HSE West, Mid-Western Regional Hospitals, Limerick, Guidelines for The Management of Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 1 of

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1 Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 1 of 21

2 Table of Contents 1.0 POLICY STATEMENT PURPOSE SCOPE LEGISLATION/OTHER RELATED POLICIES GLOSSARY OF TERMS AND DEFINITIONS Glossary Of Definitions Glossary Of Terms / Abbreviations ROLES AND RESPONSIBILITIES GUIDELINE Infection Prevention And Control Management Of CDAD Patient Placement Restricting Patient Movement and Transfer Hand Hygiene Gloves Aprons and Gowns Waste Disposal Laundry Patient Care Equipment Environmental Cleaning Specimen Taking For C Difficile Treatment Of CDAD Management Of Outbreaks Of CDAD Notification Visitors IMPLEMENTATION PLAN REVISION AND AUDIT REFERENCES/ BIBLIOGRAPHY APPENDICES...13 Appendix I Patient information leaflet...13 Appendix II Precautions for caring for patients with CDAD...15 Appendix III Antibiotic Guidelines...18 Appendix IV Signature Sheet...19 Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 2 of 21

3 1.0 POLICY STATEMENT This guideline is aimed at all healthcare professionals and outlines recommendations and best practice for the management and infection prevention and control of C. difficile- associated disease in the Mid-Western Regional Hospitals. 2.0 PURPOSE The aim of this guideline is to promote awareness of Clostridium difficile associated diarrhoea and steps taken to prevent and manage it within the hospital setting. This guideline upholds standards of safe practice which promotes patient safety at all times, and aims to prevent the spread of cross infection. 3.0 SCOPE This guideline applies to all healthcare staff involved in patient care in the Mid-Western Regional Hospitals. 4.0 LEGISLATION/OTHER RELATED POLICIES Health Protection Surveillance Centre (HPSC) Clostridium difficile Sub-Committee (2008) Surveillance, Diagnosis and Management of Clostridium difficile-associated disease in Ireland. SAFETY, HEALTH AND WELFARE AT WORK ACT (2005) and its associated regulations GLOSSARY OF TERMS AND DEFINITIONS 5.1 Glossary Of Definitions Diarrhoea is defined as three or more loose/watery bowel movements which are unusual or different for the patient) in a 24 hour period and there is no other recognised aetiology for the diarrhoea (e.g. laxative use or medical condition) Diarrhoeal Specimen Diarrhoeal stool specimens are defined as those that take up the shape of their container. Recurrent CDAD case This is a patient with an episode of CDAD that occurs within 8 weeks following the onset of a previous episode provided that CDAD symptoms from the earlier episode resolved with or without therapy. Healthcare onset Symptoms: Start during a stay in a healthcare facility Community onset Symptoms start in a community setting, outside healthcare facilities Healthcare-associated case This is a CDAD case with either: Onset of symptoms at least 48 hours following admission to a healthcare facility (healthcareonset, healthcare-associated) or With onset of symptoms in the community within 4 weeks following discharge from a healthcare facility (community onset, healthcare-associated) Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 3 of 21

