Www.porthosp.nhs.uk



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PREVENTION & MANAGEMENT OF CLOSTRIDIUM DIFFICILE POLICY

|Version |5 |

|Name of responsible (ratifying) committee |Infection Prevention Management Committee |

|Date ratified |09 November 2018 |

|Document Manager (job title) |Consultant in Infection Prevention |

|Date issued |31 January 2019 |

|Review date |30 January 2022 |

|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 |Author |

|5 |9 November 2018 |Updated to reflect changes in treatment (section 6.10) |Andrew Flatt/ IPCT |

|4 |17 March 2017 |Updated to reflect changes in reporting and testing |IPT/Micro |

|3 |October 2014 |Update against reporting and testing requirements, and updated management |IPT |

| | |guidance | |

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 14

9. EQUALITY IMPACT STATEMENT 15

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS 16

APPENDIX 1: CLOSTRIDIUM DIFFICILE INFECTION CLEANING SCHEDULE 17

APPENDIX 2: CLOSTRIDIUM DIFFICILE CARE PATHWAY 18

EQUALITY IMPACT SCREENING TOOL 19

QUICK REFERENCE GUIDE

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.

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 |Suspect that a case may be infective where there is no clear alternative |

| |cause for diarrhoea |

|I |Isolate the patient and consult with the infection prevention and control team (IPT) while determining the cause of |

| |the diarrhoea |

|G |Gloves and aprons must be used for all contacts with the patient and |

| |their environment, with chlorine/chlorine dioxide used for all cleaning |

|H |Hand washing with soap and water should be carried out before and |

| |after each contact with the patient and the patient’s environment |

|T |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 |TOX EIA |Interpretation |Action |

|Negative |(not required) |C.difficile unlikely to be present |Continue with transmission precautions if diarrhoea persists until cause |

| | |(Negative Predictive Value=98.9%) |of diarrhoea is clearly identified. Review with full enteric screen |

| | | |results. |

|Positive |Negative and PCR|C.difficile carriage with non-toxin |Colonisation with a non-toxigenic strain of C difficile. If no other |

| |negative |producing strain |infectious cause found to explain diarrheal symptoms then patient can be |

| | | |removed from isolation |

|Positive |Toxin EIA | |Indicates strain is capable of producing toxin but does not confirm |

| |Negative but PCR| |actual toxin production. Transmission precautions remain. Patient should|

| |positive | |be treated for C difficile infection if clinically symptomatic with |

| | | |diarrhea and no other obvious cause. |

|Positive |Positive |C.difficile likely to be present |Likely active infection requiring treatment and full transmission |

| | |(Positive Predictive Value=91.4%) |precautions |

|PCR | | | |

|Positive | |Toxin producing strain |Indicates strain is capable of producing toxin but does not confirm |

| | | |actual toxin production. Transmission precautions remain |

|Negative | |Non-toxin producing strain |Indicates strain is not capable of producing toxin but isolation and |

| | | |transmission precautions remain |

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.

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.

SCOPE

This Policy applies to all staff employed by Portsmouth Hospitals NHS Trust (the Trust) or Engie, 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’

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

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

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

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:

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 |Suspect that a case may be infective where there is no clear alternative |

| |cause for diarrhoea |

|I |Isolate the patient and consult with the infection prevention and control team (IPT) while determining the cause of |

| |the diarrhoea |

|G |Gloves and aprons must be used for all contacts with the patient and |

| |their environment, with chlorine/chlorine dioxide used for all cleaning |

|H |Hand washing with soap and water should be carried out before and |

| |after each contact with the patient and the patient’s environment |

|T |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 non-infectious.

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.

|Engie |Clinical Staff |

|Floors |Remove open food and declutter surfaces |

|Sinks and taps |Bed ends |

|Touch points (door handles/dispensers) |Bed rails |

|Chairs |Bedside tables and lockers |

|Base of bed |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 |Action |

|Negative |(not required) |C.difficile unlikely to be present |Continue with transmission precautions if diarrhoea persists until cause |

| | |(Negative Predictive Value=98.9%) |of diarrhoea is clearly identified. Review with full enteric screen |

| | | |results. |

|Positive |Negative and PCR|C.difficile carriage with non-toxin |Colonisation with a non-toxigenic strain of C difficile. If no other |

| |negative |producing strain |infectious cause found to explain diarrheal symptoms then patient can be |

| | | |removed from isolation |

|Positive |Toxin EIA | |Indicates strain is capable of producing toxin but does not confirm |

| |Negative but PCR| |actual toxin production. Transmission precautions remain. Patient should|

| |positive | |be treated for C difficile infection if clinically symptomatic with |

| | | |diarrhea and no other obvious cause. |

|Positive |Positive |C.difficile likely to be present |Likely active infection requiring treatment and full transmission |

| | |(Positive Predictive Value=91.4%) |precautions |

|PCR | | | |

|Positive | |Toxin producing strain |Indicates strain is capable of producing toxin but does not confirm |

| | | |actual toxin production. Transmission precautions remain |

|Negative | |Non-toxin producing strain |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 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.

• Stop other broad spectrum antibiotics where possible.

• If concomitant antimicrobial therapy required please discuss with microbiology the least ‘C.diff-ogenic’ choice.

