CLOSTRIDIUM DIFFICILE

General Information for Care Home Staff

Clostridium difficile (C diff) is a bacterium that produces spores which can survive for a long time in the environment.

C diff sometimes lives in the large intestine but is kept in check by the normal, ‘good’ bacteria. When taking certain antibiotics, the ‘good’ bacteria can be killed off. This may give C diff the opportunity to multiply and produce toxins that damage the cells lining the intestine. C diff can cause diarrhoea that ranges from mild to very severe and in some cases can cause ulceration and bleeding from the large intestine (colitis). On rare occasions this can lead to perforation of the large intestine causing peritonitis which can be fatal.

How does C diff spread?

A person with C diff diarrhoea excretes large numbers of spores in their bowel motions. These spores can contaminate the general environment around the resident’s bed, for example commodes, toilets, door frames and door handles etc. Spores can survive for months on equipment in the environment and can be a source of infection for others if not removed. Thorough cleaning of the environment and equipment as well as hands is essential to reduce the risk of spreading C Diff.

Symptoms

Watery diarrhoea; offensive smelling bowel motions/green appearance; fever; nausea; abdominal pain/tenderness; loss of appetite. (Stools do not always smell offensive so do not wait for this to happen).

Groups most at risk of developing C diff-associated diarrhoea:

The elderly

People who have had a prolonged stay in hospital

People who have been exposed to others with C diff

Patients on broad spectrum antibiotics, or who have previously been on antibiotics

Patients taking proton pump inhibitors (a type of anti-ulcer medication)

Patients on nasogastric feeding

People who have had C diff infection previously

Sampling for suspected Clostridium Difficile

  • Before taking a sample, think about alternative causes of diarrhoea e.g. overuse of laxatives, enteral feeding, known medical conditions such as colitis or food related conditions.
  • If a patient has 3 or more episodes of diarrhoea (Bristol Stool Chart types 5-7) within a 24 hour period then a stool sample should be sent to determine if this is due to the presence of CDiff.
  • The stool sample must take on the shape of the container and ideally be at least ¼ filled before it is sent to the laboratory for testing.
  • Do not take samples from patients whose symptoms have cleared.
  • Do not re test confirmed Clostridium difficile positive cases if the individual still has diarrhoea within a period of 28 days unless symptoms have resolved, reoccur and there is a need to confirm recurrent C Diff infection. Check with the individual’s GP if unsure.

Suggested Care Plan

Once Clostridium difficile is confirmed

Isolation

  • Care for the resident in a single room (with en suite toilet if possible). Commodes and bed pans should be dedicated for the sole use of the affected resident whilst they continue to have symptoms of diarrhoea.
  • If it is difficult to isolate the resident due to their mental health needs, extreme care will need to be taken to make sure any spillages are dealt with immediately.
  • Continue to care for the resident in a single room until they have been free of symptoms for 48 hours and have passed a bowel motion that is normal for them. Once this is the case the resident can come out of isolation.

Personal Protective Equipment (PPE)

  • To be kept outside the resident’s room and put on before entering.
  • Wear single use, powder free latex gloves and aprons whilst caring for the affected resident, cleaning up diarrhoea and during environmental cleaning of affected areas. Non latex gloves should be available for residents/staff with a known latex allergy.
  • If there is no automated sluice machine and waste has to be emptied down the toilet, staff should wear gloves, aprons, face mask and eye protection whilst emptying and cleaning the commode or bed pan. Care should be taken to avoid splashing of the immediate environment.
  • Hazardous/clinical waste bags should be placed inside the resident’s room for disposal of PPE.
  • PPE to be used when handling soiled linen. The affected residents clothes/linen should be washed separately from other residents laundry.

Hand washing

Remember that alcohol gel does not work against Clostridium difficile therefore:-.

  • Always wash hands with liquid soap and water before and after giving care to the resident.
  • GPs and other visiting health care professionals must wash their hands before and after providing care to the resident.
  • Visitors will need to wash their hands with liquid soap and water on arrival and on leaving the resident’s room.
  • Visitors should only go into their relative/friend’s room and should not go into other areas of the home whilst the resident has symptoms.
  • As is usual best practice, ensure all residents are encouraged to wash hands with liquid soap and water at appropriate times.