4 Community-associated case This is a CDAD case patient with either: Onset of symptoms while outside a healthcare facility, and without discharge from a healthcare facility within the previous 12 weeks (community-onset, community-associated) or With onset of symptoms within 48 hours following admission to a healthcare facility without residence in a healthcare facility within the previous 12 weeks (healthcare-onset, community-associated). Unknown Case This is a CDAD case patient who was discharged from a healthcare facility 4 12 weeks before the onset of symptoms. Pseudomembranous colitis (PMC) Severe inflammation of the inner lining of the colon. Pseudomembranous colitis is characterized by pus and blood in the stool and often caused by antibiotics. 5.2 Glossary Of Terms / Abbreviations (CDAD) C. difficile-associated disease (C. difficile) Clostridium difficile (HCAI) Healthcare-associated infection (HCW) Healthcare Workers (IPC&T) Infection Prevention & Control Team (PMC) Pseudomembranous colitis (PPE) Personal protective equipment 6.0 ROLES AND RESPONSIBILITIES It is the responsibility of department heads to ensure that healthcare staff who report to them adhere to this guideline. All Healthcare Workers should attend Infection Prevention and Control education and training at induction and yearly thereafter. Staff education and training on infection prevention and control issues should not only include medical and nursing staff, but also allied healthcare professionals and support staff (e.g., cleaning staff, portering staff, administrative staff, etc). Control of healthcare-associated infection (HCAI) must be given high priority by senior management. 7.0 GUIDELINE Clostridium difficile is a spore-forming anaerobic bacterium that is widely distributed in soil and the intestinal tracts of animals. The spectrum of C. difficile human disease ranges from asymptomatic colonisation to potentially fatal colitis. C. difficile remains the most important cause of healthcare associated diarrhoea and is increasingly important as a community pathogen. The prevalence of asymptomatic C. difficile colonisation ranges from less than 5% in community to over 20% of hospitalised patients. Typically, C. difficile-associated disease (CDAD) presents as diarrhoea, abdominal cramps, fever and leucocytosis, occurring several days up to 10 weeks after antibiotic therapy. Pseudomembranous colitis is the most severe manifestation of disease. A more virulent strain of C. difficile has been identified and has been responsible for more-severe cases of disease worldwide. The most common risk factors for CDAD are exposure to antibiotics, advanced age and hospitalisation. Clindamycin and the broad-spectrum cephalosporins are the most commonly reported antibiotics implicated in development of CDAD, however, nearly all antibiotics have been associated with CDAD. While CDAD is a disease predominantly of older patients, other risk factors such as hospitalisation, recent gastrointestinal surgery or procedures and immunosuppressive therapy can also predispose to infection. Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 4 of 21

5 C. difficile can be transmitted from patient-to-patient, via contaminated HCW hands, or via environmental (including healthcare equipment) contamination. Compliance with infection prevention and control practices is crucial in reducing the incidence of CDAD. Physical proximity to a symptomatic case has been reported as important for transmission due to contaminated near patient environmental contamination and movement of contaminated equipment between patients (e.g., commodes). 7.1 Infection Prevention And Control Management Of CDAD Prompt isolation/cohort of all patients with suspected or confirmed CDAD, in a single room with clinical hand washing sink and en-suite facilities is recommended. Patients with suspected C. diff should be isolated immediately. The use of Standard and contact precautions is recommended for all patients with known or suspected CDAD. Refer to Infection Prevention & Control Standard Precautions Guideline (2010) and Isolation Guideline (2010). If en-suite facilities are not available, patients with CDAD should be allocated a designated toilet or commode. Isolation with Contact Precautions may be discontinued when the patient has had at least 48 hrs without diarrhoea and has had a formed or normal stool for that patient. Hand hygiene should be performed before and after all patient and equipment contact and after glove removal None of the agents (including alcohols, chlorhexidine, iodophors or triclosan) used in antiseptic hand-wash or antiseptic hand-rub preparations are reliably sporicidal against Clostridium species. The current National Guidelines for Hand Hygiene in the Healthcare Settings (2005) recommend that after caring for a patient with CDAD the healthcare worker should wash hands with soap and water. (Refer to Infection Control Hand Hygiene Guideline, 2010). Adherence to contact precautions is recommended-gloves and apron should be worn for contact with the patient and the patient environment. Change Personal Protective Equipment (PPE) after each patient (Refer to Isolation Guideline 2010, Standard Precautions Guideline 2010). The environment of patients with CDAD should be cleaned with detergent and disinfected daily with Actichlor 1.7g (1000ppm), paying special attention to frequently touched sites. Environmental faecal soiling should be cleaned and disinfected immediately, refer to Guidelines on Cleaning and Disinfection of Equipment and the Environment (2010). All equipment used on CDAD patients should be thoroughly cleaned with detergent and disinfected with sodium dichloroiscyanurate (Actichlor 1.7g, 1000ppm) immediately after use. Medical devices should be dedicated to a single patient and disposable materials used whenever possible, refer to Guidelines on Cleaning and Disinfection of Equipment and the Environment (2010). Patients with CDAD and their visitors should be provided with a patient information leaflet(appendix 1) Further Infection Prevention & Control Measures (Refer to Appendix 5) Patient Placement Include the potential for transmission of infectious agents in patient placement decisions. Place all patients with known or suspected CDAD in a single room with clinical handwashing sink and ensuite facilities. If ensuite facilities are not available, dedicate toilet or commode for patients sole use. Place a notice an Isolation notice on the isolation room door advising those entering to report to the nurse-in-charge before entering. In an outbreak situation, if Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 5 of 21

