Download Clostridium Difficile Infection - Prevention and Management Policy

PREVENTION & MANAGEMENT OF CLOSTRIDIUM DIFFICILE
POLICY
Version
4
Name of responsible (ratifying) committee
Infection Prevention Management Committee
Date ratified
17 March 2017
Document Manager (job title)
Consultant in Infection Prevention
Date issued
25 April 2017
Review date
24 April 2020
Electronic location
Infection Prevention Policies
Related Procedural Documents
Hand Hygiene Policy, Isolation Policy, Standard
Precautions Policy, Antimicrobial Prescribing Policy
Key Words (to aid with searching)
Clostridium difficile; (CDI); Isolation; environmental
cleaning; antibiotic prescribing policies; best practice;
diarrhoea and stool tests; infection prevention
Version Tracking
Version
Date Ratified
Brief Summary of Changes
4
17 March 2017
Updated to reflect changes in reporting and testing
3
October 2014
Update against reporting and testing requirements, and
updated management guidance
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
Author
IPT/Micro
Page 1 of 19
IPT
CONTENTS
QUICK REFERENCE GUIDE ............................................................................................................. 3
1.
INTRODUCTION ......................................................................................................................... 5
2.
PURPOSE ................................................................................................................................... 5
3.
SCOPE ........................................................................................................................................ 6
4.
DEFINITIONS .............................................................................................................................. 6
5.
DUTIES AND RESPONSIBILITIES .............................................................................................. 6
6.
PROCESS ................................................................................................................................... 7
7.
TRAINING REQUIREMENTS .................................................................................................... 13
8.
REFERENCES AND ASSOCIATED DOCUMENTATION .......................................................... 13
9.
EQUALITY IMPACT STATEMENT ............................................................................................ 14
10.
MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS .................................... 15
APPENDIX 1: CLOSTRIDIUM DIFFICILE INFECTION CLEANING SCHEDULE .............................. 16
APPENDIX 2:CLOSTRIDIUM DIFFICILE CARE PATHWAY............................................................. 17
EQUALITY IMPACT SCREENING TOOL ......................................................................................... 18
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
Page 2 of 19
QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust procedural
documents.
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy. The quick reference can take the form of a list or a flow chart, if the latter would more easily
explain the key issues within the body of the document
1. Transmission of C.difficile is by the faecal-oral route. All healthcare workers should wash their
hands with soap and water before and after contact with patients with suspected or proven
C.difficile and after contact with the patient’s immediate environment or body fluids.
2. C.difficile infection (CDI) is predominantly associated with and triggered by the use of
antimicrobials. Antimicrobials must only be prescribed in patients who have confirmed evidence
(clinical, microbiological, and/or radiological) of a bacterial infection.
3. Administration of acid-suppressing medications, particularly PPI’s increase the likelihood of
intestinal colonisation after ingestion of C.difficile spores.
4. Staff should apply the following mnemonic when managing suspected infectious diarrhoea:
S
I
G
H
T
Suspect that a case may be infective where there is no clear alternative
cause for diarrhoea
Isolate the patient and consult with the infection prevention and control team
(IPT) while determining the cause of the diarrhoea
Gloves and aprons must be used for all contacts with the patient and
their environment, with chlorine/chlorine dioxide used for all cleaning
Hand washing with soap and water should be carried out before and
after each contact with the patient and the patient’s environment
Test the stool for toxin, by sending a specimen immediately (after isolating the
patient
5. Patients with suspected infectious diarrhoea should be isolated within two hours of onset of
symptoms, preferably in a room with an en-suite toilet and washing facilities.
6. Patients with confirmed CDI should remain in cubicle isolation for the duration of their hospital
stay, due to the risk of recurrent disease (20%), the evidence of prolonged skin and gut
colonisation after treatment and the risk of onwards transmission from asymptomatic carriers
7. Test Interpretation:
GDH EIA
Negative
TOX EIA
(not
required)
Positive
Negative
and PCR
negative
Positive
Toxin
EIA
Negative
but PCR
positive
Positive
Positive
Interpretation
C.difficile unlikely to be
present (Negative
Predictive Value=98.9%)
C.difficile carriage with
non-toxin producing strain
C.difficile likely to be
present (Positive
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
Action
Continue with transmission precautions if diarrhoea
persists until cause of diarrhoea is clearly identified.
Review with full enteric screen results.
Colonisation with a non-toxigenic strain of C difficile.
