POLICY FOR THE PREVENTION AND CONTROL OF CLOSTRIDIUM DIFFICILE INFECTION (CDI)

POLICY FOR THE PREVENTION AND CONTROL OF CLOSTRIDIUM DIFFICILE INFECTION (CDI) Please be aware that this printed version of the Policy may NOT be the latest version. Staff are reminded that they should always refer to the Intranet for the latest version. Purpose of Agreement Document Type Reference Number Version Name of Approving Committees/Groups Operational Date Document Review Date Document Sponsor (Name & Job Title) Document Manager (Name & Job Title) Document developed in consultation with Intranet Location Website Location Keywords (for website/intranet uploading) To provide clear guidance and direction to staff within Solent NHS Trust on the management of CDI Policy Solent/Policy/IPC/11 Version 3 Assurance Committee May 2015 May 2018 Mandy Rayani Director of Infection Prevention and Control Ann Bishop Lead Nurse for Infection Prevention and Control Team Infection Prevention & Control Team Infection Prevention & Control sub Committee NHSLA Policy Group Policies; Infection Control N/A Cdiff, CDI, Diarrhoea Policy For The Prevention And Control 1 of 22 Version 3

Review Log Include details of when the document was last reviewed: Review Date Name of Ratification Reason for reviewer Process amendments 07.14 E Hore NHSLA Review met Amendments Summary: Amend No Issued Page Subject Action Date 1 Dec 14 5 Updated the recognised risk Immediate factors 2 Dec 14 10 Clarified CDI care in community Immediate 3 Dec 14 12 Incorporated e-learning requirements Immediate Policy For The Prevention And Control 2 of 22 Version 3

INDEX SECTION CONTENTS PAGE 1 Introduction 4 2 Scope 4 3 Roles and Responsibilities 4 4 Definitions 4 5 Risk Factors for CDI 5 6 Clinical Presentation 5 7 Management of CDI 6 8 Treatment of CDI 8 9 Role of Infection Prevention and Control Team 9 10 CDI Care Pathway 9 11 Environmental Cleaning 9 12 CDI In the Community 10 13 Outbreaks 10 14 Discharge Planning 11 15 Death Certification 11 16 Training Implications 12 17 Monitoring Effectiveness 12 18 Equality and Diversity and Mental Capacity Implications 12 19 Policy Links 12 20 Review 13 21 References 13 Appendix 1 CDI Care Pathway 15 Appendix 2 Inter Healthcare Transfer Document 17 Appendix 3 A Simple Guide to C.Difficile 18 Appendix 4 Equality and Human Rights Impact Assessment 20 Policy For The Prevention And Control 3 of 22 Version 3

1. INTRODUCTION 1.1 Clostridium difficile (C.difficile) are spore forming, gram-positive anaerobic bacilli that produce endotoxins, cause gastrointestinal infections in humans and are shed in faeces. C.difficile may be found in the large intestine of approximately 5% of the population and up to 20% of hospital patients. 1.2 C.difficile has the potential to cause serious illness and death, therefore Clostridium difficile Infection (CDI) should be managed as a diagnosis in its own right (Healthcare Commission 2007a). 2. SCOPE 2.1 This document applies to all directly and indirectly employed staff within Solent NHS Trust and other persons working within the organisation in line with Solent NHS Trust s Equal Opportunities Document. 3. ROLES & RESPONSIBILITIES 3.1 The Chief Executive and Trust Board have a collective responsibility for infection prevention and control within the Trust. 3.2 The Director of Infection Prevention and Control (DIPC) (Chief Nurse) is responsible for ensuring that this policy is implemented and adhered to across the organisation. 3.3 Managers have a duty to ensure that all staff have access to appropriate training and that they have the resources to follow this policy. 3.4 The Infection Prevention and Control Team (IPCT) are responsible for maintaining this policy. The IPCT will support the provision of training provided by the Learning and Development Team. 3.5 The Learning and Development Team are responsible for ensuring that staff have access to Induction training on Infection Prevention upon joining the organisation and e-learning modules according to learning & development policy. 3.6 Infection Prevention Link Advisors are healthcare staff selected by their managers to receive additional training in infection prevention and control. The key role of link staff is to promote best practice within their clinical area. 3.7 All staff have individual responsibility to comply with this policy. 4. DEFINITIONS Endotoxin: is a toxin that, is not secreted in soluble form by live bacteria, but is a structural component in the bacteria which is released mainly when bacteria are destroyed. Policy For The Prevention And Control 4 of 22 Version 3