6 the number of patients with CDAD exceeds the availability of single rooms, alternative options include: Cohort ward or bay with a dedicated nursing staff for the area. Isolation/dedicated ward in the event of a large outbreak Restricting Patient Movement and Transfer The movement and transport of the isolated patient with CDAD should be limited to essential purposes only. If transport or movement is necessary, staff should ensure that precautions are maintained to minimise the risk of transmission to other patients and the contamination of environmental surfaces or equipment. Notify the receiving department of the patients CDAD status and the need for contact precautions prior internal patient transfer. For transfers to another healthcare facility, if the transfer is not urgent, the receiving healthcare facility should only accept a patient currently being treated for CDAD if: The patient has had no diarrhoea for at least 48 hours and Has had a formed or normal stool for that patient Prior to patient transfer to another healthcare facility, the receiving healthcare facility should be informed of the patients CDAD status/history. Transport personnel (e.g., porters, emergency medical technician) and the receiving healthcare facility should be informed of the need for Contact Precautions. Contaminated aprons/gowns and gloves should be removed and disposed and hand hygiene performed prior to transporting patients Hand Hygiene Good hand hygiene is effective in the prevention of HCAI including CDAD. Following care of a patient with CDAD the healthcare worker should wash hands with soap and water. None of the agents (including alcohols, Chlorhexidine, iodophors or tricolosan) used in antiseptic hand/wash or antiseptic hand/rub preparations are reliably sporicidal against Clostridium species. If a non-antimicrobial soap is used, after drying, an alcohol hand rub should be applied to the hands (Refer to Hand Hygiene Guideline 2010). In a setting in which there is an outbreak or an increased CDAD rate, instruct visitors to wash hands with soap (or antimicrobial soap) and water after contacting patients with CDAD or their environment Gloves In addition to wearing gloves as required for standard precautions, gloves should also be worn when entering a room for all interactions that may involve contact with the patient or potentially contaminated areas in the patients environment. Gloves should be removed: Immediately after contact with any infective material Before touching non-contaminated items and environmental surfaces Before leaving the patients environment Refer to Standard Precautions Guideline (2010) and Isolation Guideline (2010) for further advice. Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 6 of 21

7 Hands should be washed immediately after glove removal with soap and water (Refer to Infection Control Hand hygiene Guideline 2010). After glove removal and hand washing, dry the hands and apply an alcohol based hand rub. Hands should not touch potentially contaminated environmental surfaces or items in the patient s room to avoid cross-infection Aprons and Gowns The necessity to wear an apron/gown is based on risk assessment of the anticipated level of contact with the patient and patient environment. The need for and the type of apron/gown selected is based on the nature of patient interaction, including anticipated degree of contact with infectious material and potential for blood and body fluid penetration of the barrier. In addition to wearing apron/gowns as required for Standard Precautions, aprons/gowns should also be worn when entering a room for all interactions that may involve contact with the patient or potentially contaminated areas in the patients environment. Apron/Gown should be removed: Immediately after contact with any infective material Before leaving the patients environment Hands should be washed with soap and water (as previously outlined) immediately after apron/gown removal. When the hands are dry, apply alcohol based hand rub. Refer to Standard Precautions Guideline (2010), Isolation Guideline (2010) for further advice Waste Disposal Waste contaminated with diarrhoea from a suspected or known CDAD patient should be disposed as healthcare risk waste. Non-contaminated waste should be disposed as healthcare non-risk waste. No additional precautions are needed for non-healthcare waste that is being removed from rooms of patients on Contact precautions. All refuse bins should be hands free (i.e., lid cannot be opened by hand and must be pedal operated) to prevent soiling/contamination of the waste container and possible hand contamination. Refer to Infection Prevention and Control Policy on Healthcare risk waste and its segregation and disposal within the HSE Mid-Western Area (2010) for further guidance on waste disposal Laundry All laundry should be treated as potentially infectious and placed directly into a water-soluble bag at the bedside. The sealed bag should then be placed immediately into a RED linen bag according to local guidelines prior to transport to the central laundry facility (Refer to Guideline for the handling and segregation of Linen 2010) Patient Care Equipment All equipment which comes into close contact with the patient should be adequately cleaned with detergent and disinfected with Actichlor 1.7g (1000ppm), (refer to Guidelines on Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 7 of 21

