The first step in preventing C difficile is to prescribe and use antibiotics carefully. This includes not prescribing antibiotics when they are not needed such as with asymptomatic bacterial colonization and upper respiratory infections. And avoiding the just in case prescription. Decisions to prescribe should be justified by clinical findings and driven by culture results. If an antibiotic is prescribed, ensure that the orders include a dose, duration, and indication. When culture results come back in 24 to 48 hours, take an antibiotic time out to reassess therapy. It is important to decide if the antibiotic is still needed and more importantly that the antibiotic is still effective against the organism. A timeout is particularly helpful in long-term care facilities, where the clinician is not often on-site when prescribing the antibiotic or when culture results are reported. It is also important to monitor antibiotic prescribing practices within your facility. For instance, monitor prescribing practices around urinary tract infections and monitor for episodes when treatment was not indicated. This can be done by an infection preventionist who can feed back the information to the administration, clinical leadership, and prescribing clinicians. Finally, you can consider developing institutional specific guidelines and clinical pathways to direct prescribing to locally identified problem areas. The next step in controlling C difficile is to test residents when they have diarrhea while on antibiotics or within two months of receiving them. If C difficile is suspected, notify the physician and obtain a stool sample for toxin testing. It is important to immediately place residents with confirmed or suspected C difficile on contact precautions. This should be done as soon as a test is ordered to prevent transmission or spread. Waiting two or three days for results could allow other residents to be exposed and the patient could become very ill. It is important that staff and visitors wear gowns and gloves when entering the room even if they are not going to touch the resident. They should also be sure to wash hands only with soap and water after removing gowns and gloves and before leaving the room. Alcohol based hand sanitizers do not kill C difficile spores. It is also important that any equipment such as blood pressure cuff, stethoscope or thermometers be dedicated to residents with C difficile. If this is not possible, these shared items should be disinfected using a one to ten dilute bleach solution or an EPA registered sporicidal disinfectant between uses to prevent cross transmission. Residents should remain on contact precautions until the diarrhea has resolved and have formed stools for 48 hours. It is not necessary to perform a test because spores will still be present. In an ideal situation a private room with an attached bathroom is preferred for managing residents with C difficile infections. However this arrangement is not common in most long term care facilities. Managing a resident's diarrhea can often be difficult in a semi private room with a shared bathroom. If a roommate is not optional, two residents with C difficile can be cohorted in the same room or C difficile infected resident can be placed with a roommate who does not use the bathroom. If neither of these options is available, select a roommate who is not taking antibiotics and is not compromised to the point of being susceptible to infections and having the non C difficile infected resident use a bedside commode. In the event that a C difficile infected resident has to use a bedside commode, the commode should be lined with a plastic bag and absorbent material to reduce healthcare personnel exposure to fecal material. In order to preserve the dignity of residents and use the least restrictive approach to managing a resident with C difficile, some residents may be able to ambulate in the facility and participate in social activity. Assess the resident's bowel control and personal hygiene. If able to maintain bowel control and perform hand hygiene appropriately. Allow the resident to participate in activities when possible, prior to leaving the room have the resident wash their hands. Place a clean gown over the resident's clothing and disinfect any assistive devices. Any healthcare personnel who are assisting with ambulation should wear gloves and avoid touching items outside the resident's room without first removing the gloves and washing their hands. A gown may be needed if the workers are going to have more than hand contact with the infected resident. For those residents with chronic mental illness or dementia it is not always possible to ensure good compliance with control measures. Under these conditions it may be appropriate to provide one to one caregiving. As we stated previously, the environment plays an important role in the transmission of C difficile. Because C difficile is shed in diarrhea, any surface, item or medical device can become contaminated with spores and contribute to infection transmission. It is important that facility policies include strategies to prevent transmission from infected resident rooms to other parts of the facility. If environmental contamination is not controlled, hand contamination of health care personnel also increases. So it is important to clean frequently, thoroughly and with the right product. Disinfectants normally used in health care settings, usually quaternary ammonium compounds and phenolics are not sporicidal and will not kill C difficile spores. Only chlorine based disinfectants like bleach and a few newer EPA registered sporicidal agents are able to kill spores on surfaces and equipment. Generally, most facilities use a one to ten bleach solution for C difficile room cleaning. This solution is easily prepared by mixing one part household bleach with nine parts water. Frequently touched surfaces like the bed rail, call button, telephone, bathroom surfaces and over bed and bedside tables should be cleaned daily to reduce microbial contamination and hand transmission by healthcare workers. Any shared resident care items like blood pressure cuffs, stethoscopes, thermometers and lifts should be dedicated to affected residents if possible. Or be disinfected with the bleach solution before being used on another resident. The entire room should be cleaned when the resident is discharged. Failure to clean all surfaces on a terminal cleaning can put the next resident occupying the room at risk for acquiring C difficile. To learn more about environmental cleaning, see the environmental disinfecting module, module four. The final component of protecting against C difficile transmission is to improve communication when a resident is transferred to another facility. When transferring a resident with an active C difficile disease or a recent history of a C difficile disease, it is important to relay this information to the receiving facility, so that proper precautions can be instituted upon their arrival. It is also important to ask for this information when receiving a resident from another facility so that the proper precautions can be utilized upon arrival. Failures in communication between facilities can lead to transmission with in a facility because C difficile infection can go unrecognized for some time. Preventing C difficile infection and transmission can be done effectively if you, recognize the major reservoirs. Control surface contamination and hand transmission by frequently and thoroughly disinfecting surfaces with a bleach solution and by good hand washing with soap and water. Recognize and isolate infected residents early using contact precautions. Keep contact precautions in place as long as the resident has diarrhea. Once the resident has formed stools for 48 hours, the precautions can be discontinued. There is no need to retest following resolution of diarrhea, as spores will still be present after the diarrhea resolves. Insure that you share relevant infection related information with receiving facilities when transferring infected residents to other locations. Also, be sure to ask about infectious conditions of anyone being admitted or readmitted to your facility so the proper infection control interventions can be implemented.