GDH: The Glutamate dehydrogenase test detects the antigen that is produced in high amounts by C.difficile. Outbreak of CDI: two or more cases of the same strain related in time and place. Period of Increased Incidence (PII): two or more new cases within a ward in a 28 day period. Pseudo-membranous colitis: is 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. Spores: Spores are produced when Clostridium difficile bacteria encounter unfavorable conditions, such as being outside the body. They are very hardy and can survive on clothes and environmental surfaces for long periods. Toxic mega colon: is a life-threatening complication of several intestinal conditions. It is characterized by a very dilated colon (mega colon) accompanied by abdominal distension, and sometimes fever, abdominal pain or shock. 5. RISK FACTORS FOR CDI 5.1 These include: Over 65 years of age Antibiotics therapy in previous 1-3 months High risk are the 4C s Cephalosporins, Ciprofloxacin & Quinolones, Co-amoxiclav, and Clindamycin Immuno-compromised patients Hospital admission within previous one to three months Compromised immune system Presence of co-morbidity Bowel surgery Oncology Proton pump inhibitors (PPI) 6. CLINICAL PRESENTATION 6.1 Infection with C. difficile results in a wide spectrum of disease ranging in severity from mild diarrhoea, through moderately severe disease, to life-threatening pseudomembranous colitis with toxic mega colon, electrolyte imbalance and bowel perforation. Pseudomembraneous colitis may occur without diarrhoeal symptoms. Policy For The Prevention And Control 5 of 22 Version 3

6.2 Clostridium difficile ribotypes 015, 027 and 078 are amongst the more virulent strains capable of producing greater amounts of toxin resulting in more severe disease, increased therapeutic failure and higher mortality (Commission for Healthcare Audit and Inspection 2006; 2007). 7. MANAGEMENT OF CDI 7.1 Clinical staff must apply the following mnemonic protocol (SIGHT) when managing suspected potentially infectious diarrhoea. S I G H T Suspect that a case may be infective where there is no clear alternative cause for diarrhoea. Isolate the patient and consult with the infection prevention and control team (IPCT) while determining the cause of the diarrhoea. Gloves and aprons must be used for all contacts with the patient and their environment. Hand washing with soap and water must be carried out before and after each contact with the patient and the patient s environment. Test the stool for toxin, by sending a specimen immediately Suspected Infectious diarrhoea CDI should be suspected in patients with diarrhoea in the following situations: The patient is on or has been on antibiotics in the past 3 months. There is explosive, watery, offensive diarrhoea, fever, bloody stools or severe abdominal cramps. The patient has previously tested positive for C.difficile (GDH or Toxin). The patient developed diarrhoea on a ward where there was a known case of CDI. Isolation Patients with diarrhoea should be isolated immediately unless their diarrhoea is known to have a non-infective cause. Isolation of patients with suspected infectious diarrhoea should occur ideally within four-six 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. Patient safety must not be compromised mitigating actions should be taken to ensure safe isolation. If isolation is not possible this must be escalated to the Infection Prevention Team or out of hours to the Duty Hospital Manager. In order to maintain the safety of other patients it may be necessary to transfer the patient to an appropriate environment. Policy For The Prevention And Control 6 of 22 Version 3

