This document discusses Clostridium difficile (C. difficile) infection, including that it affects 40% of patients in hospital settings, surpasses MRSA infections, and is transmitted through the fecal-oral route. Risk factors include antibiotic use, advanced age, and recent surgery or chemotherapy. Signs and symptoms range from mild to severe diarrhea and systemic complications. Prevention strategies discussed include hand hygiene, contact precautions, environmental cleaning, and antibiotic stewardship.

1. Infection Control:
Clostridium difficile
Clinical Guided Project - Presentation
NUR 440: Dr. Deborah Garrison and Nancy Bucher
By: Krystal DeSantis, Lucy George & Melinda Gillies
1 Due: November 28, 2012

2. Clinical Issue
Clostridium Difficile
40% affected in hospital setting
Surpasses MRSA infections
Infection Control
(Grossman & Mager, 2010, p. 155) – 40% affected
(Page, 2011, p.8) - MRSA
2

3. Evolution of Clostridium difficile
1930’s: Identification
1970’s: Health issues
1978: “Infectious cause of antibiotic-associated diarrhea”
(Keske & Letizia, 2010, p. 329)
3

4. Strains of Clostridium difficile
Toxin A
Toxin B
NAPI
(Grossman & Mager, 2010, p. 155) – Toxin A and Toxin B
(Evans, 2012, p. 39) - NAPI
4

5. Mode of Transmission
Fecal-oral route
Issue at hand
Objects
(Pelleschi, 2008, p. 28) - transmission
(Keske & Letizia, 2010, p. 330) - objects
5

6. Individual Risk Factors
 Antibiotic Use
 Advanced Age
 Surgery
 Chemotherapy
 Severe illnesses
(Pelleschi, 2008, p. 29)
 Decreased stomach acidity
6

7. Signs and Symptoms
Ranging from mild to severe
Systemic Complications
(Pelleschi, 2008, p. 29-30)
7

8. Development of Clostridium difficile
8 (Pelleschi, 2008, p. 28)

9. Example of Clostridium difficile
Cancer patient with Clostridium difficile infection
Chemotherapy
Risk factors
Patient History
Nursing Role (Winkeljohn, 2011, p. 215-216)
9

10. Quantitative Data: Clostridium difficile
Age group affected
Amount of individuals affected
Costs for treatment
Mortality rate
(CDC, 2012, p. 157-158)
10

11. HAI Prevention
PA Dept. of Health requires all hospitals to report HAIs
within 24 hours of occurrence
PADOH supports a prevention collaborative between
hospitals in southeastern PA to reduce the occurrence of
CDIs
Healthcare-Associated Infections (HAI) Report: Q+A. (2011).Retrieved from
http://www.portal.state.pa.us/portal/server.pt/community/healthcare_associated_infections/14234
11

12. Infection Control & Prevention
An estimated 94% of CDIs are potentially avoidable through
responsible antibiotic use and the prevention of
horizontal transmission (Cohen et al., 2010)
 Hospitals instituting infection control and prevention
programs were successful in reducing CDI rates by 20% over
a period of 21 months. (CDC, 2012)
Cohen S et al. Infect Control Hosp Epidemiology 2010; 31(5), 431-455.CDC (2012). Vital signs:
Preventing Clostridium difficile infections. Morbidity & Mortality Weekly Report – MMWR, 61(9),
12 pp. 157-162.

13. Antibiotic Stewardship
Reduce overuse and inappropriate selection of antibiotics
Shorter duration of treatment
Cohen S et al. Infect Control Hosp Epidemiology, 2010; 31(5), 431-455.
13

14. Components of an Infection Control
& Prevention Plan
An early detection system
Interruption of person-to-person spread
Elimination of environmental contamination
Education, and
Monitoring
14

15. Early Detection
Increasing the number of diarrheal stool tested for C.
difficile
Recognizing the limits of toxin A/B immunoassay
Laboratory-based alert system for immediate notification of
positive test results
Nurse-driven protocol for stool testing
Cohen S et al. Infect Control Hosp Epidemiology, 2010; 31(5), 431-455. Christine Young,
15 personal communication, October 16, 2012

16. Interruption of Horizontal
Transmission
Place all tested patients on
preemptive contact
precautions/isolation for pending
confirmation of CDI
Extend use of contact
precautions/isolation beyond
duration of diarrhea (e.g., until
discharge and if readmitted within
6 weeks)
Sethi AK et al. Infect Control Hosp Epidemiology; 31(1), 21-27.
C. Young, personal communication, October 16, 2012
16

17. Justification for Extending Contact
Isolation
17 Bobulsky G et al. Clin Infect Dis 2008;46:447-50.

18. Interruption of Horizontal
Transmission
Implement soap and water for
hand hygiene
Hand hygiene for patients
Personal protective equipment
 Use of dedicated non-critical
medical equipment
Visitor requirement/restrictions
18

19. Elimination of Environmental
Contamination
 C. difficile spores can remain on surfaces for long periods of time
and are resistant to commonly used disinfectants.
 Transmission of C. difficile from patient-to-patient is directly
proportional to the amount of environmental contamination.
19 Weber D et al. Am J Infect Control 2010; 38(5 Suppl 1):S25-33.

