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CDI - Clostridium difficile infection

Clostridioides (Clostridium) difficile (CDI) is the most commonly recognised cause of infectious diarrhoea in hospitalised patients. Pathology results in Queensland health facilities are showing an increase in CDI since 2011.

CDI can have devastating effects for patients:

  • length of hospital stay is increased
  • severe or complicated cases can also cause severe colitis, significant systemic toxin effects and shock
  • complicated cases may require ICU admission or colectomy, and can result in death.

Since 2000, there has been an increase in the rates of CDI in many healthcare facilities worldwide that has been associated with an epidemic strain of Clostridioides (Clostridium) difficile. This strain (PCR ribotype 027) was first locally transmitted in Australia in Victoria in 2010. In the United States, Clostridioides (Clostridium) difficile now rivals methicillin-resistant Staphylococcus aureus (MRSA) as the most common healthcare-associated infection (HAI), accounting for $3.2 billion in excess costs annually.

CDI management strategies

Surveillance

Healthcare facilities should have in place reliable surveillance programs to detect patients with CDI, identify outbreaks, monitor trends and evaluate interventions aimed at reducing incidence.

Surveillance of CDI in facilities should be performed as per:

All hospitals should review surveillance data on a monthly basis to see if there has been an increase in cases or any transmission between cases.

Small facilities that do not normally get any cases of CDI should consider one case significant.

Read more about trigger response.

Antimicrobial stewardship

Clostridioides (Clostridium) difficile infection and colonisation is almost always associated with and triggered by the use of antibiotics, especially if inappropriate, excessive or prolonged.

  • Adhere to local antimicrobial stewardship guidelines and refer to to the relevant therapeutic guidelines and local procedures for antimicrobial treatment of CDI.

Diagnosis

Suspect and test for CDI in all hospitalised adult patients with diarrhoea, and all patients who present with diarrhoea in association with antibiotic or immunosuppressive therapy.

Get stool specimens as soon as possible after the onset of diarrhoea:

  • keep stool specimens refrigerated until testing can be done.
  • only test diarrhoeal stool specimens (that conform to the shape of the container).

It is not recommended to:

  • test for CDI in children under two years of age
  • perform routine screening of asymptomatic patients.

Managing transmission

Isolation

As the infection has a faecal-oral mode of transmission be aware that:

  • surfaces, devices and equipment (e.g. commodes, toilets) can serve as a reservoir for transmission
  • spores are transmitted by the hands of healthcare providers.

Transmission based contact precautions should be implemented for all patients with confirmed or suspected CDI, until the patient ceases to have diarrhoea for at least 48 hours. Some isolation strategies include:

  • isolate patient/s in a single room with dedicated ensuite; or cohort with other confirmed CDI patients
  • provide each patient with dedicated toileting facilities. See below for information on bed pans.

Dedicated patient care equipment should be utilised where possible. All equipment should be cleaned as below.

ACSQHC transmission based precautions signs should be used to identify the isolation room.

Bed pans

For bed pans used by patients with CDI:

  • use a single use bedpan, or:
    • dedicate a re-usable bed pan for each CDI patient and wash in ward washer/disinfector after each use. Send to Sterilising Services in a container or bag to undergo a standard steam sterilizing cycle when that patient is discharged or no longer considered infectious. (The pan will not need to be wrapped after sterilization)
    • dedicate a re-usable bed pan for each CDI patient, wash in ward washer/disinfector after each use and discard when that patient is discharged or no longer considered infectious.

Staff hygiene

Hand hygiene

  • Hand washing should be performed with liquid soap and water when caring for a patient with CDI,  Alcohol based hand rub is not effective against the spore-form of Clostridioides (Clostridium) difficile.
  • the effectiveness of hand hygiene is improved when skin is intact, nails are natural, short and unvarnished, hands and forearms are free of jewellery and sleeves are above the elbow. (Bare below the elbows).

Personal protective equipment—staff should use:

  • clean, non-sterile gloves to minimise hand contamination. These should be changed between hand hygiene moments
  • a single use apron, or a long sleeve gown for extensive patient contact.

Cleaning

High touch surfaces (e.g. toilets, bedrails, door handles) can be heavily contaminated. These surfaces and all patient surrounds should be cleaned daily as a minimum.

All cleaning of rooms and equipment of patients with CDI should be undertaken using detergent and 1000ppm available chlorine solution or impregnated wipe. Wipes that have a quaternary ammonium compound as their active ingredient should not be used as they are not effective against Clostridioides (Clostridium) difficile spores.

More information

Guideline for management of patients with Clostridioides (Clostridium) difficile infection (CDI) (PDF 134 kB) Queensland Health.

Clostridium difficile consumer factsheet (PDF, 324kB) provided by the Australian Commission on Safety and Quality in Health Care.

Clostridiodes difficile infection technical reports: Technical reports on monitoring and reducing the prevalence of Clostridioides difficile infection in Australia.

Last updated: 19 December 2019