Download CDAD Recommendations for LTC 9-19-08

State of Maine Recommendations for the Prevention and Control of
Infectious Conditions in Long Term Care Facilities
Chapter Two: Clostridium difficile-Associated Disease (CDAD)
Introduction and Background
CDAD is increasing in incidence and severity across the United States. As early as 2001, several
hospitals in the United States identified outbreaks with a strain of Clostridium difficle which
appears to be responsible for the increase in incidence and severity. In 2003 this strain was
identified in two Maine hospital outbreaks. Currently, this strain can be found in at least 38 states
and in several countries across the globe.
Antibiotic-associated diarrhea is common among LTCF residents. C. difficile has been identified
as the most common infectious cause of acute diarrheal illness in nursing homes. Early
recognition, strict infection control precautions and appropriate treatment have been used to
prevent transmission of this severe disease.
This guideline is meant to aid LTCF, including nursing homes, extended care facilities and
assisted housing providers in limiting the spread of CDAD. These guidelines do not take the
place of the interdisciplinary team individualized residents’ assessment and development of the
resident directed plan of care. This document will address the following components:
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Definitions
Understanding of CDAD
Common risk factors for acquiring a CDAD
Evidence Based Practice for Infection prevention and control measures
References
Resources
Appendices (i.e. CDC HICPAC Recommendations for Isolation Precautions,)
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Definitions
Antibiotic-Associated Diarrhea: benign, self-limited diarrhea, following the use of
antimicrobials. Typically no pathogens are identified and the diarrhea is due to changes in the
composition and function of the intestinal flora.
Assisted Living Program: a program of assisted living services provided to consumers in
apartments/rooms in buildings that include a common dining areas, either directly by the
provider or indirectly through contracts with persons, entities or agencies.
Bioburden: The number of microorganisms found on contaminated hands, equipment, furniture,
etc.
Bloodborne pathogens: pathogenic microorganisms that are present in human blood and can
cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus
(HBV) and human immunodeficiency virus (HIV).
CDAD: Group of conditions caused by infection with Clostridium difficile. These conditions
range from diarrhea, pseudomembraneous colitis, toxic megacolon, colonic perforation to death.
Cohort: To place two or more residents colonized or infected with the same pathogen in the
same living quarters.
Cohort staffing: The practice of assigning staff to work with previously designated groups. One
staff only cares for C.diff residents while another staff person only cares for non-C.diff residents.
Contact Precautions: A set of practices used in addition to standard precautions to prevent the
transmission of infectious agents that are spread by direct or indirect contact with the resident or
the resident’s environment.
Practice includes resident placement, barriers (may include gowns, gloves, mask and eye
protection) and hand hygiene.
Diarrhea: Loose stools (taking the shape of a container) greater than or equal to 3 loose stools
within a 24 hours time frame.
H2 Blocker: Medications given to reduce stomach acids. Common examples are ranitidine
(Zantac), cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid), This is not a complete
list.
Healthcare worker: Any individual who works within the confines of a healthcare facility, i.e.
maintenance, housekeeping dietary, nurse, provider, student, volunteer, etc.
Infectious agents: Organisms or pathogens that cause disease in an individual and can be spread
person to person.
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Infection: The condition in which the resident is infected with a pathogen and it is causing signs
and symptoms of infection i.e. redness, wound drainage, fever, swelling, burning with urination,
etc.
Line listing: A type off epidemiologic database, organized similar to a spreadsheet with rows
and columns in which information from cases or residents are listed; each column represents a
variable, and each row represents an individual case or resident
Outbreak or cluster: An increase in the normal incidence of a C.diff in a facility.
Pathogen: A microbe able to cause infection in an individual.
Proton Pump Inhibitors: Medications given to reduce stomach acid. Some examples are
omeprazole (Prilosce), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix),
esomeprazole (Nexium). This is not a complete list.
Standard Precautions: A group of infection prevention practices that apply to all residents.
Standard precautions are based on the principle that all blood, body fluids, secretions, excretions
(except sweat), non-intact skin and mucous membranes may contain transmissible bloodborne
pathogens and other infectious agents. Standard Precautions include hand hygiene, and
depending on the anticipated exposure, use of gloves, gown, mask, eye protection, or face shield.