20. Environmental Cleaning
 Reduces the load of C. difficile spores within the environment
preventing the transmission of the disease to uninfected patients.
 Recommendations include routine daily isolation cleaning using a
low-level disinfectant.
 Terminal cleaning with a 10% chlorine-based product: results in a
48% reduction in the prevalence density of C. difficile.
CDC (2012). Vital signs: Preventing Clostridium difficile infections. Morbidity & Mortality Weekly
Report – MMWR, 61(9), pp. 157-162. Hacek, D et al. Am J Infect Control 2010; 38(5), 350-3.
20

21. Supplemental Measures for High –
Risk Units
High loads of C. difficile spores or outbreaks of CDI will
necessitate daily cleaning with Clorox ultra-germicidal
bleach wipes containing 6.15 percent sodium hypochlorite.
Orenstein (2011) showed daily use of these wipes on a high-
risk unit “effectively reduced the acquisition rates of CDI by
one-third and time between cases from 8 to 80 days.”
Orenstein R et al. Infect Control Hosp Epidemiology 2011;32(11), 1137-9.
21

22. Education of Hospital Personnel
 Annual education regarding CDI prevention with special attention
to appropriate hand hygiene and contact isolation precautions
 Re-education of staff if the hospital experiences an outbreak
 Allen and Nones-Cronin (2012) report an increase in staff
members’ compliance with infection control measures after
educational intervention
Allen S et al. Dim Crit Care Nurs 2012, 31(5), 290-294. Retrieved from CINAHL database. Carboneau C
et al. J Healthc Qual 2010 ; 34(4) 61-70.
22

23. Impact of Education Intervention
Important in overcoming barriers to effective
implementation
Inconsistent cleaning of high-touch surfaces (i.e. bedrails,
telephones, call buttons, door knobs, toilet seats, and
bedside tables)
Educational intervention for housekeeping staff resulted in a
70% reduction in positive cultures for C. difficile
23 Eckstein B et al. BMC Infect Dis 2007; 7, 61.

24. Education of Patients & Visitors
Basic facts
Infection Control Measures
Special discharge teaching – patients may be at an
increased risk for developing CDIs up to 3 months after
hospital discharge
24 Murphy C et al. Infect Control Hosp Epidemiology 2010; 33(1), 20-28.

25. Monitoring
 Determines the success of the infection control and prevention
program
 Ensures the continual use of best practices by hospital staff and
helps to determine if interventions are positively impacting
patient outcomes
 Effectiveness of environmental cleaning by housekeeping
Guh, A., & Carling, P. (2010). Options for evaluating environmental cleaning. Retrieved from the
Centers for Disease Control and Prevention website:
25 http://www.cdc.gov/HAI/pdfs/toolkits/Environ-Cleaning-Eval-Toolkit12-2-2010.pdf

26. Monitoring (continued)
Track monthly compliance with infection control measures
including hand hygiene and PPE use
Track number of CDIs per 1,000 patient days
Effectiveness of environmental cleaning by housekeeping
staff will also be assessed.
26

27. Cost Savings
 Centers for Medicare and Medicaid Services (CMS) will reduce or
eliminate payment for hospital-acquired CDI.
 Hospitals responsible for cost of treatment estimated at $35.7
billion to $45 billion for in-patient services
 Potential annual savings due to infection control measures range
from $5.7 billion to $31.5 billion
Scott, R. (2009). The direct medical costs of healthcare-associated infections in U.S. hospitals
and the benefits of prevention. Retrieved from the Centers for Disease Control and Prevention
website: http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf
27

28. Quantum Leadership Theory
Shared decision making
Coaching
Mentoring
Employee empowerment
28

29. Successful and Effective Leader
Constructs effective teams
Shared vision
Believes every employee is unique and important
(Ercetin and kamaci, 2008)
29

30. Communication
Necessary for successful decision making and implementing
change
Active listening essential
Leader must be able to acknowledge and respond to staff
emotions
(Porter-O’Grady & Malloch, 2011)
30

