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Introduction to C. difficile

Justin Moriarty Peel LTC IPAC Education Day

October 10, 2013

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What is C. diff ?

• Clostridium difficile bacteria • Many different types (strains) • Pathogenic strains = capable

of causing illness • Non-pathogenic strains • Found everywhere in the

environment • Colonizes 3-5% of adults

without causing symptoms

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Why is C. diff a problematic pathogen?

• Produces toxins • Produces spores • Naturally highly resistant to antibiotics • Some strains have evolved additional antibiotic

resistance

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What are toxins?

• Chemicals produced by the bacteria that damage cells • Toxins are produced by the living (vegetative) bacteria • A • B • Binary (sometimes)

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What are spores?

• Spores are like seeds • Not really “alive” • Have potential to grow into living bacteria (germinate) • Spores are extremely resistant

– Boiling, freezing, drying [5] – Stomach acid – Most common hospital-grade disinfectants

• Clostridium spores from Greenland ice cores from a depth of 834 m (4,000 years old) started to germinate within the first 5 min [4]

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What are the two forms of C. diff ?

• Vegetative • Living • Easy to kill

• Spore • Not really “alive” • Almost indestructible • Germinate and grow into

vegetative C. diff

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How bad can C. diff infection get?

• Asymptomatic colonization • Mild to moderate diarrhea • Pseudomembranous colitis • Toxic dilation of the colon (megacolon) • Sepsis • Death

Colitis Megacolon

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What is the role of antibiotics?

• Most Clostridium difficile infections (CDI) are associated with antibiotic use

• Antibiotics kill the normal gut bacteria, clearing the way for the resistant C. diff to flourish

• Even a single dose of antibiotics increases the risk of CDI [2]

• People remain at increased risk for CDI for at least 3 months after they have stopped antibiotic treatment [2]

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What are the other risk factors?

• Immunosuppressive therapy post-transplant • Proton pump inhibitors • Bowel disease and bowel surgery • Chemotherapy • Hospitalization

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How is C. diff spread?

• Fecal oral route (ingestion of spores) • Inadequate hand hygiene • Inadequate environmental cleaning • Sloppy handling of bedpans and commodes • Direct or indirect contact with contaminated surfaces or

objects

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When should I suspect C. diff ?

• DIARRHEA • Liquid stool

– Lab will only test liquid stool that takes the shape of the container

• 3 or more episodes of diarrhea within a 24h period – Unusual for the person, no known cause

• Other symptoms: fever, loss of appetite, nausea, and abdominal pain/tenderness

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What are my immediate actions?

• Isolate resident • Initiate contact precautions • Obtain a sample • Send sample to lab for analysis • Every case of C. diff is top priority • The spores are extremely persistent and you can’t give

them a chance to accumulate in the environment (bioburden)

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What are the additional interventions for CDI?

• Residents isolated while symptomatic • Contact precautions

– Signs – Gloves and gown – Direct care minimum (Any staff touching anything in the room)

• Gloves and gown removed in the room – Large garbage can with foot pedal (no-touch) [3]

• Dedicated toilet or commode • If bedpans are used, they should be disposable • Bedpan cleaning wands or toilet taps should not be used • Dedicated equipment where possible

– Sling for mechanical lift • Soiled linen into no-touch receptacle at point of use [3]

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What are the environmental cleaning requirements?

• Special SPORICIDAL cleaning products are essential • Sporicides:

– Sodium hypochlorite (bleach) solution at 5000 parts per million chlorine (10 min contact time)

– Hydrogen peroxide enhanced action formulation at 4.5% concentration (10 min contact time)

• Fresh bucket and mop head for each CDI room

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What are the environmental cleaning requirements?

• Twice daily cleaning and disinfection of the room and bathroom with a sporicide

• If a commode is used, twice daily cleaning with a sporicide

• Cleaning of shared equipment with a sporicide after every use – Mechanical lift – BP machine

• Items used to clean the bathroom must be disinfected before use in another room

• Dedicated toilet brush (discarded after)

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What are the environmental cleaning requirements?