Isolation room doors must remain closed (when safe to do so) and an isolation notice placed on the door. If the patient is required to leave the room for clinically urgent diagnostic or treatment purposes the IPCT should be contacted for advice. Steps taken to minimise transmission must not in any way impact on management or care given to the patient. Communication with colleagues is key. Gloves and Aprons (Personal Protective Equipment) On entering the room, staff must wash hands with soap and water and wear an apron and gloves. Visitors who do not assist in patient care and who have minimal patient contact do not need to wear gloves and an apron. Visitors assisting with patient care should wear gloves and an apron. All visitors and staff should wash their hands with soap and water before they leave the room. Visitors or staff should not eat or drink in the vicinity of the patient. On leaving the room all staff or visitors (who wear gloves and aprons) must remove and dispose of apron and gloves into the clinical waste bin and wash hands using soap and water. Enhanced Environmental Cleaning For cleaning and disinfection in the presence of CDI, all surfaces and equipment should be cleaned and disinfected minimum of twice daily using Actichlor plus. Commodes and raised toilet seats must be cleaned after each use with Actichlor plus Clinical staff must ensure the room remains clutter free to enable effective cleaning. This must be communicated to the patient and visitors. All open food such as fruit bowls should be removed due to high risk of contamination from the environment Clinical staff are responsible for the daily cleaning within the isolation room of clinical equipment such as commodes and bed above the mattress base. Domestic Services are responsible for floors, sinks, touch points i.e. door handles, light switches, chairs and base of bed frame. Hand Hygiene Alcohol hand rubs are not effective against C.difficile spores. Hands must always be cleaned with soap and water to facilitate the physical removal of spores. If staff visit a patient in their own home without access to soap and running water then a moist hand wipe (such as Clinell hand wipe) must be used before using alcohol hand rub. Testing In the case of unexplained diarrhoea (type 6 or 7) a stool sample must be taken and sent to the microbiology lab ASAP. Formed stool will not be tested. Clinical details should include duration of symptoms, any current or recent antibiotic therapy and any recent hospital admission (if known). A two stage test is used to detect presence of glutamate dehydrogenase (GDH) and C.difficile toxins. Policy For The Prevention And Control 7 of 22 Version 3

Possible results are outlined below: 1 st Stage GDH test 2 nd Stage Toxin Test Interpretation Action Negative (not required) C.difficile negative Proceed to full enteric screen with transmission precautions if diarrhoea persists Positive Negative C.difficile carriage Positive Positive C.difficile positive Potential for transmission requiring transmission precautions. Potential for future active infection Active infection requiring treatment and full transmission precautions GDH has a high negative predictive value. In GDH negative patients, C.difficile can reasonably be excluded. If a GDH positive, toxin negative sample is obtained but clinical symptoms of C.difficile persist a repeat stool sample should be taken and advice sought from Infection Prevention & Control Team or Microbiology. Repeat testing of stool specimens following a positive result looking for continued carriage of C.difficile provides little further information to direct treatment and should be avoided 8. TREATMENT OF CDI 8.1 Treat according to severity: Mild disease: 3 or fewer type 6-7 stools on Bristol Chart per day and a normal white cell count (WCC). Moderate disease: 3 to 5 stools of type 6-7 per day and a raised WCC (but less than 15). Severe disease: WCC greater than15, OR a temperature greater than 38.5, OR an acutely rising serum creatinine (e.g. greater than 50% increase above baseline) with evidence of severe colitis (abdominal, endoscopic or radiological signs). (The number of stools may be a less reliable indicator of severity). Life threatening disease: complete ileus or toxic megacolon with a systemic inflammatory response or septic shock. Patients should be reviewed daily for fluid resuscitation, electrolyte replacement, nutritional status and monitored for signs of increasing disease severity. Consideration should be given to stopping precipitating antibiotic if safe to do so or switching to a lower risk antibiotic. Policy For The Prevention And Control 8 of 22 Version 3

Stopping PPI, laxatives and anti-motility drugs due to risk of ileus and toxic megacolon. Medical staff should follow the appropriate guidance on Antibiotic prescribing according to their location. Further advice on the medical management can be sought from a microbiologist or the IPCT, or within Solent NHS Trust Antimicrobial Strategy 9. INFECTION PREVENTION TEAM 9.1 The ward will be advised of a positive C.difficile result either directly from the laboratory or from the Infection Prevention & Control team. 9.2 The IPCT will visit the clinical inpatient area as a matter of priority and discuss treatment and appropriate infection control precautions with staff. 9.3 IPCT will ensure staff have commenced a C.difficile Care pathway. (Appendix 1) 9.4 The IPCT will undertake a High Impact Intervention (HII) assessment to confirm that appropriate practices are being followed. If the outcome is below 100% the nurse in charge will be advised of necessary immediate interventions required. The IPCT will undertake this HII assessment at each subsequent visit. 10. CLOSTRIDIUM DIFFICILE CARE PATHWAY (CDCP) 10.1 This must be initiated ASAP following a positive C.difficile toxin or GDH result when symptomatic The consistency of stools should be assessed and recorded using the Bristol Stool Chart Stool charts should be recorded accurately after each bowel motion. It is recommended that bowels not opened is recorded for completeness. All urine or faeces must be disposed of as rapidly as possible All waste should be placed in an orange clinical waste bag All linen should be placed in a water soluble/ alginate bag before being placed in a secondary laundry bag (as per local practice) 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 based detergent/disinfectant i.e. Actichlor Plus Use normal crockery and cutlery and wash in dishwasher 11. ENVIRONMENTAL CLEANING 11.1 Daily environmental cleaning of rooms of C.difficile patients must be carried at least twice daily using Chlorine releasing agents i.e. Actichlor Plus (with 1,000 ppm Policy For The Prevention And Control 9 of 22 Version 3