8 Cleaning and Disinfection of Equipment and the Environment (2010). Non-critical patientcare equipment should be dedicated to a single patient to avoid sharing between patients and cleaned carefully after use. If use of common equipment or items is unavoidable, this should be adequately cleaned and disinfected before use for another patient. The combination of hot water and detergents used in dishwashers is sufficient to decontaminate dishware and eating utensils. Medical devices designated as Single Use Only must not be reprocessed or reused under any circumstances (MDA DB 2000), (MDD) 93/42/EEC. Reusable medical devices should be cleaned and reprocessed according to the manufacturer s instructions and local policy. (Refer to the Infection Control Decontamination Folder 2006). This symbol means Single Use Only (BS EN 980:1997) Environmental Cleaning Environmental contamination with C. difficile spores is common and persistent despite cleaning. Spores can survive up to five months in the environment. The need to clean frequently touched sites (e.g. doorknobs, bedrails, light switches, commodes, wall areas around the toilet in the patient s room, toilet flush handle, curtains and the bed frame) is necessary as these areas are frequently contaminated, refer to Guidelines on Cleaning and Disinfection of Equipment and the Environment (2010) for further advice. Other sources of environmental contamination can include thermometers, staff uniforms, and blood pressure cuffs. The environment of patients with CDAD should be cleaned with detergent and then disinfected daily with Actichlor 1.7g (1000ppm), All visibly dirty surfaces need to be cleaned with a detergent first, before disinfection (refer to Guidelines on Cleaning and Disinfection of Equipment and the Environment (2010). On resolution of CDAD symptoms or patient discharge/transfer, cleaning and disinfection of the environment must occur. Prior to initiating environmental cleaning and disinfection, all privacy, shower and window curtains must be removed and sent for laundering. All disposable items including paper towels and toilet paper must be discarded. Refer to Appendix II, Precautions for caring for patients with CDAD. 7.2 Specimen Taking For C Difficile Testing of asymptomatic individuals is not recommended. Diarrhoeal specimens are defined as those that take up the shape of their container. In the case where clinical suspicion of CDAD is high, yet C. difficile toxin is negative, patients should be retested. If the specimen is negative and the patient has not been treated with specific antibiotic therapy, the specimen should be tested for C. difficile culture and toxin testing. If recurrence of diarrhoea after a symptom-free interval occurs, a repeat specimen should be tested for C. difficile toxin and other potential causes of diarrhoea excluded. Once the diagnosis of CDAD is confirmed, patients should not be retested for C. difficile toxin when on treatment. Performing a test of cure or clearance on stool specimens after C. difficile treatment is not recommended For optimal laboratory investigation, freshly taken faecal specimens should be examined. Same day C difficile results are available from the Microbiology Laboratory. Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 8 of 21