• If only mild symptoms (less than 3 loose motions over 24h and systemically well) and with known precipitating antibiotics, consider stopping current antibiotics and monitor closely

• If >3 loose motions/day or failing to improve after stopping precipitating antibiotics, treat as follows:

• Oral Vancomycin 125mg QDS for 14 days (never shorter)

• IV Metronidazole 500mg TDS should be added in severe disease with probable ileus or where oral absorption is in doubt

• Note that improvement should occur within 3-4 days.  If this does not occur, do rediscuss with Microbiology as oral Vancomycin dosage can be increased, and a slowly-reducing "tapering" regime may be appropriate

• For cases of toxin-positive C. diffile which has recurred despite oral Vancomycin, oral Fidaxomicin 200mg BD for 10 days is advised, though this may only used on case-by-case authorisation by a Consultant Microbiologist. 

• For patients who have relapsed despite tapering Vancomycin or Fidaxomicin therapy, or whom are still having any ongoing diarrhoea despite either of these, do be in touch with Microbiology to discuss possible faecal transplantation.  This may be done either on current inpatients or arranged via overnight elective stay.  Contact Andrew Flatt Consultant Microbiologist on bleep 0217 or Trust email during weekdays to discuss. 

• Faecal transplant also has a role in fulminant severe Clostridium difficile infection though is considered on a case-by-case basis. 

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

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 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 Engie 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 28-day 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

• 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.

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

REFERENCES AND ASSOCIATED DOCUMENTATION

1. Clostridium difficile: Health Protection Agency, August 2013. Accessed January 2014

2. National Clostridium difficile Standards Group. Report to the Department of Health, February 2003.

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.

4. Updated guidance on the management and treatment of Clostridium difficile infection. Public Health England, May 2013.

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.

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.

10. Updated guidance on the diagnosis and reporting of clostridium difficile. Department of Health, March 2012

11. Inclusion criteria for reporting C. difficile infection to the surveillance system. Health Protection Agency, March 2012

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

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:

Working together for patients

Working together with compassion

Working together as one team

Working together always improving

This policy should be read and implemented with the Trust Values in mind at all times.

MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

This document will be monitored to ensure it is effective and to assure compliance.

|Minimum requirement to be|Lead |Tool |Frequency of Report of |Reporting arrangements |Lead(s) for acting on |

|monitored | | |Compliance | |Recommendations |

|100% of staff following |CSC Matron |Peer Review |Quarterly |Policy audit report to: |Infection Prevention & Control |

|appropriate hand hygiene | | | |Infection Prevention Management |Team |

|procedures | | | |Committee | |

|Weekly Isolation of |IPT |Infection Control |Weekly |Policy audit report to: |Infection Prevention & Control |

|patients with suspected | |Dashboards | |Infection Prevention Management |Team |

|infectious diarrhoea | | | |Committee | |

|Monthly monitoring of |IPT |Infection Control |Weekly |Policy audit report to: |Infection Prevention & Control |

|cleaning (ATP scores) and | |Dashboards | |Infection Prevention Management |Team |

|compliance with CDCP | | | |Committee | |

|Antimicrobial Prescribing |Medical |Audit against |Annual |Policy audit report to: |Medical Microbiology |

| |Microbiology |Antimicrobial | |Infection Prevention Management | |

| | |guidelines | |Committee | |

APPENDIX 1: CLOSTRIDIUM DIFFICILE INFECTION CLEANING SCHEDULE

DAILY CLEANING

APPENDIX 2: CLOSTRIDIUM DIFFICILE CARE PATHWAY



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 |23/10/2018 |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 |Comments |

|Age |No | |

|Disability |No | |

|Gender reassignment |No | |

|Pregnancy and Maternity |No | |

|Race |No | |

|Sex |No | |

|Religion or Belief |No | |

|Sexual Orientation |No | |

|Marriage and Civil Partnership |No | |

|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 | | |

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|More Information can be found be following the link below | | |

| | | |

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|.uk/ukpga/2010/15/contents | | |

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|Stage 2 – Full Impact Assessment |

|What is the impact |Level of Impact |Mitigating Actions |Responsible Officer |

| | |(what needs to be done to minimise / remove the | |

| | |impact) | |

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|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 |

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Working together to drive excellence in care for our patients and communities

our patients and communities

Exposure to Toxigenic C.difficile

Exposure to Toxigenic C.difficile

Disruption of normal

Intestinal flora (antimicrobials)

Alteration of stomach acid (PPIs)

Acquisition of Toxigenic C.difficile

Clinical risk factors:

• Poor antibody response to Toxin A

• Exposure to additional antimicrobials

• Age (>65 years)

• Underlying disease severity

Asymptomatic C.difficile carriage

(may act as reservoir from spread)

Mild/Moderate CDI

Severe/Life threatening CDI

CLINICAL STAFF

Clean all areas with Actichlor Plus

Ensure that fresh Actichlor Plus is made up every day and stored correctly with cap closed

Wash hands with soap and water – wear disposable gloves and plastic apron

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

ENGIE

Clean all areas with Actichlor Plus

Wash hands with soap and water – wear disposable gloves and plastic apron

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 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

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