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Winnipeg Regional Health Authority
Infection Prevention & Control Manual
DIARRHEA DISEASE SPECIFIC PROTOCOL FOR COMMUNITY HEALTH SERVICES
Worldwide, acute gastroenteritis is one of the most common diseases in humans. Many
gastroenteritis cases are self-limiting, highly contagious and may be associated with an
increased risk of outbreaks. Disease manifestations range from asymptomatic to
severe, and, in some cases, fatal. Viruses, parasites, or bacteria are the infectious
agents which may cause these episodes
The primary mode of transmission for most gastroenteritis agents is fecal-oral by
ingestion of contaminated food or water
Acute diarrhea is often accompanied by other clinical signs and symptoms including
vomiting, fever, dehydration and electrolyte disturbances.
In most cases in Community Health Services the cause of diarrhea will not be confirmed
by laboratory testing. If a client has acute diarrheal stool Routine Practices should
always be followed.
While Routine Practices are usually adequate for all patients with acute diarrheal stool,
Contact Precautions should be considered for incontinent adults with poor hygiene who
contaminate their environment.
I. Bacterial Diarrhea
Cause/Epidemiology
Many bacterial organisms cause infectious diarrhea illness in humans.
The most common and important are:
 Campylobacter
 Cholera
 Escherichia coli-Pathogenic strains (e.g., 0157: H7)
 Salmonella (including S. typhi)
 Shigella
 Yersinia
Clinical Presentation
Diarrhea is the passing of loose or watery stools and is often associated with
vomiting and fever. Symptoms may be of variable severity.
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Infection Prevention & Control Manual
Incubation Period
Bacterial Microorganism
Incubation Period
Campylobacter
1-7 days
Cholera
1-5 days
Escherichia coli-Pathogenic strain (e.g., 0157: H7)
10 hours-8 days
Salmonella (including S.typhi)
Diarrhea: 6-72 hours
Enteric Fever: 3-60 days
Shigella
1-7 days
Yersinia
1-14 days
Transmission
Transmission can occur: through direct contact via hands, indirectly through
contaminated environmental surfaces and equipment, and/or by ingestion of
contaminated food or water.
Fecal shedding may continue after symptoms have subsided.
Infection Prevention and Control Practices
Consider Contact Precautions:
o For a patient under 6 years of age.
o For a patient with non-contained fecal incontinence
o For a patient with increased probability to contaminate the environment
e.g.; poor cognition, unable to follow instructions, poor hygiene
practices.
 Follow Routine Practices for all other patients 6 years of age and over with
bacterial diarrhea,
 Refer to Routine Practices section and/or Routine Practices policy for specific
information.
 If applicable refer to Contact Precautions in the Additional Precautions
section.
 Refer to the Clinical Presentation/Microorganism/Infectious Disease Table for
specific disease/microorganism information.
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Occupational Health Issues
Definitions of Occupational Exposure
 A healthcare worker who has had direct or indirect oral contact with infectious
feces. Exposure may also occur with ingestion of contaminated food or water.
A Healthcare Worker Exposed to Bacterial Diarrhea
 No modifications to work practices or work restrictions
A Healthcare Worker Symptomatic or Infected with Bacterial Diarrhea
 Physician/Laboratory confirmed diagnosis
 Healthcare workers shall be referred to Occupational Health for clinical
management
 Healthcare workers with diarrhea shall be excluded from work until stools are
formed
II. Clostridium difficile Associated Diarrhea (CDAD)
Cause/Epidemiology
Clostridium difficile (C. difficile) is the most common cause of antibiotic associated
diarrhea. It is a spore forming gram-positive bacillus which produces toxins causing
the diarrhea. Clostridium difficile associated diarrhea (CDAD) is one of the most
common and costly healthcare-associated infections.
Children 1year of age and under, are commonly asymptomatic carriers of
Clostridium difficile bacteria. Previous antibiotic use increases the prevalence. In
healthy children with antibiotic associated watery diarrhea, discontinuation of the
antibiotic is usually sufficient to resolve the diarrhea. In this age category, it is not
recommended to send a stool for C. diff culture/toxin.
CDAD can be minimized by the practice of good antimicrobial stewardship as part of
the infection prevention & control effort.
Risk factors for acquiring CDAD include:
 A prolonged hospital stay
 Previous antibiotics
 Contact with someone with the disease
 Individuals who are very young or very old
 Chronic underlying disease or health condition
 Intestinal tube feeding
 Individuals who have had gastrointestinal surgery/manipulation
 Use of agents which alter normal intestinal motility
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Clinical Presentation
Signs and symptoms of CDAD include:
 Loose watery stools
 Abdominal pain and cramping
 Fever
 Mucous or blood in the stool and dehydration
 A characteristic odor to the stool
Pseudomembraneous colitis (PMC) is a more severe form of CDAD in which
patients exhibit a colitis characterized by the presence of pseudomembranes on the
colon surface.