If no other infectious cause found to explain diarrheal
symptoms then patient can be removed from
isolation
Indicates strain is capable of producing toxin but
does not confirm actual toxin production.
Transmission precautions remain. Patient should be
treated for C difficile infection if clinically symptomatic
with diarrhea and no other obvious cause.
Likely active infection requiring treatment and full
transmission precautions
Page 3 of 19
Predictive Value=91.4%)
PCR
Positive
Toxin producing strain
Negative
Non-toxin producing strain
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
Indicates strain is capable of producing toxin but
does not confirm actual toxin production.
Transmission precautions remain
Indicates strain is not capable of producing toxin but
isolation and transmission precautions remain
Page 4 of 19
1. INTRODUCTION
Clostridium difficile (C.difficile) is a Gram-positive, anaerobic bacteria capable of causing
severe diarrhoea and life-threatening intestinal conditions in humans.
C.difficile bacteria exist in two forms – a vegetative and a spore form. C.difficile spores are
resistant to drying, heat, stomach acid and alcohol and can survive outside the body on
inanimate surfaces for months. Transmission is by the faecal-oral route often during close
contact with a symptomatic patient or indirectly through contact with a contaminated
environment or equipment (e.g. frequently touched surfaces like bed rails, IV poles, toilets, light
switches).
Once ingested, C.difficile spores germinate into vegetative bacteria in the small intestine,
capable of releasing endotoxins which damage the gastrointestinal mucosa.
Asymptomatic carriage is seen in up to 3% of healthy adults, where normal intestinal flora
inhibits the over-population of C.difficile bacteria1. The decline of intestinal flora with age,
together with a reduction in immune response increases the risk of C.difficile infection (CDI) in
the elderly, with over 80% of cases reported occurring in people aged over 65 years2. Carriage
may be as high as 20% in elderly patients in hospital2 and 50% in some long-term care
facilties3.
C.difficile remains a leading cause of infectious diarrhoea in healthcare1 and is associated with
considerable morbidity and risk of mortality4.
Exposure to Toxigenic C.difficile
Disruption of normal
Intestinal flora (antimicrobials)
Alteration of stomach acid (PPIs)
Exposure to Toxigenic C.difficile
Acquisition of Toxigenic C.difficile
Clinical risk factors:
 Poor antibody response to Toxin A
 Exposure to additional antimicrobials
 Age (>65 years)
 Underlying disease severity
Severe/Life threatening CDI
Mild/Moderate CDI
Asymptomatic C.difficile carriage
(may act as reservoir from spread)
2. PURPOSE
The purpose of this document is to provide guidance on the prevention, management and
control of C.difficile within Portsmouth Hospitals NHS Trust in compliance with local and
national requirements5,6.
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
Page 5 of 19
3. SCOPE
This Policy applies to all staff employed by Portsmouth Hospitals NHS Trust (the Trust) or
Carillion, and also to all visiting staff including staff from external agencies (e.g. CCG or other
Trusts), tutors, students, agency/locum staff and contractors.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
4. DEFINITIONS
Colonisation (or asymptomatic carriage): the presence of an organism in the body with no
clinical symptoms of infection
EIA Toxin test: an Enzyme immunoassay that detects the presence of toxin in faeces
Endotoxin: a toxin produced by C.difficile that damages the intestinal mucosa causing
inflammation, diarrhoea and potentially pseudo-membraneous colitis
Faecal transplant: the use of healthy stool from a donor to rebalance gut flora
Glutamate dehydrogenase (GDH): an antigen produced in high amounts by C.difficile, both
toxin and non-toxin producing strains which can be used to identify the presence of C.difficile.