available chlorine). The Infection Prevention team may request additional frequency of cleaning based upon a risk assessment. 11.2 Patient s toilets or commodes must be cleaned after each use with a chlorine releasing agent i.e. Actichlor Plus (with 1,000 ppm available chlorine). 11.3 Terminal Environmental Cleaning Once the patient is 72 hours clear of symptoms CDI, the patient environment must be thoroughly cleaned and disinfected with actichlor plus, with careful attention to toilets, bathrooms and sluices, beds, commodes and bedpans. The correct order of terminal cleaning is as follows: Strip beds and remove linen placing in a water soluble/alginate bag before being placed in a secondary laundry bag as per local protocol Disinfect equipment (including beds) with Actichlor Plus 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 Arrange terminal clean via domestic department Curtains must be removed bagged and laundered Cleaning should always start with high surfaces leaving the floor until last Please refer to of The NHS Cleaning Manual (NPSA, 2009) for further guidance on terminal cleaning. 12. CDI IN THE COMMUNITY 12.1 All unexplained cases of diarrhoea in the community (aged 2 years and above) should be investigated for CDI. Samples should clearly state who to inform with results. 12.2 There should be no restrictions on institutions such as care homes receiving patients who have had CDI and are now clinically asymptomatic. IPCT can assist if additional reassurance is required regarding perceived risks. 12.3 Staff working in the community who have contact with people with diarrhoea must wear gloves and aprons for all contact with them and their environment. 12.4 All staff in contact with patients with diarrhoea must wash their hands with soap and water even if hands are not visibly soiled. If soap and water are not available a moist hand wipe must be used before using alcohol hand rub. 13. OUTBREAKS 13.1 An outbreak of C.difficile is classified as two or more patients with the same strain related in time and place. 13.2 Guidance described above must be followed and the following additional measures should be implemented if an outbreak of C.difficile is suspected. Policy For The Prevention And Control 10 of 22 Version 3

Director of Infection Prevention and Control (DIPC) and Infection Prevention Team in consultation with a microbiologist should consider the need to form an outbreak committee. The Chief Executive is to be informed of their decision Any potential outbreak of CDI must to be reported to Public Health England (PHE) and relevant CCG (Clinical Commissioning Group) A SIRI will be raised. Restriction on admissions to and transfer from all affected areas. Resolution of the cluster/outbreak will be confirmed by the outbreak committee. Following confirmation, the affected area and all patient equipment will undergo a 'terminal' clean Patients may not be admitted to the ward until the 'terminal' clean is completed and the nurse in charge/ipct is satisfied with the standard of cleanliness An outbreak report will be prepared and submitted to the Infection Prevention and Control Sub Committee (IPCC) and other relevant authorities Any subsequent Post Infection Review (PIR) will be presented to the SIRI panel, IPCC along with recommendations. 14. DISCHARGE PLANNING 14.1 Patients should not be discharged to other healthcare environments with symptoms of diarrhoea which are considered abnormal for the patient unless clinically imperative; and only following detailed communications ensuring adequate precautions are established before the patient arrives. 14.2 Patients diagnosed with CDI may be discharged to their own home as soon as considered clinically fit and able to manage. If external care agencies in place they must be advised of transmission risk. If discharged to own home with CDI the GP should be advised by telephone. 14.3 There should be no restrictions on community institutions i.e. care homes, care agencies or community nursing services receiving patients who have had CDI where symptoms are now resolved. However good communication is imperative before the patient is transferred, this should be supported by written information e.g. discharge letter or the Inter Health Care Transfer Form (Appendix 2). 14.4 Persistent diarrhoea after recommended course of antibiotics may be due to a) relapse or b) post infective irritable bowel syndrome. Advice on clinical management must be sought from microbiology. 15. DEATH CERTIFICATION 15.1 If C.difficile is believed to have directly caused or contributed to the death of the patient this must be recorded on Part 1of the death certificate. These cases will then be treated as a SIRI. A full PIR will be carried out by the IPCT in conjunction with clinical staff. A summary of the case and findings will be disseminated via IPCC. 15.2 If C.difficile contributed, but was not part of the direct sequence leading to the patient s death this must be recorded in part 2 of the death certificate (DOH, 2007) Policy For The Prevention And Control 11 of 22 Version 3