The overall mortality is usually low in patients with CDAD because of effective
treatment. Recurrence of CDAD after treatment occurs in 15 - 25% of patients.
Incubation Period
Variable
Transmission
Transmission occurs: through direct contact via hands, or indirectly through
contaminated environmental surfaces and equipment. C. difficile has the ability to
produce spores, enabling it to survive for months in the environment, with ongoing
transmission.
Infection Prevention and Control Practices
 Perform hand hygiene at the point of care using soap and water. If a sink is not
available at the point-of-care use alcohol-based hand rub. Perform hand hygiene
with soap and water as soon as a sink is available
 Routine Practices are usually adequate for all patients with acute diarrheal stool,
Contact Precautions should be considered for incontinent adults with poor
hygiene who contaminate their environment.
 If applicable refer to Contact Precautions in the Additional Precautions section
 Refer to the Clinical Presentation/Microorganism/Infectious Disease Table for
specific disease/microorganism information
 If using Contact Precautions discontinue them when the patient has had at least
48 hours without diarrhea (e.g., formed or normal stool for the individual)
 Re-testing to test for cure or determine discontinuation of Additional Precautions
is not recommended
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Occupational Health Issues
Definitions of Occupational Exposure
 A healthcare worker who has had direct or indirect oral contact with infectious
feces. Exposure may also occur with ingestion of contaminated food or water.
A Healthcare Worker Exposed to C. difficile
 No modifications to work practices or work restrictions
A Healthcare Worker Symptomatic or Infected with C. difficile
 Physician/Laboratory confirmed diagnosis
 Healthcare workers shall be referred to Occupational Health for clinical
management
 Healthcare workers with diarrhea shall be excluded from work until stools are
formed
III. Diarrhea: Other Infectious Microorganisms
Cause/Epidemiology
Protozoa are microscopic, one-celled organisms that can be free-living or parasitic in
nature. They are able to multiply in humans, leading to serious infections. The
following protozoan infections are most common to humans:



Amebiasis, caused by Entamoeba species
Giardiasis, caused by Giardia lamblia species
Crytosporidiosis, caused by Cryptosporidium
Clinical Presentation
The symptoms vary according to the specific microorganism. Some infections do not
have symptoms while others can cause diarrhea, nausea, vomiting and abdominal
pain as well as bloody stools.
Incubation Period
Microorganism
Incubation Period
Entamoeba species
Giardia lamblia species
Cryptosporidium parvum
Days to weeks
2-14 days
1-4 weeks
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Transmission
Transmission occurs: through direct contact via hands, or indirect contact through
contaminated food, water, environmental surfaces and equipment.
Shedding of these microorganisms can continue even after symptoms have
subsided.
Infection Prevention and Control Practices
Consider Contact Precautions:
o For a patient under 6 years of age.
o For a patient with non-contained fecal incontinence
o For a patient with increased probability to contaminate the environment
e.g.; poor cognition, unable to follow instructions, poor hygiene
practices.
 Follow Routine Practices for all other patients 6 years of age and over with
diarrhea.
 Refer to Routine Practices section and/or Routine Practices policy for specific
information.
 If applicable refer to Contact Precautions in the Additional Precautions
section.
 Refer to the Clinical Presentation/Microorganism/Infectious Disease Table for
specific disease/microorganism information.
Occupational Health Issues
Definitions of Occupational Exposure
 A healthcare worker who has had direct or indirect oral contact with infectious
feces. Exposure may also occur with ingestion of contaminated food or water.
A Healthcare Worker Exposed to Infectious Diarrhea
 No modifications to work practices or work restrictions
A Healthcare Worker Symptomatic or Infected with Infectious Diarrhea
 Physician/Laboratory confirmed diagnosis
 Healthcare workers shall be referred to Occupational Health for clinical
management
 Healthcare workers with diarrhea shall be excluded from work until stools are
formed
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IV. Viral Diarrhea
Cause/Epidemiology
Viruses are recognized as a leading cause of acute gastroenteritis. Many different
viruses can cause gastroenteritis. Norovirus, also known as Norwalk-like virus or
small round enteric virus (SREV) is part of a larger family of human viruses called
caliciviridae that can cause gastroenteritis. Norovirus has been associated with
outbreaks on cruise ships, as well as hospitals and nursing homes. Rotavirus,
adenovirus, astrovirus and coxsackievirus are other viruses and are more common
in children under the age of four.