Polymerase Chain Reaction test (PCR): a type of nucleic acid amplifiication test that detects
the presence of toxin genes
Pseudomembraneous colitis: an infection of the colon, frequently, but not exclusively caused
by C.difficile. In severe cases, life-threatening complications, such as toxic mega-colon can
occur
Toxic Mega-colon: is a life-threatening complication, characterized by extreme dilatation of the
colon, accompanied by abdominal distension and sometimes fever, abdominal pain or shock
5. DUTIES AND RESPONSIBILITIES
Corporate Responsibilities:
 Support mandatory education at induction for all staff and appropriate updates for staff
involved on direct patient contact
 Ensure necessary facilities for the isolation with suspected or proven CDI
 Support the IPT in the implementation of this policy and promoting good practice
All Healthcare Staff:
 Must be familiar with and adhere to the relevant infection prevention policies to reduce
the risk of cross infection of patients
 Must adhere to the full terms and conditions documented in this policy
 Report to their managers and/or IPT if they are unable to do so
Infection Prevention & Control Team (IPT):
 Provide advice relating to the prevention and management of patients with C.difficile
 Include C.difficile in all induction and update training for clinical staff
 Promote good practice and challenge poor practice
 Conduct audit and inspection of C.difficile management with feedback to clinical staff
 Review and update C.difficile policy
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
Page 6 of 19
Matrons / Ward Managers:
 Must establish a culture of compliance with infection prevention guidelines across their
units
 Promote good practice and challenge poor practice
Medical Microbiology:
 Alert Infection Prevention Team and clinical teams (where appropriate) of patients with
CDI
 Provide antimicrobial management advice for patients with or at risk of C.difficile
 Advise on and provide faecal transplantation when required
Antimicrobial Pharmacists (AMP) and Ward Pharmacists:
 Monitor the use of antimicrobial agents and feed back on areas for improvement
 Daily review of drug charts by ward pharmacists with escalation of deviations from
policy to medical microbiology or the AMP
Patient Flow / Duty Hospital Managers:
 Facilitate placement of patients with C.difficile into appropriate isolation rooms
 Escalate difficulties in management/placement of C.difficile patients to the Infection
Prevention Team
 Ensure effective communication of patients risk and carriage status
6. PROCESS
6.1 Strategies for Preventing C.difficile:
Prudent Antimicrobial Prescribing:
CDI is predominantly associated with and triggered by the use of antimicrobials, which disrupt
the normal intestinal flora which would ordinarily compete with and suppress non-indigenous
species like C.difficile2
 Antimicrobials must only be prescribed in patients who have confirmed evidence
(clinical, microbiologic, and radiologic) of a bacterial infection6
 Staff prescribing antimicrobials must adhere to the Trust’s antimicrobial guidelines
available on Microguide
 Where antimicrobial prescription cannot be avoided, a narrow spectrum antibiotic should
be prescribed and the prescription reviewed daily and stopped as soon as possible
 Wards and specialties should be provided with antibiotic prescription data regularly
highlighting compliance6
 There is no evidence to support using metronidazole or vancomycin to prevent CDI (in
patients receiving antibiotic therapy); this approach may actually increase risk4
Decreased use of Proton Pump Inhibitors (PPI’s)
Administration of acid-suppressing medications, particularly PPI’s increase the likelihood of
intestinal colonisation after ingestion of C.difficile spores4,7,8
 All long-standing PPI prescriptions should be reviewed on admission to hospital
 All acid-suppressing medications should be reviewed prior to discharge
Environmental cleaning and disinfection:
 All clinical areas should be regularly assessed for cleanliness and results fed back to
clinical and cleaning teams
 The ward environment should be kept uncluttered with clear surfaces
 Medical equipment should be thoroughly cleaned before and after each new patient use
 Each clinical area should have an infection control link practitioner, whose role should
include training, auditing and feeding back to staff on cleaning, isolation, hand hygiene
and personal protective equipment
6.2 Management of Patients with Diarrhoea:
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
Page 7 of 19
All patients should be monitored daily for frequency and severity of diarrhoea using the Bristol
Stool Chart.
Staff should apply the following mnemonic protocol (SIGHT) when managing patients with
suspected infectious diarrhoea6:
S
I
G
H
T
Suspect that a case may be infective where there is no clear alternative
cause for diarrhoea
Isolate the patient and consult with the infection prevention and control team
(IPT) while determining the cause of the diarrhoea
Gloves and aprons must be used for all contacts with the patient and
their environment, with chlorine/chlorine dioxide used for all cleaning
Hand washing with soap and water should be carried out before and
after each contact with the patient and the patient’s environment
Test the stool for toxin, by sending a specimen immediately (after isolating the
patient
Suspected Infectious Diarrhoea:
CDI should be suspected in patients with diarrhoea in the following situations:
 The diarrhoea is not clearly attributable to an underlying condition (e.g. inflammatory
colitis, overflow) or therapy (e.g. laxatives, enteral feeding)
 The diarrhoea is explosive, watery or offensive, or the patient has fever, bloody stools or
severe abdominal cramps
 The patient is on or has been on antibiotics in the past 3 months
 The patient has previously tested positive for C.difficile
 The patient developed diarrhoea on a ward where there was a known case of CDI
6.3 Isolation:
Patients with suspected infectious diarrhoea should be isolated within two hours of onset of
symptoms, preferably in a room with an en-suite toilet and washing facilities. If an en-suite is
not available a commode should be provided for their sole use.
