Clostridium difficile

Clostridium difficile infection (CDI) is a diagnosis in its own right. It covers a spectrum of disease from mild diarrhoea to a severe and life-threatening condition. Older patients and those who have had a recent course of antibiotics are thought to be most at risk.

NHS organisations need to ensure they have policies and systems in place that make provision for prompt diagnosis, isolation and cohort nursing of patients infected with Clostridium difficile, together with effective procedures for infection control, environmental decontamination and antibiotic prescribing.

When a patient presents with diarrhoea, it is important to consider the possibility that it may have an infectious cause. Patients with suspected potentially infectious diarrhoea should be isolated.

Implementing the following recommendations for healthcare providers and Commissioners, taken from Clostridium difficile: how to deal with the problem, DH and HPA, January 2009, will assist registered providers reduce cases of CDI:

Use of the SIGHT protocol is advised when managing suspected potentially 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 control team (ICT) while determining the cause of the diarrhoea.
G Gloves and aprons must be used for all contacts with the patient and their environment.
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.

Clinicians should consider CDI as a diagnosis in its own right, grading each confirmed case for severity, treating accordingly and reviewing each patient daily. PCTs should ensure that Trusts establish a multidisciplinary clinical review team to review all CDI patients at least weekly.

Trusts should provide sufficient capacity to isolate or cohort all known CDI patients.

All Trusts should have an antimicrobial management team (AMT) or equivalent to ensure the prudent use of antibiotics and guidelines recommending narrow-spectrum agents alone or in combination for empirical and definitive treatment where appropriate. Ideally, daily review of drug charts by pharmacists or AMT during ward rounds will provide feedback to clinical teams.

Directors of nursing and human resources should ensure each clinical area has reliable systems in place for training, auditing and feeding back to staff on cleaning, isolation, hand hygiene and protective clothing practices.

Trusts should ensure all clinical areas assess cleanliness and that they have introduced the National Specifications for Cleanliness (or an equivalent process). In particular, they should ensure an appropriate auditing process is in place and fully complied with.

Trusts should support the control and reduction of CDI from board level downwards, prioritising the management of risk to patients and ensuring the safety of patients is not compromised by the pursuit of other strategic objectives.

Clostridium difficile: how to deal with the problem, DH and HPA, January 2009
This guidance is aimed at healthcare professionals involved in the prevention and control of CDI and in managing outbreaks, particularly clinicians and NHS managers.

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