Standard Precautions also focus on appropriate environmental cleaning, cleaning of shared
patient equipment and exposure prevention.
Understanding CDAD
CDAD can range from colonization, uncomplicated diarrhea, to sepsis and even death. More
than 90% of health-care associated C. difficile infections occur after or during antibiotic therapy.
Spread of C. difficile has been well documented, occurring primarily person-to person through
contaminated hands and via contamination of the patient care environment. The most effective
means of decreasing spread of C. difficile has been a combination of vigilant hand hygiene,
meticulous environmental cleaning and use of standard and contact precautions.
Common Risk Factors for Acquiring CDAD
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Antibiotic exposure
Proton Pump Inhibitors and H2 Blockers
Exposure to hospital or LTC environments
Proximity to CDAD patients
GI surgery
Age
Chemotherapy
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Early Recognition of CDAD Residents
Testing and Stool Collection
 Encourage testing of any resident who has risk factors for acquisition of CDAD and
diarrheal stools
o Facility specific standing orders may be helpful
 Do Not test formed stool. (Formed stools are not helpful for testing for CDAD diagnosis)
 Follow laboratory specific guidelines for stool collection and handling. i.e. stool must be
refrigerated during transport.
 Maximum of one test per 24 hour period when testing for the diagnosis of CDAD.
 Any resident, who continues with symptoms in spite of a negative test, should continue
on standard and contact precautions.
 Do NOT test for Cure (Once resident’s normal bowel function returns, discontinue
precautions)
Precautions
Standard Precautions and Contact Precautions for C.diff
Standard Precautions are defined by the Centers for Disease Control (CDC) as a group of
infection prevention practices that apply to all residents.
For the CDAD residents (either suspected or confirmed) the following precautions will also
apply:
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Hand Hygiene –
o Performed prior to and after every resident contact.
o Hand hygiene consists of routine hand washing with soap and water.
o Do Not Use Alcohol Based Gel or hand sanitizers.
 Alcohol is not effective against C.diff spores.
o Hand hygiene must always be performed before putting gloves on and after
glove removal
o Special attention should be paid to meticulous mechanical friction of handwashing to physically remove spores
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Soap and Water Hand Hygiene Proper steps for Success
o Wet hands first with water,
o Apply an amount of product recommended by the manufacturer to hands,
o Rub hands together vigorously for at least 15 seconds, covering all surfaces of
the hands and fingers.
o Rinse hands with water and dry thoroughly with a disposable towel.
o Use towel to turn off the faucet
o Avoid using hot water, because repeated exposure to hot water may increase
the risk of dermatitis
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Gloves – wear gloves
o Any time you will be in contact with the resident
o Any contact with items in the resident’s environment
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Gowns –
o Worn during procedures and resident care activities when there may be
anticipated contact of the healthcare worker’s clothing or exposed skin with
blood, body fluids, secretions, excretions (except sweat), mucous membranes
and non-intact skin. (i.e. complete bed baths, complete bed changes, changing
incontinent residents, etc.) The purpose is two fold: to protect the employee
and to keep the uniform from being contaminated and reducing risk of
transmission to other residents cared for by the employee.
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Masks with eye protection and/or face shield - worn during procedures and patient
care activities that are likely to generate splashes.
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Resident care equipment –
o All shared resident equipment must be cleaned as described below between
each resident use. (i.e. clean blood pressure cuffs, pulse oximeters and
stethoscopes).
o A facility may have different options for equipment including the following:
1. a resident may have disposable equipment
2. a resident may have designated equipment that is well cleaned or
disposed of after the resident leaves the facility
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Environmental surfaces
o CDC recommends the use of a bleach solution of 1:10. This solution remains
effective if it is made up daily.
o Special attention should be paid to meticulous mechanical friction of cleaning
to physically remove spores.
o Cleaned and disinfected on a routine basis with extra attention to frequently
touched surfaces. (i.e. doorknobs, over the bed tables, bathrooms, etc)
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Textiles and laundry
o handled in a manner that prevents spread/transfer of microorganisms to the
environment and others. (i.e. when removing soiled/used linen from the
residents bed, do not shake linen, or hold linen against healthcare workers
clothing)
o Currently there are no guidelines for noncommercial laundry machines used in
some assisted housing settings.