It is not acceptable to leave a patient with suspected infectious diarrhoea on an open
ward
Where no suitable single room is available in the immediate clinical area, staff should escalate
to:
i. Specialty flow coordinator (then)
ii. Duty hospital manager (then)
iii. (On-call) Infection Prevention Team



The use of faecal management systems should be considered for patients with type 7
stool, to contain spores and aid isolation
Failure to isolate a patient with subsequently confirmed C.difficile will be reported as an
AMBER incident for investigation by the Clinical Service Centre
Patient safety must not be compromised – mitigating actions should be taken to ensure
safe isolation
Duration of Isolation:
Patients with confirmed CDI or who are found to have a toxigenic strain of C difficile by PCR
should remain in cubicle isolation for the duration of their hospital stay, due to the risk of
recurrent disease (20%)4, the evidence of prolonged skin and gut colonisation after treatment3,9
and the risk of onwards transmission from asymptomatic carriers.
Patients isolated but found not to have a toxigenic strain of C.difficile may be removed from
isolation once the cause of their diarrhoea has been identified and determined as noninfectious.
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
Page 8 of 19
Principles of Isolation:
 Isolation room doors must remain closed and an isolation notice displayed
 Cohorting of suspected or proven C.difficile patients should not be undertaken unless
authorised by the IPT
 If the patient is required to leave the room for clinically urgent diagnostic or treatment
purposes the IPT should be contacted for advice. Steps taken to minimise transmission
must not in any way impact on management or care given to the patient
6.4 Gloves and Aprons (Personal Protective Equipment): (Standard Precautions Policy)
All healthcare workers must use disposable gloves and aprons for any physical contact with
patients with suspected or proven C.difficile, and the patient’s immediate environment and body
fluids
 Visitors do not need to wear gloves or aprons unless providing personal care.
 Gloves are not a substitute for soap and water hand hygiene (see hand hygiene)
 Visitors or staff should not eat or drink in the vicinity of the patient
6.5 Routine Enhanced Environmental Cleaning
All surfaces and equipment should be cleaned twice daily and disinfected using Actichlor Plus.
The daily cleaning schedule for isolation rooms being used for patients with C.difficile is in
appendix 1.
Carillion
 Floors
 Sinks and taps
 Touch points (door
handles/dispensers)
 Chairs
 Base of bed
Clinical Staff
 Remove open food and declutter surfaces
 Bed ends
 Bed rails
 Bedside tables and lockers
 Touch points (door
handles/taps/dispensers)
 Clinical equipment (commode, drip stand
etc)
It is vital that all flat surfaces are kept free from clutter to aid enhanced cleaning
6.6 Hand Hygiene:
All healthcare workers should wash their hands with soap and water before and after contact
with patients with suspected or proven C.difficile and after contact with the patient’s immediate
environment or body fluids.
 Alcohol handrub must not be used as an alternative to soap. It can be applied after
washing to rid hands of remaining non-clostridial organisms
6.7 Testing (Diagnosis)
A stool sample should be taken as soon as infectious diarrhoea is suspected.
 Specimens must be liquid or take the shape of the container
 The laboratory operate 6-day a week testing which for all current in-patients comprises
screening for C difficile glutamate dehydrogenase (GDH), followed by C.difficile toxin
EIA where the screening test is positive. If found to be GDH positive but toxin negative
by EIA then a C difficile toxin PCR is performed10 All community diarrhoeal samples and
all new admissions now get a full enteric screen by PCR which looks for bacterial
pathogens including Campylobacter, C difficile, shigella/enteroinvasive E coli, verotoxin
producing E coli (e.g. E coli 0157), Salmonella species and Yersinia enterocolitica. A
parasite and a viral enteric PCR panel are also available. All community samples from
patients over the age of 65 or from patients who have had recent antibiotic or hospital
exposure which are C difficile positive by PCR will automatically get tested for the
presence of toxin by C difficile toxin EIA. This is in line with mandatory reporting.
