(c) MRSA Action UK June 2008
Clostridium difficile (C diff) is highly infectious and spreads very easily from person to person. C diff is a bacteria that produces spores that can survive for a long time in the environment.
C diff is found in the large intestine and is normally kept in check by the normal, good bacteria. When a resident is taking antibiotics, the good bacteria are killed off. This gives C diff the opportunity to multiply, then to produce toxins that damage the cells lining the intestine. C diff can cause diarrhoea, ranging from a mild case to a very severe illness with ulceration and bleeding from the colon (colitis) and at worst perforation of the intestine leading to peritonitis. It can be fatal.
Over 100 types of C diff have been identified but some recent outbreaks have been caused by Type 027 that has only recently been identified in the
How does C diff spread?
A resident with C diff diarrhoea excretes large numbers of spores in their liquid faeces. These spores can contaminate the general environment around the resident?s bed, for example commodes. Spores can survive for a long time (months) and be a source of hand-to-mouth infection for others. This can be either through direct person-to-person contact, via healthcare staff (often on the hands of staff), or via the home's surroundings.
Symptoms
Watery diarrhoea; offensive smelling stool/green appearance; fever; nausea; abdominal pain/tenderness; loss of appetite.
Some people can be carriers of C diff without any symptoms.
How is it diagnosed?
Early diagnosis prevents complications and saves lives. A stool sample should be sent for analysis as soon as symptoms start (especially if the resident has been taking antibiotics). Watery diarrhoea only can be tested for toxin, so formed or semi formed stools should not be sent.
General Points
Each home should have a named senior member of staff who is responsible for infection control.
Care staff should adhere to a uniform code and should not wear uniforms outside the care home.
Staff should limit jewellery to one plain ring (wedding band) and not wear wrist watches, bracelets, charity or friendship bands. Nails need to be kept short and clean. Nail varnish and false nails should not be worn. Long hair should be tied back.
All staff must be trained in correct hand washing/hand hygiene techniques and this needs updating every 6 months.
If you suspect an outbreak (2 or more cases)
ring the Health Protection Unit straight away
Control measures
No single measure will be sufficient to prevent an outbreak. All 5 measures listed below need to be implemented 100% of the time to achieve control of this preventable infection and protect your residents.
The resident's clinical condition must be monitored carefully, at least on a daily basis. In nursing homes, record observations and keep a fluid balance chart. Monitor and record diarrhoea using the
Alcohol gel does not work against C diff
Step 1 - Hand washing
Reinforce hand washing with soap and water in your staff and residents. In an outbreak you may find it useful to use cleansing hand-wipes for residents (you don?t need to use antibacterial wipes).
Step 2 - Isolation
Affected residents must be isolated immediately. Dedicate equipment to the affected resident (including BP monitors). If two or more people are affected and no single rooms are available, try to nurse or cohort the affected residents together. Residents should remain isolated until they have been free of symptoms for 48 hours.
Step 3 - Cleaning
The environment must be kept thoroughly clean to prevent spores spreading. Cleaning with detergent needs to be more frequent when there is a case of C diff (twice daily and also immediately following contamination).
After cleaning, use a chlorine based disinfectant to wipe all surfaces, equipment, call bells, toilet areas, wash basins, bathroom fittings, sluices, commodes, bed pan washers etc. Pay special attention to all areas that can be touched by hand.
Step 4 - PPE
Use personal protective equipment when caring for affected residents, emptying commodes, cleaning up diarrhoea and during environmental cleaning of affected areas. This should include single use gloves and aprons as a minimum and should include masks and goggles when handling faeces or emptying commodes. Keep PPE outside the room of the affected resident and put this on before entering the room. Have clinical waste bags inside the room for disposal of PPE.
Step 5 - Treatment
Do not use anti-diarrhoea treatments such as codeine phosphate or imodium. These could make the patient worse because toxins will not be eliminated from the body.
The GP should review any antibiotic therapy and stop any antibiotics which are no longer essential.
The GP should prescribe metronidazole for 10-14 days. If metronidazole has not worked after 5 days the GP should discuss alternative treatment with the Consultant Microbiologist. Usually, oral vancomycin for a further 10 days is advised. Residents with mild symptoms (less than 4 liquid stools in 24 hours and not generally unwell) may not require treatment.
All residents who are prescribed antibiotics for whatever reason should have their prescription carefully monitored and reviewed by the GP. You should record the reason why the antibiotics have been prescribed and make sure that the GP indicates when the antibiotics should be stopped.
References:
A Good Practice Guide to Control Clostridium difficile HPA Regional Microbiology Network January 2007 www.hpa.org.uk
Bristol stool chart, Dr K Hering, Bristol University/BMJ 1990
Guidance produced by Surrey & Sussex HPU February 2008, with thanks to Consultant Microbiologists at Royal Sussex Co Hospital.
If you or someone you care about has been affected by a healthcare infection and you wish to discuss this with us, please contact us at info@mrsaactionuk.net