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Needles and other sharps - utilize sharps protective devices to prevent puncture
transmission of infection per facility policy.
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Resident resuscitation - performed with a mouth piece with a one-way valve,
resuscitation bag or other ventilation device.
Discontinuing Contact Precautions
 CDC guidelines recommend resolution of symptoms i.e. No diarrheal stools for 24 hours
 NO Testing for Cure is recommended
Infection Prevention and Control Guidelines for Residents with CDAD
1. Surveillance and Monitoring of Residents with a CDAD
Surveillance for CDAD in LTC facilities is very important. It allows the facility staff to know
which residents are infected with CDAD, enabling them to perform appropriate measures to
contain and prevent the spread of this pathogen. Additionally it provides information on whether
there is an increase in transmission of CDAD infections in the facility. The following are
methods to identify and track residents with a CDAD:
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Designate an individual or individuals to routinely review culture reports on all residents,
so as to be aware as soon as possible when a resident becomes positive for CDAD.
(Inform providers (physician or midlevel’s) of any reports of CDAD).
Use of standardized surveillance definitions is helpful when comparing data
Encourage testing of any resident who has risk factors for acquisition of CDAD AND
diarrheal stools (defined as taking the shape of the container)
Quality improvement based review of infection rate data to determine if CDAD rates are
maintaining, decreasing or increasing in each facility. The goal being to have as little
transmission (lowest infection rates) as possible.
2. Acknowledgement of Residents with a CDAD
Note: Infection with CDAD cannot be the sole criteria for admission refusal or premature
discharge.
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Upon admission to the facility, verify with the referring facility if the resident has had a
current infection with Clostridium difficle.
When sending a resident to another facility (hospital or residential care), it is important
for the sending facility to alert the accepting facility of the patient’s diagnosis of CDAD.
Communication between staff about the resident diagnosis of CDAD will occur in such a
way that ensures proper care and safety without compromising the resident’s privacy and
integrity.
o There are different methods to facilitate staff notification.
o Examples of these may include labeling the resident chart, computerized care
plan alerts or providing confidential signage on the door of the resident’s room;
i.e. “Please see the nurse before entering room” or “ Contact Precautions, please
see the nurse before entering room”
o Each facility may implement its own system for this communication
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3. Resident Placement All residents who are infected with CDAD should be in a private
room or cohorted together whenever possible. Consider the following issues of placement in
attempting to minimize infection transmission;
a Resident is likely to contaminate the environment (i.e. unable to or refuses to
control secretions).
b. Resident does not maintain appropriate hygiene.
c. Resident is at increased risk of acquiring CDAD (i.e. recent antibiotic or proton
pump inhibitor use.)
d. Resident is at increased risk of developing an adverse outcome following an
infection due to a fragile health state.
Based on the above criteria resident placements would be:
 Most Desirable: A private room or cohort with another resident who is infected with
CDAD. A commode or private bath is required for the CDAD resident.
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Less Desirable: A room with another resident who has no risk factors for CDAD
acquisition. A commode for the CDAD resident is required.
4. Resident Hygiene
Hand hygiene and bathing – teach proper hand hygiene as described above to all residents.
This is the most effective method for decreasing the “bio-burden” of CDAD. The longer the
interval between bathing the higher the number of bacteria that can accumulate on the skin
and can then be transmitted to other residents or staff. The regularity of bathing will depend
upon continence, willingness and skin condition.
5. Resident Movement about the facility
Resident Rights mandate that nursing facility residents are allowed to move about the facility at
will, go to activities and events, with consideration given to the following:
 The resident must be continent of stool or stool must be able to be contained with a
barrier method. If stool can not be contained, the resident should be restricted to his/her
room.
 The resident has good personal hygiene, wears clean clothes daily and performs hand
hygiene prior to leaving the resident’s room.
 If a resident is unwilling or unable to comply with recommendations (for example
cognitive impairment), staff may need to discuss alternative methods that will maintain
the safety of the other residents from transmission of infection.