GDH EIA
TOX EIA
Interpretation
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
Action
Page 9 of 19
Negative
(not
required)
Positive
Negative
and PCR
negative
Positive
Toxin
EIA
Negative
but PCR
positive
Positive
Positive
C.difficile unlikely to be
present (Negative
Predictive Value=98.9%)
C.difficile carriage with
non-toxin producing strain
C.difficile likely to be
present (Positive
Predictive Value=91.4%)
PCR
Positive
Toxin producing strain
Negative
Non-toxin producing strain
Continue with transmission precautions if diarrhoea
persists until cause of diarrhoea is clearly identified.
Review with full enteric screen results.
Colonisation with a non-toxigenic strain of C difficile.
If no other infectious cause found to explain diarrheal
symptoms then patient can be removed from
isolation
Indicates strain is capable of producing toxin but
does not confirm actual toxin production.
Transmission precautions remain. Patient should be
treated for C difficile infection if clinically symptomatic
with diarrhea and no other obvious cause.
Likely active infection requiring treatment and full
transmission precautions
Indicates strain is capable of producing toxin but
does not confirm actual toxin production.
Transmission precautions remain
Indicates strain is not capable of producing toxin but
isolation and transmission precautions remain

PCR may be helpful in limiting antimicrobial exposure in patients determined to have
non-toxigenic C.difficile carriage
 Repeat stool specimens are not needed whilst a person is symptomatic with confirmed
C difficile infection and no specimen should to sent to ascertain clearance once
diarrhoea ceases
 Positive results on the same patient within 28 days should be regarded as a single
episode; positive results on the same patient more than 28 days apart are reported as
separate episodes
6.8 Reporting
Any of the following defines a C. difficile infection in patients aged 2 years and above and will
be reported to PHE11:






Diarrhoeal stools where the specimen is GDH EIA positive and Toxin EIA positive
Diarrhoeal stools where the C difficile toxin PCR is positive and the toxin EIA is positive
Toxic megacolon or ileostomy where the specimen is GDH EIA positive, toxin EIA
positive
Pseudomembranous colitis revealed by lower gastro-intestinal endoscopy or CT
Colonic histopathology characteristic of CDI (with or without diarrhoea or toxin
detection) on a specimen obtained during endoscopy or colectomy
Faecal specimens collected post-mortem where the specimen is C. difficile toxin EIA
positive or tissue specimens collected post-mortem where pseudomembranous colitis is
revealed or colonic histopathology is characteristic of CDI
6.9 Management:
CDI should be managed as a diagnosis in its own right, with each patient reviewed daily
regarding fluid resuscitation, electrolye replacement and nutritional review4.
If clinically appropriate, non-C. difficile antibiotics should be discontinued to allow normal
intestinal flora to be re-established4.
The severity of CDI should be assessed daily as follows4:


Mild CDI is not associated with a raised WCC; it is typically associated with <3 stools of
type 5–7 on the Bristol Stool Chart per day
Moderate CDI is associated with a raised WCC that is <15 109/L; it is typically
associated with 3–5 stools per day.
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
Page 10 of 19


Severe CDI is associated with a WCC >15 109/L, or an acute rising serum creatinine
(i.e. >50% increase above baseline), or a temperature of >38.5°C, or evidence of severe
colitis (abdominal or radiological signs). The number of stools may be a less reliable
indicator of severity.
Life-threatening CDI includes hypotension, partial or complete ileus or toxic
megacolon, or CT evidence of severe disease
Do not give anti-motility agents such as Loperamide where active CDI is suspected.
6.10 Treat according to Severity4:
Detailed management guidance is available on Microguide. Advice on the medical
management of severe or life threatening CDI should always be sought from a microbiologist.



Mild and Moderate CDI: oral metronidazole 400–500 mg tds for 10–14 days*
*Patients with mild disease may not require specific C. difficile antibiotic treatment
Severe CDI: –oral vancomycin 125 mg qds for 10–14 days
In severe CDI cases not responding to oral vancomycin 125 mg qds, oral fidaxomicin
200 mg bd is an alternative; or high-dosage oral vancomycin (up to 500 mg qds, if
necessary administered via a nasogastric tube), +/- iv metronidazole 500 mg tds. The
addition of oral rifampicin (300 mg bd) or iv immunoglobulin (400 mg/kg) may also be
considered.
Life-threatening CDI – oral vancomycin up to 500 mg qds for 10–14 days via nasogastric tube or rectal installation plus iv metronidazole 500 mg tds.
Probiotics:
There are no current recommendations for the use of probiotics for the prevention of
antimicrobial-associated diarrhoea or CDI4.