Monitoring of resident

  • Document the plan of care in the resident’s notes. Keep a written record of all care given, including a daily record of the resident’s condition e.g. any abdominal pain, fever or vomiting and record all fluid/food intake/output and bowel movements. This information will be important if the resident is transferred to hospital.
  • Monitor the resident’s condition carefully as this infection can cause rapid deterioration (within hours). Signs of deterioration may include the following:- tummy pain, bloated abdomen/tummy, raised temperature, low blood pressure, poor fluid intake, increased frequency and type of stool passed (refer to Bristol Stool Chart)
  • Residents who are ill need to be monitored hourly day and night.
  • Keep a food and fluid chart recording all drinks taken and the number of times the resident passes urine (and how much, if possible)
  • Record all bowel actions on a bowel chart, as per the Bristol Stool Chart.
  • Record the resident’s temperature daily. Report to GP if raised above 37 degrees centigrade.
  • Monitor the resident for abdominal pain. Report to GP if abdominal/tummypain develops or continues/worsens.
  • Monitor the resident’s blood pressure four hourly (this should always be done in nursing homes and if possible in residential care homes). Report to GP if outside normal limits for the resident.
  • If the resident becomes confused, stops eating or if you are at all concerned inform the GP immediately.
  • Keep the resident and their relatives informed about their condition and why you are taking special precautions.
  • If the resident is admitted to hospital, please call the hospital before the resident is transferredso they can arrange immediate isolation and prevent a hospital outbreak. Ensure you tell the ambulance crew in advance and complete the inter-health care transfer form.

Treatment

  • Request a GP visit to assess the resident and to review any medication such as current antibiotics, laxatives etc. Antimotility drugs which stop diarrhoea such as loperamide should not be used to treat diarrhoea associated with Clostridium difficile infection.
  • Treatment with antibiotics may be required. The recommended therapy for mild disease is metronidazole 400mg three times per day for ten days.
  • Metronidazole is not always indicated for patients with very mild symptoms i.e. less than four liquid stools in 24 hours and not systemically unwell.
  • If diarrhoea fails to respond after 5 days of treatment with metronidazole contact the GP who,after reviewing the resident, may wish to change treatment or discuss treatment options with the Consultant Microbiologist.

Cleaning

Whilst a resident is being treated for C Diff it is important that the environment is thoroughly cleaned at least daily to prevent spores spreading.This is addition to the usual cleaning schedule in the care home.

  • Declutter the resident’s room as much as possible to assist in minimising the spread of spores.
  • Food stuffs such as sweets, fruit and biscuits should be kept in air-tight containers in a cupboard.
  • Clean the environment and any resident’s equipment at least daily with detergent, followed by a weak bleach solution (one part bleach to ten parts

water solution) on areas that will tolerate bleach. Pay special attention to lavatories and commodes. Clean anything that is touched by hand – e.g.all hard surfaces, door handles, light switches, call bells etc. Waste bins should be cleaned inside and out.

  • All equipment (blood pressure monitors etc.) should remain in the resident’s room for the duration of the illness.
  • Treat all waste as hazardous/infected waste.
  • When the resident has recovered and isolation has ceased, the resident’s room must be deep-cleaned. This means cleaning all curtains and soft furnishings, washing walls, cleaning all surfaces and steam cleaning the carpet.
  • All surfaces and equipment must be cleaned with detergent followed by 1000ppm chlorine based solution e.g. Milton before being used elsewhere in the home.
  • Consideration should be given to discarding items/equipment that cannot be cleaned by the above method
  • All equipment used to clean affected area should be cleaned and disinfected as above.

Root Cause Analysis

  • In line with Department of Health requirements, all cases of Clostridium difficile are followed up with a ‘root cause analysis’. This means that the resident’s care will be reviewed to try and identify why the resident developed the infection. It is a ‘non-blame’ process and is a way of learning lessons and improving care. Following a confirmed case, the care home will thereforebe contacted to discuss the care management of the patient.

References

  1. Health Protection Agency (2010): Suggested Care Plan for residents of care homes with Clostridium difficile infection.
  2. Department of Health (2008) “Clostridium difficile infection – How to deal with the problem” Department of Health, London, December 2008

Useful Contact Numbers

Public Health England 0344 224 4524

Leicester Partnership Trust (LPT) Community Infection Control Team: 0116 295 1668

Clinical Commissioning Group (CCG) Infection Control Team

Tel: 0116 295 5105 ext 3445/5118

Clostridium Difficile Care Pathway (includes useful contact numbers and Bristol Stool Chart)

Website Links

Public Health England:

Leicestershire Antibiotic Guidance for Primary Care

Care Homes KW January15