6. Staff
Contact Precautions are necessary when caring for a resident with a CDAD infection. Gloves
and a gown must be worn prior to entering the resident’s room if contact with the resident or
environment is anticipated. A barrier such as a gown (an impervious gown is necessary if there is
a likelihood contact with body fluids) will protect the staff person from carrying Clostridium
difficile from that resident to the next. Hand hygiene must be performed when barriers are
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removed and prior to leaving the resident’s room. The healthcare worker must take care, once
barriers are removed, not to contaminate clothing and/or hands before leaving the room. If
residents are cohorted with CDAD then barrier methods must be changed between each resident.
Any staff persons with a new onset diarrheal illness, not explained by previous medical history,
should consult with their supervisor or employee health.
7. Education and Training
All healthcare workers in LTC facilities must be educated about infection control and the use of
Standard and Transmission based precautions.
Residents and when possible and appropriate, families of residents with a CDAD, should be
educated. (A resource for residents with CDAD, “General information about Clostridium difficile
infections” booklet located on the CDC website
http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_general.html ) may be used for resident and
family education.) Resident education about CDAD is vitally important for the cognitively intact
resident to understand why precautions are in place. Educate the resident regarding the
importance of good hygiene to maintain health and reduce the risk of the reoccurrence of another
infection.
8. Visitors
All visitors should be advised when meeting with residents within their room/environment to
practice appropriate precautions. Ongoing efforts to educate and facilitate soap and water hand
hygiene and risk of acquisition of CDAD by visitors are encouraged.
9. Ongoing Transmission
Reporting and Consultation to the Maine Center for Disease Control and Prevention
(Maine CDC).
Individual Cases of Clostridium difficile-Associated Disease are not on the Maine CDC’s
Notifiable Conditions list. Any pattern of cases or increased incidence of cases or illness beyond
the expected number of cases in a given period, or cases or illness regardless of the apparent
agent which may indicate a newly recognized infectious agent, or an outbreak or related public
health hazard (including suspected or confirmed outbreaks of food borne, water borne,
respiratory and exposure to toxic agents or environmental hazards, must be reported immediately
by telephone to the department.
Field Epidemiologists are available for consultation and/or outbreak investigation of any
infectious agent. Requests for consultation or disease/outbreak reports should be directed to the
central office and will be sent to the field epidemiologist for follow-up. The number is 1-800821-5821
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Authors:
Kim M. Ware, RN, BSN, CIC; Togus VA Medical Center
Barbara Walker, RN, Seaside Rehabilitation and HealthCare Center
Jeanne Delicata, ACNS, BC, Maine Veterans’ Homes
Amy Cotton, MSN, FNP-BC; Rosscare, EMHS
Carol Cole; Maine Department of Health & Human Services, Licensing and Regulation
Kathleen Gensheimer, MD, MPH; Maine State Epidemiologist
Donna Guppy, RN, BSN, Maine Center for Disease Control & Prevention
Tammy Rolfe RN, MS; Maine Healthcare Association
Erin King, RN, BSN MaineGeneral Medical Center
Anne Paradis, RN, BS, CIC, MaineGeneral Medical Center
Michelle Dubord, RN-C, BSN, North Country Associates
Christina Pratley, RN, CIC, Mayo Regional Hospital
September, 2008
References
MaineHealth Infection Prevention and Control Consortium. Infection Prevention and Control
Considerations for the Patient with Clostridium difficile-associated Disease. Accessed at
http://www.mainehealth.org/workfiles/CdiffICConsiderationsSept07.pdf on 6/15/08.
State of Maine Recommendations for the Prevention and Control of Infectious Conditions in
Long Term Care Facilities, Chapter One: MRSA 2008.
Walker, B. Infection Control: C.diff Management, 2007
Siegel J, Rhinehart E, Jackson M, Chiarello L. Centers for Disease Control and Prevention.
Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare
Settings 2007. June 2007.
1995 SHEA guidelines. Clostridium difficile-associated diarrhea and colitis. Accessed at
http://www.shea-online.org/Assets/files/position_papers/Cldiff95.PDF on 6/15/08.
2002 SHEA guidelines. Clostridium difficile in Long Term Care Facilities for the Elderly.
Accessed at http://www.shea-online.org/Assets/files/position_papers/SHEA_Cdiff.pdf on
6/15/08.
Resources
Websites:
1. National Centers for Disease Control
http://www.cdc.gov/ncidod/dhqp/id_Cdiff.html
2. Society for Healthcare Epidemiology of America (SHEA)
http://www.shea-online.org/index.cfm
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