Faecal microbiota transplantation (FMT):
Faecal transplantation to replenish gastro-intestinal flora using healthy donor stool has been
shown to be highly effective at achieving resolution of recurrent CDI. It is appropriate for use in
patients who have experienced multiple relapses despite treatment4. FMT is NICE accredited
for recurrent C difficile infection. FMT is co-ordinated by the medical microbiology team.
Action by the Infection Prevention & Control Team
The IPT will visit all C.difficile cases on the day of diagnosis (Mon-Fri) to provide verbal and
written information to the patient, inform staff and implement appropriate management and
placement of the patient. A Clostridium Difficile Care Pathway will be initiated by the IPT or
outside working hours by nursing staff in the clinical area (appendix 2) or
http://pht/Departments/InfectionControl/Audit%20tools/Draft%20C%20diff%20care%20pathway
2%20BW.pdf
6.11 Clostridium Difficile Care Pathway (CDCP)
This must be initiated within 24 hours of a positive C.difficile result (GDH or Toxin EIA)
(Appendix 2). The severity of the CDI will be assessed and noted on the CDCP by the IPT or
microbiologist using the clinical definitions in 6.9.






Stool frequency and consistency should be recorded following every bowel action on
VitalPAC or the CDCP. Stool charts should be updated daily even if the patient does not
have their bowels opened to assess effectiveness of treatment
The DH Saving Lives section on the CDCP must be completed daily
All urine or faeces should be disposed of in the macerator as rapidly as possible
All waste should be placed in a orange waste bag
All linen should be placed in a red alginate (dissolvable) bag before being placed in a
red laundry bag
Equipment such as blood pressure monitors, commodes, temperature probe, etc.
should be used only on that patient. If the equipment is taken for use elsewhere it
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
Page 11 of 19

should be effectively decontaminated with a chlorine dioxide based
detergent/disinfectant i.e. Actichlor-Plus (instructions for dilution and use are at
appendix 1)
Use normal crockery and cutlery and wash in machine dishwasher
6.12 Transfer and Discharge:
Patients should only be discharged once they have been established on effective treatment for
CDI and the risk of relapse, dehydration or malnourishment has been assessed. The diagnosis
of CDI must be clearly communicated to the GP, nursing/care home and care agencies and the
patient should be advised to contact their GP if they experience further diarrhoea.
6.13 Terminal environmental cleaning
Following CDI, the patient environment must be thoroughly cleaned and disinfected with
Actichlor-Plus as described in appendix 1, with careful attention to toilets, bathrooms and
sluices, beds, mattresses, commodes and bedpans.

Terminal disinfection with Hydrogen peroxide vapour may be carried out by IPT. The
IPT should be contacted on Extension 6261 or Bleep 0064 for advice. For out of hour’s
on-call service, call Switchboard and ask for Infection Prevention.
The correct order of terminal cleaning is as follows:
 Strip beds and remove linen placing in a red alginate (dissolvable) bag before being
placed in a red laundry bag
 Disinfect equipment (including beds) with Actichlor-Plus. Leave all equipment in the
room for hydrogen peroxide decontamination
 Dispose of unused consumables i.e. gloves and wipes into orange clinical waste bag,
unless stored in sealed apron and glove dispenser (Dani centre) which can be
disinfected externally with Actichlor-Plus
 Contact Carillion Helpdesk (Ext 6321) and arrange terminal clean post CDI
 Curtains must be removed bagged and laundered
 Cleaning should always start with high surfaces leaving the floor until last
6.14 Periods of Increased Incidence (PII) and Outbreaks:
PII of CDI: two or more new cases (occurring >72 hours post admission, not relapses) in a 28day period on a ward
Outbreak of CDI: two or more cases caused by the same strain related in time and place over
a defined period that is based on the date of onset of the first case
PII will be investigated by the IPT who will review:
 Clinical patient history and potential links between cases
 Environmental and patient equipment cleaning
 Compliance to hand hygiene and isolation
 Antimicrobial prescribing
The IPT may recommend:
 Deep cleaning of ward areas
 Ribotyping of isolates
In addition to guidance provided for PII, the following additional measures should be
implemented if an outbreak is suspected.