16. TRAINING IMPLICATIONS 16.1 All new staff attend the Corporate Induction programme which incorporates Infection Prevention and Control, including standard precautions. 16.2 All clinical staff are expected to carry out a hand hygiene competency assessment annually in their clinical area, a record of this competency updated via survey monkey link to Learning and Development. 16.3 Infection Control is an annual mandatory requirement for clinical staff and non-clinical staff as per Learning and Development policy and is assessed via e-learning modules. 16.4 Managers need to ensure all staff are up to date with Essential Training in accordance with the Learning and Development policy. 17. MONITORING THE EFFECTIVENESS OF THIS POLICY 17.1 The Infection Prevention and Control service will ensure the policy has been implemented and that it has been effective in practice, by undertaking the following measures. The IPCT will use the HII tool for any CDI within Solent NHS Trust inpatient beds to identify compliance or highlight practice in need of improvement. Learning & Development collate and report comments related to the Infection Prevention Session. Reviewing Incident forms for actions for learning. The continued reporting of C. difficile on part 1 of a death certificate in line with DOH guidance via the SIRI process and therefore identifying actions for learning. Ongoing daily surveillance by IPCT 18. EQUALITY & DIVERSITY AND MENTAL CAPACITY ACT IMPACT STATEMENT This policy aims to improve safety and reduce risk of onward transmission of infections and consequently improve patient/service user care and outcomes and staff safety. As part of Trust Policy an equality impact assessment (Steps 1 & 2 of cycle) was undertaken. The Infection Prevention and Control Team are not aware of any evidence or concern that this Policy may discriminate against a particular population group 19. POLICY LINKS Policy for infection Prevention and Control Framework for the Trust Hand Hygiene Policy Decontamination policy Policy for Dealing with an Outbreak of Infection or an Infection Control Incident Policy For The Prevention And Control 12 of 22 Version 3

Diarrhoea and Vomiting Outbreak Policy Waste Management Policy 20. REVIEW This policy may be reviewed at any time at the request of either staff side or management, but will automatically be reviewed three yearly unless legislation, guidance or non-compliance prompt an earlier review. 21. REFERENCES Department of Health & Health Protection Agency (2009). Clostridium difficile infection: How to deal with the problem. DH/ HPA: London. Hawker J et al (2001). Communicable Disease Control Handbook. Oxford: Blackwell Publishing. Wilson J (2006). Infection Control in Clinical Practice, third edition. London: Bailliere Tindall. Lance R, Peterson, Ari Robicsek (2009). Does my patient have Clostridium difficile infection. Annals of Internal Medicine 151(3) 176-179. National Clostridium difficile Standards Group (2003) Report to the Department Of Health, Journal of Hospital Infection. South Central Strategic Health Authority (2008). Guidance- Serious Untoward Incident Reporting Process. For Implementation by all Trusts in NHS South Central. Department of Health (2005) Surveillance of Clostridium difficile associated disease (CDAD) http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyand Guidance/DH_4118344 Department of Health (2006) Healthcare associated infections, in particular infection caused by Clostridium difficile (letter to all Trust, PCT and SHA Chief Executives). London. Department of Health. Department of Health (2007) High Impact Intervention No 7: care bundle to reduce the risk from Clostridium difficile. London. Department of Health. Department of Health (2007) Changes to the mandatory healthcare associated infection surveillance system for Clostridium difficile associated diarrhoea (letter from CMO & CNO dated 11 th April 2007). London. Department of Health (2007). Healthcare Associated Infections and Death certification. (Letter from CMO PL/CMO/2007/8). London. Department of Health. http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/@dh/@en/documents/d igitalasset/dh_079103.pdf Policy For The Prevention And Control 13 of 22 Version 3

