for sure. It's complicated. You see [inaudible] That is some story. I told you it's complicated. I just want to get everything out in the open. Before I- Get another infection. Mrs. Houston, look who I have found. David, you're a site for sore eyes. I've missed you. This is my new friend, Jacqueline. Jacqueline, this is my grandson, David. Hi, Jacqueline. Nice to meet you. Sorry, it has to be under these circumstances. Oh, Elaine and I are making the best of it; aren't we, Elaine? Yes. She'd been very kind to put up with my rambling. Elaine, before I forget, I have something I want to show you that's going to cheer you up and get you excited for the outside world again. It's my secret family recipe for brownies. Let me take a look at that. It's funny. Wait a minute. This is our secret family recipe. What are you talking about? What other secret family recipe calls for cayenne pepper and the brownies? Ours does. Priscilla, I didn't know. But now I think I know. Elaine spit it out. Priscilla, do you know who this is? Mom. What are you doing with a picture of my mom? Priscilla, your mom is my daughter, Elizabeth. We were estranged for many years before she died. She kept herself away from me. Kept you away from me. From the day you were born. As time went by, the reason for her estrangement faded , we never spoke again. You have no idea how many years a long awaited to be able to find you, and to give you my locket. Hey Cuz. Elaine, what's going on? I'll tell you what's going on. You and your wife have been sneaking around Sunnyside Nursing Home, picking up every infection you possibly could, feeling sick, fighting off illnesses just to get close to me, just to find out if we're family. Wow, you really do care about me. Now, can we give grandmother and granddaughter a chance to reconnect? Everybody, Just leave Elaine and Priscilla and me alone, give us some privacy. You can pull this curtain for some privacy. Not that far. Yes, dear. I found them all. Everything is in place for your return. The first step in preventing C. difficile is to prescribe and use antibiotics carefully. This includes not prescribing antibiotics when they are not needed, such as with asymptomatic bacterial colonization and upper respiratory infections, and avoiding the just in case prescription. Decisions to prescribe should be justified by clinical findings and driven by culture results. If an antibiotic is prescribed, ensure that the orders include: a dose, duration, and indication. When culture results come back in 24-48 hours, take an antibiotic timeout to reassess therapy. It is important to decide if the antibiotic is still needed and more importantly, that the antibiotic is still effective against the organism. A timeout is particularly helpful in long-term care facilities where the clinician is not often on-site when prescribing the antibiotic or when culture results are reported. It is also important to monitor antibiotic prescribing practices within your facility. For instance, monitor prescribing practices around urinary tract infections and monitor for episodes when treatment was not indicated. This can be done by an infection preventionist who can feed back the information to: the administration, clinical leadership, and prescribing clinicians. Finally, you can consider developing institutional specific guidelines and clinical pathways to direct prescribing to locally identified problem areas. The next step in controlling C. difficile is to test residents when they have diarrhea while on antibiotics or within two months of receiving them. If C. difficile is suspected, notify the physician and obtain a stool sample for toxin testing. It is important to immediately place residents with confirmed or suspected C. difficile on enteric precautions. This should be done as soon as the test is ordered to prevent transmission or spread. Waiting two or three days for results could allow other residents to be exposed, and the resident could become very ill. It is important that staff and visitors wear gowns and gloves when entering the room. Even if they are not going to touch the resident. Hands should be washed with soap and water or disinfected with an alcohol-based hand rub. During outbreaks of C. difficile related infections, washing hands with soap and water after removing gloves is prudent. It is also important that any equipment such as blood pressure cuff, stethoscope, or thermometers be dedicated to residents with C. difficile. If this is not possible, these shared items should be disinfected using1-10 dilute bleach solution or an EPA registered sporicidal disinfectant between uses to prevent cross transmission. Residents should remain on enteric precautions until the diarrhea has resolved, and have formed stools for 48 hours. It is not necessary to perform a test because spores will still be present. In an ideal situation, a private room with an attached bathroom is preferred for managing residents with C. difficile infections. However, this arrangement is not common in most long-term care facilities. Managing a resident's diarrhea can often be difficult in a semi-private room with a shared bathroom. If a roommate is not optional, two residents with C. difficile can be cohorted in the same room. Or a C. difficile infected resident can be placed with a roommate who does not use the bathroom. If neither of these options is available, select a roommate who is not taking antibiotics and is not compromised to the point of being susceptible to infection, and having the non C. difficile infected resident use a bedside commode. In the event that a C. difficile infected resident has to use a bedside commode, the commode should be lined with a plastic bag and absorbent material to reduce health care personnel exposure to fecal material. In order to preserve the dignity of residents and use the least restrictive approach to managing a resident with C. difficile. Some residents may be able to ambulate in the facility and participate in social activities. Assess the resident's bowel control and personal hygiene. If able to maintain bowel control and perform hand hygiene appropriately, allow the resident to participate in activities when possible. Prior to leaving the room, have the resident wash their hands, place a clean gown over the resident's clothing, and disinfect any assistive devices. Any health care personnel who are assisting with ambulation should wear gloves and avoid touching items outside the resident's room without first removing the gloves and washing their hands. A gown may be needed if the workers are going to have more than hand contact with the infected resident. For those residents with chronic mental illness or dementia, it is not always possible to ensure good compliance with control measures. Under these conditions, it may be appropriate to provide one-to-one caregiving. As we stated previously, the environment plays an important role in the transmission of C. difficile. Because C. difficile is shed in diarrhea, any surface item or medical device can become contaminated with spores and contribute to infection transmission. It is important that facility policies include strategies to prevent transmission from infected resident rooms to other parts of the facility. If environmental contamination is not controlled, and contamination of health care personnel also increases. It is important to clean frequently, thoroughly and with the right product. Disinfectants normally used in health care settings. Usually, quaternary ammonium compounds and phenolics are not sporicidal and will not kill C. difficile spores. Only chlorine based disinfectants like bleach and a few newer EPA registered sporicidal agents are able to kill spores on surfaces and equipment. Generally, most facilities use a 1-10 bleach solution for C. difficile room cleaning. This solution is easily prepared by mixing one part household bleach with nine parts water. Frequently touched surfaces like the bed rail, call button, telephone, bathroom surfaces, and overbed and bedside tables should be cleaned daily to reduce microbial contamination and hand transmission by healthcare workers. Any shared resident care items like blood pressure cuffs, stethoscopes, thermometers, and lifts should be dedicated to infected residents if possible, or be disinfected with an EPA approved sporicidal disinfectant or bleach solution before being used on another resident. The entire room should be cleaned when the resident is discharged. Failure to clean all surfaces on a terminal cleaning can put the next resident occupying the room at risk for acquiring C. difficile. To learn more about environmental cleaning, see the environmental disinfection module, Module 4. The final component of protecting against C. difficile transmission is to improve communication when a resident is transferred to another facility. When transferring a resident with an active C. difficile disease or recent history of a C. difficile disease, it is important to relay this information to the receiving facility so that proper precautions can be instituted upon their arrival. It is also important to ask for this information when receiving a resident from another facility so that the proper precautions can be utilized upon arrival. Failures in communication between facilities can lead to transmission within a facility because C. difficile infection can go unrecognized for some time. Preventing C. difficile infection and transmission can be done effectively. If you recognize the major reservoirs, understand that thoroughly cleaning the resident's environment and performing hand hygiene can reduce the spread of C. difficile. Recognize and isolate infected residents early using enteric precautions, which should remain in place until the resident has formed stools for 48 hours. Do not test for cure once diarrhea resolves or in order to remove residents from enteric precautions and notify facilities if you are transferring a resident with a C. difficile infection.