• Consider showers instead of baths • Last bath of the day, then disinfect tub with sporicide

– Standard tub disinfectants are not sporicidal • Rooms should be cleaned last if possible • Discharge = double clean • Audit – Who is responsible for cleaning each item /

surface?

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How should I manage C. diff in a multi-bed room?

• One resident assigned to the toilet • Physical separation • Curtains drawn between beds at all times • Dedicated toilet or commode for each individual with

diarrhea • Laundry hamper, PPE cart and garbage as close as

possible

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What about hand hygiene?

• Hands that are visibly soiled must be washed with soap and water

• Always use ABHR following the four moments of hand hygiene • After removing gloves staff should use ABHR (unless a

dedicated hand hygiene sink is available) • When caring for a resident with CDI, also wash with soap and

water periodically throughout the day – Alcohol does not kill C. diff spores

• Staff and visitors should not use resident sinks for hand hygiene • Educate the resident on the importance of hand washing

– Help the resident wash their hands if necessary

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When do I discontinue Contact Precautions?

• For lab confirmed CDI: – After a MINIMUM of 48 hours of “normal” stools, by the ICP – Contact Precautions are not discontinued until the room and

bathroom have been terminally cleaned – We do not re-test stool (no test for cure)

• For suspected CDI: – Consult with ICP – 2 negative EIA toxin test or 1 negative molecular (PCR) test

• Relapse – Relapse of CDI is common – 30%

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What is the role of education?

• Education is a key component in C. diff management • Educate the resident, visitors, and staff • Resident

– Hand hygiene – PIDAC Annex C: Sample Patient Information

• Visitors – Hand hygiene – PPE (same as staff) – Not eating or drinking in resident's room – Not visiting other residents – Not using the resident’s bathroom

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When do I have an outbreak?

• Every case of C. diff is top priority • Legally required to report outbreaks • If you have more than one case of CDI at a time, please

call Public Health to discuss IPAC measures • Multiple cases of CDI on a unit = additional cleaning

requirements

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References

1. Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Annex C: Testing, Surveillance and Management of Clostridium difficile in All Health Care Settings. Revised. Toronto, ON: Queen’s Printer for Ontario; January 2013.

2. Association for Professionals in Infection Control and Epidemiology, Inc. (APIC). APIC Implementation Guide: Guide to Preventing Clostridium difficile Infections. 2013.

3. Public Health Agency of Canada. Clostridium Difficile Infection. Infection Prevention and Control Guidance for Management in Long-term Care Facilities. http://www.phac-aspc.gc.ca/nois-sinp/guide/c-dif-ltc-sld/index-eng.php

4. Validation of a Clostridium Endospore Viability Assay and Analysis of Greenland Ices and Atacama Desert Soils. Appl. Environ. Microbiol. April 2011 vol. 77 no. 7 2352-2358.

5. Measures to Control and Prevent Clostridium difficile Infection. Clin Infect Dis. (2008) 46 (Supplement 1): S43-S49. doi: 10.1086/521861.

6. Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings. Revised. Toronto, ON: Queen’s Printer for Ontario; May 2012.

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Photo References

• http://en.wikipedia.org/wiki/Pseudomembranous_colitis • http://www.examiner.com/slideshow/c-diff#slide=6 • http://nationalnursingreview.com/tag/stop-nail-biting-

hypnosis/ • http://www.nytimes.com/imagepages/2007/08/01/health/

adam/9856Fecalsample.html • http://fineartamerica.com/featured/4-clostridium-difficile-

bacteria-tem-biomedical-imaging-unit-southampton-general-hospital.html

• http://upload.wikimedia.org/wikipedia/commons/thumb/2/29/C_Diff_ToxB_2BVM.png/618px-C_Diff_ToxB_2BVM.png

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Questions?