The Infection Prevention Consultant (IPC), Infection Prevention Doctor (IPD) and
Director of Infection Prevention and Control (DIPC) should consider the need to form an
outbreak committee. The Chief Executive is to be informed of their decision
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
Page 12 of 19



Potential outbreaks to be reported to Public Health England (PHE) by the IPT with
completion of the SIRI process
Resolution of the outbreak will be confirmed by the outbreak committee
An outbreak report is to be prepared and submitted to the Infection Prevention
Management Committee (IPMC) for investigation into further necessary actions
6.15 C.difficile Deaths
Deaths where CDI is involved should be recorded on the death certificate as follows:
Part 1: CDI directly caused or contributed to the death
Part 2: CDI was present, but was not a part of the direct sequence leading to the patient’s
death
All CDI deaths recorded in part 1 of the death certificate should be declared a Serious Incident
Requiring Investigation (SIRI) and investigated accordingly.
7. TRAINING REQUIREMENTS
Training forms part of the Trust’s Essential Skills and Training Requirements; as identified in
the Training Needs Analysis. C.difficile information is included in mandatory Corporate
Induction (Setting Direction) and in local updates
Staff must attend classroom delivered update training every two years, including CDI
prevention and management, and undertake refresher training via the Electronic Staff Record
(ESR) system in the intervening years
All training (including ad hoc sessions) is recorded on the ESR from which the Learning and
Development Team provide a monthly heat map to each CSC, to enable monitoring of
compliance
Compliance is further monitored through the CSC performance reviews with the Executive
Team
8. REFERENCES AND ASSOCIATED DOCUMENTATION
1. Clostridium difficile: Health Protection Agency, August 2013. Accessed January 2014
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/ClostridiumDifficile/
2. National Clostridium difficile Standards Group. Report to the Department of Health, February
2003. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947372533
3. Asymptomatic Carriers Are a Potential Source for Transmission of Epidemic and
Nonepidemic Clostridium difficile Strains among Long-Term Care Facility Residents: Riggs et
al, October 2007. http://cid.oxfordjournals.org/content/45/8/992.full.pdf+html
4. Updated guidance on the management and treatment of Clostridium difficile infection. Public
Health England, May 2013.
http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1317139166803
5. Department of Health (2008) The Health and Social Care Act 2008: Code of Practice on the
prevention and control of infections and related guidance. Department of Health, December
2010. London. HMSO
6. Clostridium difficile infection: how to deal with the problem. Department of Health, December
2008. http://www.hpa.org.uk/webc/hpawebfile/hpaweb_c/1232006607827
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
Page 13 of 19
7. Howell et al. (2010). Iatrogenic gastric acid suppression and the risk of nosocomial
Clostridium difficile infection. Arch Intern Med 170: 784-90.
8. Janarthanan et al. (2012). Clostridium difficile-associated diarrhea and proton pump inhibitor
therapy: a meta-analysis. Am J Gastroenterol 107: 1001-10.
9. Persistence of Skin Contamination and Environmental Shedding of Clostridium difficile
during and after Treatment of C. difficile Infection: Sethi et al, January 2010.
http://www.jstor.org/stable/full/10.1086/649016
10. Updated guidance on the diagnosis and reporting of clostridium difficile. Department of
Health, March 2012
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215135/dh_1330
16.pdf
11. Inclusion criteria for reporting C. difficile infection to the surveillance system. Health
Protection Agency, March 2012
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317132954594
12. van Nood E, Vrieze A, Nieuwdorp M, et al. Duodenal infusion of donor feces for recurrent
Clostridium difficile. N Engl J Med 2013. DOI: 10.1056/NEJMoa1205037
13. National Institute for Health and Care Excellence IPG485 Faecal microbiota transplant for
recurrent Clostridium difficile infection. March 2014
14. Sofi AA, Silverman AL. et al. Relationship of symptom duration and faecal bacteriotherapy
in Clostridium difficile infection-pooled data analysis and a systematic review. Scandinavian
Journal of Gastroenterology 2013; 48(3): 266-273
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They
are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision
to be the best hospital, providing the best care by the best people and ensure that our patients
are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our
Trust:
Respect and dignity
Quality of care
Working together
Efficiency
This policy should be read and implemented with the Trust Values in mind at all times.
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
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10.
MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
This document will be monitored to ensure it is effective and to assurance compliance.