31. Communication (continued)
Important to have effective plan of early communication to
implement a change
Everyone affected by proposed plan of change should be
involved
Imperative to provide as much information as possible
31

32. Implementation of an Infection
Control Plan
 Establish infection control committee
 Multidisciplinary team
 One member trained in infection control, responsible for education,
surveillance and tracking
 Perform risk assessment to guide plan implementation
 Investigate and analyze clusters of Clostridium difficile infection
 Data collected and analyzed for infection and manner of spread
 Information kept in computer and manual
 Hope to decrease to decrease CDI within six months
32

33. Proposed CDI Plan
 Hold in-service for all medical staff
 Educate staff regarding what C.diff is and the mode of infection
transmission
 Explain importance of rapid identification to place patient in
isolation
 Importance of contact precautions explained
 Educate staff on personal protective equipment (PPE)
 PPE includes use of gloves and gowns
 Educate staff on how to put on and remove PPE
33

34. Implementation of Contact
Precautions Protocols
Staff expected to demonstrate proper way to put on and
remove PPE
Point person assigned to units to assure PPE readily available
Point person to ensure staff compliance
Point person will keep surveillance forms and send to
infection control committee
34

35. Hand Hygiene Education
Critical element of plan
Essential to eliminating CDI outbreaks
Only acceptable method is soap and water
Quizzes given to staff to ensure understanding
35

36. Implementation of Hand Hygiene
Protocols
 Hands to be washed for at least 15 seconds before and after
entering a patient’s room
 Point person assigned to perform hand washing checks
 Monitor use of soap and water
 Use skill validation check list
 Use check list as a tool to counsel staff as needed
 Staff encouraged to ask each other about hand washing
36
(Pyrek & Orenstein, 2010)

37. Environmental Cleaning
 Transmission of contaminated patient surfaces and medical equipment is
significant if not cleaned properly
 Important to educate housekeeping on cleaning high touch areas to eliminate
spread of infection
 Daily cleaning of high touch areas vital
 Educate staff to use 10% chlorine bleach solution or bleach wipes.
 Educate importance of cleaning bathrooms twice a day
 Educate importance of dedicated cleaning equipment to be kept in patient’s
bathroom
37

38. Implementation of Environmental
Cleaning Hygiene
Environmental manager in charge of monitoring appropriate
chemicals being used
Environmental manager will utilize Digiglo light to evaluate
proper disinfecting
Digiglo will be used to decide if further education is needed
regarding cleaning is required
38

39. Conclusion
 Not one strategy alone can eradicate or lower CDI
 Combination of antibiotic control, good hygiene and
environmental cleaning
 Hold staff accountable with help of management and infection
control committee
 Regular education of staff is an important driving force behind
lowering CDI rates
 Have staff demonstrate competency
 Most important factor behind implementing change is patient
safety
39

40. References
 Allen, S., & Nones-Cronin, S. (2012). Improving staff compliance with isolation
precautions through use of an educational intervention and behavioral contract.
Dimensions of Critical Care Nursing, 31(5), 290-294. Retrieved from CINAHL
database.
 Bobulsky, G., Al Nassir, W., & Riggs, M. (2008). Clostridium difficile skin
contamination in patients with C. difficile-associated disease. Clinical Infectious
Diseases, 46, 447–450.
 Carboneau, C., Benge, E., Mary T. Jaco, M., & Robinson, M. (2010). A lean six sigma
team increases hand hygiene compliance and reduces hospital-acquired MRSA infections
by 51%. Journal for Healthcare Quality, 34(4) 61-70. Retrieved from CINAHL
database.
 Cohen, S., Gerding, D., Johnson, S., Kelly, C., Loo, V., McDonald, L., Pepin, J., &
Wilcox, M.(2010). Clinical practice guidelines for C. difficile infection in adults: 2010
update by the Society for Healthcare Epidemiology of America and the Infectious
Diseases Society of America. Infection Control and Hospital Epidemiology, 31(5), 431-
455. Retrieved from CINAHL database.
40