Department of Health (2008) The Health Act 2006 Code of Practice for the Prevention and Control of Health Care Associated Infections (revised 2010). London. Department of Health. http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyand Guidance/DH_093762 Department of Health (2008) Clostridium difficile infection: How to deal with the problem. London. Department Of Health. Health Protection Agency (2007) HPA Regional Microbiology Network. A good practice guide to control Clostridium difficile. London. Health Protection Agency. Health Protection Agency (2006) Clostridium difficile: Findings and recommendations from a review of the epidemiology and a survey of Directors of Infection Prevention and Control in England [online] [25.11.07] http://www.hpa.org.uk/infections/topicsaz/clostridiumdifficile/publications.htm Investigation into outbreaks of Clostridium difficile at Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust. London. Commission for Healthcare Audit and Inspection (2006) http://www.healthcarecommission.org.uk/_db/_documents/stoke_mandeville.pdf Investigation into outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust. Commission for Healthcare Audit and Inspection (2007) http://www.healthcarecommission.org.uk/_db/_documents/maidstone_and_tunbridge _Wells_investigation_report_Oct_2007.pdf National Institute for Clinical Excellence (2014) Faecal Microbiota transplant for recurrent Clostridium Difficile Infection National Patient Safety Agency (2007) Safer Practice Notice 15: Colour coding hospital cleaning material materials and equipment http://www.npsa.nhs.uk/site/media/documents/2140_0429colourcodingsp1d2f4.pdf National Patient Safety Agency (2009) The NHS Cleaning Manual. http://www.nrls.npsa.nhs.uk/resources/patient-safetytopics/environment/?entryid45=61830 Public Health England (2013) The updated guidance on the management and treatment of Clostridium difficile infection The management of Clostridium difficile. Commission for Healthcare Audit and Inspection (2007) London. Policy For The Prevention And Control 14 of 22 Version 3

APPENDIX 1 Policy For The Prevention And Control 15 of 22 Version 3

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APPENDIX 2 Policy For The Prevention And Control 17 of 22 Version 3

APPENDIX 3 A simple guide to C.difficile This guide explains what C.difficile is, how it developed and ways in which it can cause infection. What is C.difficile? C.difficile is an abbreviation of Clostridium difficile and it is the major cause of antibioticassociated diarrhoea and colitis, an infection of the intestines. It is part of the Clostridium family of bacteria, which also includes the bacteria that cause tetanus, botulism, and gas gangrene. It is an anaerobic bacterium (i.e. it does not grow in the presence of oxygen) and produces spores that can survive for a long time in the environment. It most commonly affects elderly patients with other underlying diseases. C.difficile background and a short history Although C. difficile was first described in the 1930s, it was not identified until the late 1970s as the cause of diarrhoea and colitis following antibiotic therapy. Even once this was recognised, laboratory diagnosis was difficult and the number of cases was not monitored. Lab tests have identified over 100 different types of C.difficile. One of these, type 027, is of particular concern because it causes a greater proportion of severe disease and appears to have a higher mortality. It also seems to be very capable of spreading between patients. Type 027 was found to be the main cause of infection in the outbreaks of C.difficile at Stoke Mandeville Hospital and elsewhere that have been investigated since 2005. Since January 2004, C.difficile has been part of the mandatory surveillance programme for healthcare associated infections. What does C.difficile cause in patients? C difficile can cause diarrhoea, ranging from a mild disturbance to a very severe illness with ulceration and bleeding from the colon (colitis) and, at worst, perforation of the intestine leading to peritonitis. It can be fatal. Most of those affected are elderly patients with serious underlying illnesses. Most infections occur in hospitals (including community hospitals), nursing homes etc, but it can also occur in primary care settings. How do patients become infected? C.difficile bacteria can be found living in the large intestine of a small proportion (less than 5%) of the healthy adult population. It is also common in the intestine of babies and infants. It is normally kept in check by the good bacterial population of the intestine. But when these good bacteria have been killed off by antibiotics, C.difficile is able to multiply in the intestine and produces two toxins that damage the cells lining the intestine. The result is diarrhoea. Because it develops in this way, the patients who are most at risk of infection with C.difficile are those who have been treated with broad spectrum antibiotics (those that affect a wide range of bacteria, including intestinal bacteria). Policy For The Prevention And Control 18 of 22 Version 3