Minimum requirement to
be monitored
Lead
Tool
Frequency of Report
of Compliance
100% of staff following
appropriate hand hygiene
procedures
CSC Matron
Self Assessment
Monthly
100% of staff following
appropriate hand hygiene
procedures
CSC Matron
Weekly Isolation of patients
with suspected infectious
diarrhoea
IPT
Monthly monitoring of
cleaning (ATP scores) and
compliance with CDCP
IPT
Antimicrobial Prescribing
Medical
Microbiology
Reporting arrangements
Policy audit report to:

Peer Review
Quarterly
Policy audit report to:

Infection Control
Dashboards
Weekly
Infection Control
Dashboards
Weekly
Audit against
Antimicrobial guidelines
Annual
Infection Prevention
Management Committee
Lead(s) for acting on
Recommendations
Infection Prevention & Control Team
Matron
Infection Prevention Link Advisors
Infection Prevention & Control Team
Infection Prevention
Management Committee
Policy audit report to:
Infection Prevention & Control Team
 Infection Prevention
Management Committee
Policy audit report to:
Infection Prevention & Control Team
 Infection Prevention
Management Committee
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
Policy audit report to:
Infection Prevention
Management Committee
Page 15 of 19
Medical Microbiology
APPENDIX 1: CLOSTRIDIUM DIFFICILE INFECTION CLEANING SCHEDULE
DAILY CLEANING
CARILLION
Clean all areas with Actichlor Plus
CLINICAL STAFF
Clean all areas with Actichlor Plus
Wash hands with soap and water – wear
disposable gloves and plastic apron
Ensure that fresh Actichlor Plus is made up
every day and stored correctly with cap closed
Clean room, floors, sinks, toilets and all
surfaces and equipment (pay
particular attention to all patient contact areas
such as table, locker,
patient line, chairs, door handles, taps, walking
aids etc.)
Wash hands with soap and water – wear
disposable gloves and plastic apron
Wash walls if visibly soiled
Use separate cleaning equipment
(Single-use disposable cloths, disposable mop
heads or launder after
each use)
Dispose of cloths, gloves and apron in an
orange clinical waste sack
Wash hands with soap and water
Clean all non-perishable surfaces and
equipment with Actichlor Plus (pay
particular attention to bed rails, bed ends and
all patient contact areas such as tables,
lockers,
chairs, door handles, taps, walking aids,
commodes etc, IV poles, IV pumps.)
Clean all perishable surfaces and equipment
(including mattresses) with Actichlor-Plus
Use disposable cloths
Dispose of cloths, gloves and apron in an
orange clinical waste sack
Wash hands with soap and water
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
Page 16 of 19
APPENDIX 2:CLOSTRIDIUM DIFFICILE CARE PATHWAY
http://pht/Departments/InfectionPreventionandControl/Infection%20Information/C.difficile/C.di
fficile%20Care%20Pathway.pdf
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
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EQUALITY IMPACT SCREENING TOOL
To be completed and attached to any procedural document when submitted to the
appropriate committee for consideration and approval for service and policy
changes/amendments.
Stage 1 - Screening
Title of Procedural Document: Prevention and Management of Clostridium Difficile Policy
Date of Assessment
20/02/2017
Responsible
Department
Infection Prevention
Name of person
completing
assessment
Kathryn Noble
Job Title
Infection
Prevention
Manager/Analyst
Does the policy/function affect one group less or more favourably than another on the basis
of :
Yes/No
 Age
No
 Disability
Learning disability; physical disability; sensory
impairment and/or mental health problems e.g.
dementia
No
 Ethnic Origin (including gypsies and travellers)
No
 Gender reassignment
No
 Pregnancy or Maternity
No
 Race
No
 Sex
No
 Religion and Belief
No
 Sexual Orientation
No
Comments
If the answer to all of the above questions is NO,
the EIA is complete. If YES, a full impact
assessment is required: go on to stage 2, page 2
More Information can be found be following the link
below
www.legislation.gov.uk/ukpga/2010/15/contents
Prevention & Management of Clostridium Difficile Policy
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Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
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Stage 2 – Full Impact Assessment
What is the impact
Level of
Impact
Responsible
Officer
Mitigating Actions
(what needs to be done to minimise /
remove the impact)
Monitoring of Actions
The monitoring of actions to mitigate any impact will be undertaken at the appropriate level
Specialty Procedural Document:
Specialty Governance Committee
Clinical Service Centre Procedural Document:
Clinical Service Centre Governance Committee
Corporate Procedural Document:
Relevant Corporate Committee
All actions will be further monitored as part of reporting schedule to the Equality and Diversity
Committee
Prevention & Management of Clostridium Difficile Policy
Version: 4
Issue Date: 25 April 2017
Review Date: 24 April 2020 (unless requirements change)
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