41. References (continued)
 Eckstein B., Adams, D., Eckstein, E., Rao, A., Sethi, A., Yadavalli, G., & Donskey, C.
(2007). Reduction of Clostridium Difficile and vancomycin-resistant Enterococcus
contamination of environmental surfaces after an intervention to improve cleaning
methods. BioMed Central Infectious Diseases, 7, 61. Retrieved from CINAHL database.
 Ercetin, S., & Kamaci, M., (2008). Quantum Leadership Paradigm. World Applied
Sciences Journal, 3(6), 865-868. Retrieved from
http://www.idosi.org/wasj/wasj3(6)/1.pdf
 Evans, G. (2012). Time to put the gloves on: C. diff patients death hit a historic high.
Hospital Infection Control & Prevention, 39(4), pp. 37-42. Retrieved from CINAHL EBSCO
Host database.
 Grossman, S. & Mager, D. (2010). Clostridium difficile: Implications for nursing.
MEDSURG Nursing, 19(3), pp. 155-158. Retrieved from CINAHL EBSCO Host database.
 Guh, A., & Carling, P. (2010). Options for evaluating environmental cleaning. Retrieved
from the Centers for Disease Control and Prevention website:
http://www.cdc.gov/HAI/pdfs/toolkits/Environ-Cleaning-Eval-Toolkit12-2-2010.pdf
41

42. References (continued)
 Hacek, D., Ogle, A., Fisher, A., Robicsek, A., Peterson, L. (2010). Significant impact
of terminal room cleaning with bleach on reducing nosocomial Clostridium difficile.
American Journal of Infection Control, 38(5), 350-3.
 Healthcare-Associated Infections (HAI) Report: Q+A. (2011). Retrieved from
http://www.portal.state.pa.us/portal/server.pt/community/healthcare_associated_in
fections/14234
 Keske L. A. & Letizia, M. (2010). Clostridium difficile infection: Essential information
for nurses. MEDSURG Nursing, 19(6), pp. 329-333. Retrieved from CINAHL EBSCO
Host database.
 Murphy, C., Avery, T., Dubberke, E., & Huang, S. (2012). Frequent hospital
readmissions for Clostridium difficile infection and the impact on estimates of hospital-
associated C. difficile burden. Infection Control and Hospital Epidemiology, 33(1), 20-
28. Retrieved from CINAHL database.
 Orenstein, R., Aronhalt, K., & McManus, J. (2011). A targeted strategy to wipe out
Clostridium difficile. Infection Control and Hospital Epidemiology, 32(11), 1137-9.
Retrieved from CINAHL database.
42

43. References (continued)
 Page, S. (2011). C. difficile surpasses MRSA as leading cause of nosocomial infections in
community hospitals. New Hampshire Nursing News, 35(1), p. 8. Retrieved from CINAHL
EBSCO Host database.
 Pelleschi, M. E. (2008). Clostridium difficile – Associated Disease: Diagnosis,
prevention, treatment and nursing care. Critical Care Nurse, 28(1), pp. 27-36. Retrieved
from CINAHL EBSCO Host database.
 Porter-O’Grady, T., & Malloch, K. (2011). Quantum leadership: Advancing
innovation,
transforming healthcare. Sudbury, MA: Jones & Bartlett Learning.
 Pyrek, K., & Orenstein, R., (2010). Cleaning Intervention Cuts C. difficile Acquisition
Rates by One-Third. Retrieved fromhttp://www.infectioncontroltoday.com/s.aspx?
exp=1&u=http%3A//www.infectioncontroltoday.com/
 Scott, R. (2009). The direct medical costs of healthcare-associated infections in U.S.
hospitals and the benefits of prevention. Retrieved from the Centers for Disease
Control and Prevention website:
http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf
43

44. References (continued)
 Sethi, A., Al-Nassir, W., Nerandzic, M., Bobulsky, G., & Donskey, C. (2010).
Persistence of skin contamination and environmental shedding of C. difficile during and
after treatment of C. difficile infection. Infection Control and Hospital Epidemiology, 31(1),
21-27.
 Weber, D., Rutala, W., Miller, M., Huslage, K., & Sickbert-Bennett, E. (2010). Role
of hospital surfaces in the transmission of emerging health care-associated pathogens:
norovirus, Clostridium difficile, and Acinetobacter species. American Journal of Infection
Control, 38(5 Suppl 1):S25-33. Retrieved from CINAHL database.
 Weiss, K., Boisvert, A., Chagnon, M., Duchesne, C., Habash, S., Lepage, Y.,
Letourneau, J., Raty, J., & Savoie, M. (2009). Multipronged intervention strategy to
control an outbreak of Clostridium difficile infection (CDI) and its impact on the rates
of CDI from 2002 to 2007. Infection Control & Hospital Epidemiology, 30(2), 156-162.
 Winkeljohn, D. (2011). Clostridium difficile infection in patients with cancer. Clinical
Journal of Oncology Nursing, 15(2), pp. 215-217. doi:10.1188/11.CJON.215-21
44