Although some people can be healthy carriers of C.difficile, in most cases the disease develops after cross-infection from another patient, either through direct patient to patient contact, via healthcare staff, or via a contaminated environment. A patient who has C.difficile diarrhoea excretes large numbers of the spores in their liquid faeces. These can contaminate the general environment around the patient s bed (including surfaces, keypads, and equipment), the toilet areas, sluices, commodes, bedpan washers, etc. They can survive for a long time and be a source of hand-to-mouth infection for others. If these others have also been given antibiotics, they are at risk of C. difficile disease. What can we do to prevent infection? Always wash your hands after you have had any physical contact with a patient. Do not rely solely on alcohol gel as this does not kill C.difficile spores. To keep cases of C.difficile down, healthcare workers should look to avoid prescribing broad spectrum antibiotics, as far as possible, so that patients natural protection is not weakened If you suspect infection, there is a simple diagnostic test that can be done on a sample of diarrhoeal faeces to see if C. difficile toxins are present. It gives a result within a few hours. In outbreaks, or for surveillance of the different strains circulating in the population, C. difficile can be cultured from faeces and the isolates sent to the Anaerobe Reference Laboratory (National Public Health Service, Wales; Microbiology, Cardiff) or HPA Regional Laboratories for typing and testing for susceptibility to antibiotics. Infected patients should be isolated and healthcare workers dealing with them should wear gloves and aprons, especially when dealing with bedpans, etc Environments should be kept clean at all times. Where there are cases of C. difficile infection, a disinfectant containing chlorine or other sporicidal agent should be used to reduce environmental contamination with the spores. Visit www.clean safe care.nhs.uk for further copies of this Simple Guide. Policy For The Prevention And Control 19 of 22 Version 3

APPENDIX 4 Policy and procedure for Prevention and Control of Suspected/confirmed Clostridium difficile infection Lead Manager: Consultant Nurse IPCT Contact: SJH: Ex 3755 Step 1 Scoping Question 1. What are the main aims and objectives? Answer This document has been written to provide staff with clear guidance for the prevention of Clostridium difficile and the management of patients with infection to aid recovery; avoid complications and prevent cross infection to other patients. 2. Who will be affected by it? Staff and service users of Solent NHS Trust. 3. What are the existing performance indicators/measures for this? Expected outcomes? > National and international guidance from various sources. > Health & Social Care Act 2008 > Department of Health & Health Protection Agency (2009). Clostridium difficile infection: How to deal with the problem. DH/ HPA: London. 4. What information do you already have Assumption that this will potentially impact on Policy For The Prevention And Control 20 of 22 Version 3

on the equality impact of this policy, strategy, proposal, function or service? a diverse group of service users. Local and National Surveillance data. 5. Are there demographic changes or trends locally to be considered? Not aware of any local incidents which would have increased local population susceptibility to infections.e.g. public health incident. 6. What other information do you need? None Step 2 Assessing the Impact Question Answer Yes No Provide Evidence 1. Could the policy, strategy, proposal, function, or service discriminate unlawfully against any group? X 2. Can any group benefit or be excluded from the service? X 3. Can any group be denied fair & equal access to or treatment as a result of this? X 4. Can this actively promote good X Policy For The Prevention And Control 21 of 22 Version 3

relations with and between different groups? X 5. Have you carried out any consultation internally/externally with relevant individual groups? 6. Have you used a variety of different methods of consultation/involvement? X If there is no negative impact end the cycle. 11.06.14: At this time no negative impact identified. At this time positive impact identified- Compliance with Health & Social Care Act 2008 & DH: Clostridium difficile- How to deal with the problem 2009. Policy For The Prevention And Control 22 of 22 Version 3