Clinical Presentation
Viral gastroenteritis can vary from asymptomatic to severe disease leading to
dehydration and death. Symptoms include sudden onset of vomiting and non
bloody, watery diarrhea, with abdominal cramps and nausea. Low grade fever may
also occur. Diarrhea is more common in children than vomiting. Symptoms usually
last anywhere from 48 to 72 hours; dehydration is the most common complication.
People of all ages may be infected but the greatest severity is at extreme ages such
as young children and the elderly.
Incubation Period
Viral Agent
Incubation Period
Norovirus, Calcivirus (SREV)
12-48 hours
Rotavirus
1-3 days
Coxsackievirus
3-6 days
Adenovirus
3-10 days
Astrovirus
1-4 days
Transmission
Transmission occurs through direct contact of fecal microorganisms via hands, or
indirect contact through contaminated food, water, environmental surfaces and
equipment.
Shedding of these microorganisms can still occur after symptoms have subsided.
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Infection Prevention & Control Manual
Infection Prevention and Control Practices
Consider Contact Precautions:
o For a patient under 6 years of age.
o For a patient with non-contained fecal incontinence
o For a patient with increased probability to contaminate the environment
e.g.; poor cognition, unable to follow instructions, poor hygiene
practices.
 Follow Routine Practices for all other patients 6 years of age and over with
viral diarrhea,
 Refer to Routine Practices section and/or Routine Practices policy for specific
information.
 If applicable refer to Contact Precautions in the Additional Precautions
section.
 Refer to the Clinical Presentation/Microorganism/Infectious Disease Table for
specific disease/microorganism information.
Occupational Health Issues
Definitions of Occupational Exposure
 A healthcare worker who has had direct or indirect oral contact with infectious
feces. Exposure may also occur with ingestion of contaminated food or water.
A Healthcare Worker Exposed to Viral Diarrhea
 No modifications to work practices or work restrictions
A Healthcare Worker Symptomatic or Infected with Viral Diarrhea
 Physician/laboratory confirmed diagnosis
 Healthcare workers shall be referred to Occupational Health for clinical
management
 Healthcare workers with diarrhea shall be excluded from work until stools are
formed
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References
1. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious
Agents in Healthcare Settings, Appendix A-Gastroenteritis. CDC. Retrieved March
19, 2010 from: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf
2. Communicable Disease Management Protocol, Clostridium difficile Associated
Diseases (CDAD). (September, 2006). Winnipeg, Manitoba: Manitoba Health,
Communicable Disease Branch. Retrieved March 19, 2010 from:
http://www.gov.mb.ca/health/publichealth/cdc/protocol/cdifficile.pdf
3. Enteric Illness Protocol. (March, 2008). Winnipeg, Manitoba: Manitoba Health,
Communicable Disease Branch. Retrieved March 19, 2010 from
http://www.gov.mb.ca/health/publichealth/cdc/protocol/enteric.pdf
4. Gerding, D. (ed) Clostridium Difficile Infection and Pseudomembranous Colitis: in
APIC Text of Infection Control and Epidemiology. 3rd edn. (2009). Chapter 76, p.76-1
to 76-6. Washington, DC. APIC.
5. Summaries of Infectious Diseases, Section 3, pp 204-206, 225. (2009). Retrieved
March 19, 2010 from: American Academy of Pediatrics Red Book Online Red Book®
Online -- Table of Contents (2009)
6. Best Practices for Hand Hygiene in All Health Care Settings (2010) Provincial
Infectious Disease Committee (PIDAC). Available at:
http://www.publichealthontario.ca/en/eRepository/201012%20BP%20Hand%20Hygiene.pdf
7. Public Health Agency of Canada (2011) Fact Sheet - Clostridium difficile (C. difficile).
Available at: Fact Sheet – Clostridium difficile (C. difficile) - Public Health Agency of
Canada
8. Routine Practices and Additional Precautions: Preventing the Transmission of
Infection in Healthcare (2012) Manitoba Health. Available at
http://www.gov.mb.ca/health/publichealth/cdc/docs/ipc/rpap.pdf
9. Guide to Preventing Clostridium difficile Infections (2013) Association for
Professionals in Infection Control (APIC) available at:
http://apic.org/Resource_/EliminationGuideForm/e3a85b7e-7ad8-4ab6-989254aef516cf10/File/2013CDiffFinal.pdf
10. Clostridium difficile Infection-Infection Prevention and Control Guidance for
Management in Acute Settings (2013) Public Health Agency of Canada (PHAC)
available at http://www.phac-aspc.gc.ca/nois-sinp/guide/c-dif-acs-esa/index-eng.php
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