9 7.3 Treatment Of CDAD Routine identification of asymptomatic carriers (patients or healthcare workers) for infection control purposes is not recommended and treatment of such identified patients is not effective. Antiperistaltic agents should be avoided because of lack of evidence that they improve diarrhoea in this situation and the theoretical risk of precipitating toxic megacolon by slowing clearance of C. difficile toxin from the intestine. See Appendix III, Antibiotic Guidelines. 7.4 Management Of Outbreaks Of CDAD An outbreak is defined as the occurrence of two or more epidemiologically linked CDAD cases over a defined period agreed locally. Contact the Infection Prevention and Control Team for advice if there is a suspected outbreak of CDAD. When an outbreak of CDAD is suspected, a multi-disciplinary outbreak control team (OCT) should be established. Additional measures advised by the Outbreak Control Team to control the outbreak must be implemented. In an outbreak setting, the number of cases of CDAD may exceed the availability of single rooms and alternative placement options include: Cohort ward or bay with a dedicated nursing staff for the area. Isolation / dedicated ward in the event of a large outbreak If en-suite facilities are not available it is essential that patients with CDAD have a dedicated toilet or commode and are not permitted to use the general toilet facilities on the ward. Refer to Mid Western Regional Hospital Complex, Guidelines for the Management of an Outbreak (2010), for further advice. 7.5 Notification The Department of Health and Children has instructed the HSE to include Clostridium difficile (toxin producing) as an organism notifiable under the category of Acute Infectious Gastroenteritis (AIG). Please notify all cases of Clostridium difficile associated disease (CDAD) as per case definition under Acute infectious gastroenteritis to the relevant Department of Public Health. All new events of CDAD will be entered onto the national Computerised Infectious Disease Reporting system (CIDR). 7.6 Visitors Patients with CDAD and their visitors/carers should be given information on preventing transmission of CDAD outlining the range and need for appropriate infection control precautions (e.g. patient information leaflet Appendix 1). Visitors should be shown how to carry out hand hygiene (Refer to Appendix 1, Patient Information Leaflet). Visitors should be alerted to check with ward nursing staff regarding hand hygiene and other requirements before and after visiting a patient with CDAD. Visitors should not use the patient s bathroom and should not go into other patients rooms or bed spaces. Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 9 of 21

10 Further advice is available from the Health Protection Surveillance Centre (HPSC) Clostridium difficile Sub-Committee (2008) Surveillance, Diagnosis and Management of Clostridium difficile-associated disease in Ireland. Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 10 of 21

11 8.0 IMPLEMENTATION PLAN 8.1 This guideline will be implemented by Heads of Disciplines, Nursing Support Service Management, General Services Management, Heads of Departments and the Infection Prevention & Control Team in the Mid-Western Regional Hospitals. 8.2 The Heads of Disciplines and Heads of Departments are responsible to ensure that this guideline is available/ brought to the attention to staff who report to them in their areas of responsibility. 8.3 Staff have a responsibility to read this guideline and sign the Signature Sheet (Refer to Appendices). 8.4 The Infection Prevention and Control Team will provide education and training sessions to relevant staff as part of the implementation process of this guideline. 8.5 The receipt sheet should be returned to the infection Prevention and Control secretary. 8.6 The Infection Prevention & Control team will be responsible for maintaining guideline receipt sheets from all Wards/Departments. It is the responsibility of Heads of Disciplines and Heads of Departments to maintain records locally. 9.0 REVISION AND AUDIT 9.1 The Guideline will be reviewed by the Infection Prevention and Control Team and updated as necessary and at least every 2 years. 9.2 An audit will be undertaken within one year of issue. Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 11 of 21

12 10.0 REFERENCES/ BIBLIOGRAPHY Health Protection Surveillance Centre (HPSC) Clostridium difficile Sub-Committee (2008) Surveillance, Diagnosis and Management of Clostridium difficile-associated disease in Ireland. Mid Western Regional Hospitals (MWRHs) (2010); Policy on Healthcare Risk Waste and its Segregation & Disposal within the HSE Mid-West Area. Mid Western Regional Hospitals (MWRHs) (2010); Guideline for the Handling and Segregation of Linen. Mid Western Regional Hospitals (MWRHs) (2010); Infection Control Standard Precautions Guideline. Mid Western Regional Hospitals (MWRHs) (2010); Guidelines for Isolation Precautions. Mid Western Regional Hospitals (MWRHs) (2010); Guidelines for Cleaning and Disinfection of Equipment and the Environment. Mid Western Regional Hospitals (MWRHs) (2010); Hand Hygiene Guideline. Mid Western Regional Hospital Complex (MWRHs) (2010); Guidelines for the Management of an Outbreak. The Mid-Western Regional Hospitals Complex, St. Camillus and St. Ita s Hospitals (2009) Adult Antibiotic Policy, Second Edition. National C difficile Standards Group (2004); National Clostridium difficile Standards Group: Report to the Department of Health. Journal of Hospital Infection Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) Stuart H. Cohen, MD; Dale N. Gerding, MD; Stuart Johnson, MD; Ciaran P. Kelly, MD; Vivian G. Loo, MD; L. Clifford McDonald, MD; Jacques Pepin, MD; Mark H. Wilcox, MD (2010) Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update. Infection Control and Hospital Epidemiology; Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 12 of 21

