1. Clostridium Difficile
The prescriber’s role in prevention & treatment
Linda Nazarko
MSc, PgDip, PgCert, BSc(Hons), RN, NIP, OBE, FRCN
Consultant Nurse West London Mental Health Trust
Nurse Prescribing; LSBU 18th
October 2016

2. Aims and objectives
To enable you to:
 Be aware what Clostridium Difficile is
 Be aware of who is at risk
 What the risk factors are
 How to reduce risks
 How to recognise and respond
 How to minimise risks
 Be aware of the importance of infection control

3. What is Clostridium Difficile?
 Gram positive spore
forming anaerobic
bacteria.
 Lives in soil
 Discovered 1935 in
faeces of newborns
 Became a problem when
broad spectrum
antibiotics introduced
late 1960s early 1970s

4. Clostridium Difficile
 Older person 10 times more likely to be
killed by C.Diff than a car
 50,392 ,older people infected in 2007
 In 2004 934 deaths – mostly older
people
 Death rate doubled 2007/2008
 In 2008 8,324 deaths
 Killed four times as many as MRSA

5. Risk factors
Age – over 65
Current or recent antibiotic therapy
Poor physical health
Admission to intensive care unit
Recent surgery
Use of antacids or drugs such as ranitidine or omeprazole (these
reduce stomach acidity and increase the risk of infection.
Nasogastric or gastrostomy tube in place
Prolonged hospital stay
Use of enemas
Pre-existing bowel disease
Sharing a room with some one with C. difficile

6. E coli antibiotic Resistance
0
10
20
30
40
50
60
70
Coamoxiclav Ampicillin Cefalexin Cefpodoxime Ciprofloxacin Gentamycin Nitrofurantoin Trimethoprim
Community Hospital

7. Reducing risk factors
 Proton pump inhibitors (PPIs) such as
omeprazole or lansoprazole increase risk of
developing C. Difficile.
 They reduce the acidity in the stomach and
small bowel and affect the natural bowel flora
in the large bowel (Cunningham et al. 2003:
Chitnis et al, 2013).
 Ensure PPIs are clinically indicated
 Review “orphan” medication

8. Reducing risk factors
 Prudent antimicrobial prescribing, 50%
Px unecessary
 Use narrow spectrum not wide (co-
amoxiclav,cephalosporins and
quinolones). GP practices monitored
only max 10% incentives for meeting
targets (NHS England, 2016).
 Avoid high risk ABX whenever possible

9. Reducing risk factors
 Reduce use invasive medical devices
 In NHS hospitals 1 million catheterised every
year
 Reduce use IV cannula
 When med device isn’t needed take it out
 Avoid discharge delays
 Avoid over-occupancy 85% regarded as
safest

10. Falling rates of C. Difficile
infection

11. If a patient develops diarrhoea
SIMS

12. Stop
 Any medication that is making the
diarrhoea worse. Discontinue laxatives
 Any prescribed proton pump inhibition
(PPI) that can be safety discontinued.
 Any antibiotics that can be
discontinued
 In mild cases of C. difficile antibiotic
treatment may not be required.

13. C. Difficile treatment recommendations
(Public Health England, 2013)
Level of
severity
Treatment
Mild Patients with mild disease may not require specific C. difficile
antibiotic treatment. If treatment is required, oral metronidazole
400=500mg three times a day for 10-14 days is recommended
Moderate Patients with moderate disease should be treated with oral
metronidazole 400-500mg three times a day for 10-14 days.
Oral vancomycin is not recommended as may lead to the
development of further antibiotic resistance
Severe For patients with severe disease should be treated with oral
vancomycin (dose: 125 mg four times daily for 10-14 days.
Fidaxomicin should be considered for patients with severe
disease who are considered at high risk for recurrence, such as
older people who need to have other antibiotics and have
multiple long term conditions.

14. Isolate
 C. Difficile is spread; by faecal/oral
transmission and by spores.
 Faecal oral transmission occurs when
bacteria from faeces passes into the
mouth of another person. Poor hand
washing
 Contaminated healthcare environment
toilet seats, commodes, bedpans,
bedside lockers, beds and floors.

15. Monitor
Monitor

16. Monitor patient
 Age and general health affect condition
 acutely unwell or simply have mild symptoms.
 Monitor carefully and be alert to any deterioration.
 Fluid intake and output recorded on a fluid balance chart.
 Stool frequency, volume and consistency will be
monitored.
 Maintain observations of temperature, pulse, blood
pressure, respirations and oxygen saturations.
 Diarrhoea increases the risk of skin becoming sore and
excoriated and skin health should be monitored.

17. Support
 The person may be weak and unwell.
 Assist with hygiene and continence
 Encourage oral fluids
 Monitor any prescribed IV fluids
 Treat pain
 Skin care, barrier creams
 Combating isolation and offering
supportive care

18. Clinical features C. difficile
 Cramping abdominal pain, tenderness in the
lower abdomen
 Pyrexia
 Mild to moderate watery diarrhorrea
 Feeling unwell
 Loss of appetite
 Dehydration
 Dry mouth
 Tachycardia

19. Importance prompt treatment
 8,324 reasons why we need to treat promptly
 Toxins released by C. diff set up inflammation
 Life threatening complications such as colitis,
oedema of bowel, bowel perforation,
pseudomembranous colitis can develop.

21. Diagnosis and treatment
 Diagnosed by clinical features and stool
sample
 Treatment may begin before results of
specimen available
 Stop antibiotics if possible
 Antibiotic therapy may be needed
 Normal therapy metronidazole or
vancomycin

22. Preventing cross infection
 Spread by spores.
 Can live on floors, toilet seats, furniture,
equipment for months.
 Common cleaning agents can spread spores
 Alcohol gels ineffective
 Hand washing removes
 Killed by sodium hypochlorite (bleach)
 Separate toilet, commode, bedpan for person
with C. Diff.

23. Preventing C. Difficile
 Prudent antibiotic use
 Avoiding cephalosporins and broad
spectrum antibiotics whenever possible
 Strict hand hygiene
 Correct cleaning & use chlorine based
disinfectants when C. Difficile occurs
 Early detection and treatment

24. Outbreak management
 Emphasise importance hand washing – alcogels
useless
 Isolate if not possible cohort nurse
 Barrier nurse
 Get more staff, especially domestics!
 Step up cleaning “using chlorine based disinfectants”
 Stop visiting –limits infection, reduces pressures
 Stop admissions – 48 hours after last symptoms
 Stop outpatient visits

25. Managing outbreak well
 Outbreak can happen to the best of us
 Be open, honest and decent
 Work with others, if patients are
admitted to another hospital
communicate with hospital staff
 Communicate with relatives, face to
face, email, letters
 Take time with people and reassure

26. Gaps in infection control
 Poor compliance with hand
washing
 “Magic” gloves
 Poor cleaning
 Poor food handling
 Sick staff coming to work
 Lack of isolation and risk
assessment
 Lack of gloves, aprons,
alcohol gel, bleach in some
healthcare settings.

27. Demystifying infection control
Infection control is simple:
 Wash your hands
 Keep things clean
 Use gloves and aprons when needed
 Avoid unnecessary antibiotics
 Keep people well by giving good care

28. References
Chitnis AS, Holzbauer SM, Belflower RM, et al (2013). Epidemiology of Community-Associated Clostridium difficile Infection, 2009 Through
2011. JAMA Intern Med. 2013;173(14):1359-1367. doi:10.1001/jamainternmed.2013.7056
http://archinte.jamanetwork.com/article.aspx?articleid=1697791
Cunningham R, Dale B, Undy B, Gaunt N (2003). Proton pump inhibitors as a risk factor for Clostridium difficile diarrhoea. J Hosp Infect.
54(3):243-5.
http://www.journalofhospitalinfection.com/article/S0195-6701%2803%2900088-4/abstract?
utm_campaign=Eyes+on+Evidence+email+campaign&utm_medium=email&utm_source=NewZapp
Deshpande A, Pasupuleti V, Thota P, Pant C, Rolston DD, Sferra TJ, Hernandez AV, Donskey CJ (2013). Community-associated Clostridium
difficile infection and antibiotics: a meta-analysis. J Antimicrob Chemother.68(9):1951-1961.
http://jac.oxfordjournals.org/content/68/9/1951.abstract?utm_source=NewZapp&utm_medium=email&utm_campaign=Eyes%20on%20Evidence
%20email%20campaign
Public Health England (2013) Summary Points on Clostridium difficile Infection
(CDI). Public Health, England.
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1278944283388?utm_source=NewZapp&utm_medium=email&utm_campaign=Eyes%20on
%20Evidence%20email%20campaign
NICE (2015). Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. NICE guidelines [NG15].
NICE, London
http://www.nice.org.uk/guidance/ng15
NHS England (2016). Quality Premium Guidance for 2016/17. NHS England, London
https://www.england.nhs.uk/wp-content/uploads/2016/03/qualty-prem-guid-2016-17.pdf

29. Thank you for listening
Any questions?
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