13 11.0 APPENDICES Appendix I Patient information leaflet This leaflet is intended for patients in hospital, their families and carers to give them a greater understanding of Clostridium difficile (also called C. difficile and C. diff ). Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 13 of 21

14 Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 14 of 21

15 Appendix II Precautions for caring for patients with CDAD Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 15 of 21

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18 Appendix III Antibiotic Guidelines Mid-Western Regional Hospitals Complex St. Camillus and St. Ita s Hospitals Adult ANTIBIOTIC GUIDELINES (Second Edition Issued 2009) Good antimicrobial prescribing is a key to preventing infection, particularly avoiding use of Cephalosporins where possible (and quinolones in 027 ribotype outbreak). Diagnosis should be confirmed by microbiological examination of stool specimen. Please ask for Clostridium difficile toxin investigation on laboratory request form. Contact microbiologist where negative toxin studies are reported in high risk case so that culture for organism is performed. TREATMENT 1. Correction of fluid / electrolyte imbalance every case. 2. Withdraw offending antibiotic where possible. 3. Specific antimicrobial therapy against Clostridium difficile where indicated. 4. Isolate the patient whilst they have diarrhea to prevent cross infection. SPECIFIC ANTIMICROBIAL THERAPY Mild disease-patient still on offending antibiotic. Where possible stopping the offending antibiotic may be sufficient to control the infection. If the antibiotic cannot be stopped or symptoms persist after stopping the offending antibiotic administer specific anti Clostridium difficile therapy. Apart from the instance mentioned above other patients warrant specific anti- Clostridium difficile therapy. FIRST LINE THERAPY metronidazole 400mg 8H orally for 10 days or 500mg 8H intravenously if the patient is unable to take oral medication. SECOND LINE THERAPY vancomycin 125mg 6H orally for 14 days should only be used if metronidazole is contraindicated or metronidazole therapy has failed or severe infection. There is no role for intravenous vancomycin in therapy, as it does not reach therapeutic levels in the bowel which is the site of infection. There is also no need to send vancomycin levels following oral administration of vancomycin. If patients fail both metronidazole and vancomycin therapy please ring and discuss with consultant Micro/ID. Also, seek urgent surgical review with regard to potential colonoscopy / colectomy in severe infection. PRACTICE POINT 1. Good antimicrobial prescribing is key to preventing infection. 2. Please inform General Practitioner on day of discharge if patient has or has had Clostridium difficile during the hospital stay. 3. There is no need to check for microbiological clearance of C. difficile toxins as a patient can remain toxin positive for an indefinite period. Resolution of symptoms is the main clinical consideration. 4. Ensure C. difficile infection is treated for full recommended duration of course, regardless of resolution of symptoms. 5. Notify Public Health specialists. 6. See HPSC website: Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 18 of 21

19 Appendix IV Signature Sheet I have read, understand and agree to adhere to the attached Guideline Printed Name Signature Area of Work Date Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 19 of 21

20 I have read, understand and agree to adhere to the attached Guideline Printed Name Signature Area of Work Date Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 20 of 21

21 I have read, understand and agree to adhere to the attached Guideline Printed Name Signature Area of Work Date Clostridium Difficile, MGIP&C 09/10, Revision 02, 09/12 pg 21 of 21