Best Practice Guidelines for

the Prevention & Management of

Clostridium difficile Infection
In Prehospital, Acute & Continuing Care

October 2013

Infection Prevention and Control Nova Scotia (IPCNS), Department of Health and Wellness

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Acknowledgements:
Infection Prevention and Control Nova Scotia (IPCNS) would like to acknowledge the contribution and
expertise of the following individuals in the development of this policy.

Principal Authors:

Kim Allain BScN RN MHS CIC Suzanne Rhodenizer Rose RN BScN MHS CIC
Provincial Infection Control Consultant Director, Quality, Patient Safety & IPCNS
Nova Scotia Department of Health & Wellness (DHW) Nova Scotia DHW
Halifax, Nova Scotia Halifax, Nova Scotia

IPCNS would like to acknowledge the contribution and expertise of the following individuals in providing
subject matter expertise for this document.

Faith Stoll BScN RN CIC, Infection Control Practitioner, South West Health Authority
Elizabeth Watson RN BScN CIC, Infection Control Practitioner, South Shore Health
Melissa Jenkins RN BScN MHSM, Administrator, Shannex Corporation
Tammy MacDonald RN BScN MBA CIC, Health Services Manager, Infection Prevention and Control,
Capital Health
Bridget Maxwell BN RN, Infection Control Practitioner, IWK Health Centre
Pam Smith RN, Resource Coordinator, Home Support Nova Scotia Association
Randy Dean, Occupational Health and Safety, EHS Emergency Health Services
Teri Cole RN BN, Consultant, Communicable Disease Prevention and Control, DHW
Mary Musgrave RN BScN MPH, Manager, Communicable Disease Control, Public Health Services, Cape
Breton District Health Authority
Field Surveillance Officer, Public Health Agency of Canada formerly placed at Population Health
Assessment and Surveillance, DHW
Dr. Lynn Johnston MD, MSc, FRCPC, Hospital Epidemiologist and Professor of Medicine, QEII Health
Sciences Centre
Dr. David Haldane MB ChB, FRCPC, Director Provincial Public Health Laboratory Network, Director of
Special Pathogens (CDHA), Division of Microbiology, Dept of Pathology and Laboratory Medicine

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Table of Contents
1. Glossary of Terms………………………………………………………………………………………………...……….page 5

2. General Assumptions…………………………………………………………………………………………….………page 8

3. Introduction………………………………………………………………………………………………………...……..page 11

4. Background

What is Clostridium difficile?...........................................................................................page 12

How is Clostridium difficile spread?.................................................................................page 12

What are the risk factors for Clostridium difficile infection (CDI)?...................................page 13

5. Recommendations

A. Surveillance………………………………………………………………………………………………………….page 14

Table 1. Case Definition of CDI for Surveillance and Reporting………………….…………page 14

B. Laboratory Testing/Reporting …………………………………………………………………….…..….page 15

C. Duration of Precautions…………………………………………………………………………………….…page 16

D. Infection Prevention and Control Measures

i. Initiation of Contact Precautions……………………………………………….……….……page 17

ii. Personal Protective Equipment……………………………………………….……………….page 17

iii. Hand Hygiene………………………………………………………………………………..………..page 20

iv. Accommodation……………………………………………………………………….……….…….page 21

v. Handling Linen, Dishes and Cutlery…………………………………………………..…....page 22

vi. Patient Flow/Activities……………………………………………………...…………………….page 23

vii. Patient/Resident Transfer ……………………….………………………….…………….…...page 23

viii. Management of Patient/Resident Care Equipment……………….………….…….page 25

ix. Environmental Cleaning& Disinfection………………………….…………………………page 25

x. Disposal of Fecal Matter…………………………………….…………………………………...page 29

xi. Education of Patients, Families and Visitors…………………………………………….page 29

xii. Visitor Management……………………………………………….………………..…….………page 30

E. Patient Discharge………………..…………………………………………………………………….…….....page 30

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 F. Recurrence of Symptoms……………………………………….……………………………….…….…….page 30

G. Outbreak Management………………………………………………..……………………………….….…page 31

H. Guidance for Healthcare Workers ………………………………………….……………………….…..page 32

i. Education………………………………………………………………………………………………..page 32

ii. Hazard Assessment………………………………………….….……………………………….…page 33

6. References……………………………………………………………………………………………………………………....page 34

Appendices
A. Bristol Stool Chart

B. Point-of-Care Risk Assessment

C. Continuum of Care Comparison Chart for Additional Precautions for Clostridium difficile

D. Sample Posters for Putting On and Removing Personal Protective Equipment

E. Sample Contact Precautions Signage

F. Sample Information Sheet: Patients/Resident and Family Information about Clostridium difficile

G. Sample Information Sheet: Clostridium difficile for Healthcare Workers

H. Sample Clostridium difficile Infection (CDI) Outbreak Line Listing Form

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1. Glossary of Terms

Additional Precautions: Precautions (i.e. Contact, Droplet, Airborne) that are applied, in addition to
Routine Practices, when infection, caused by microorganisms transmitted by these routes, is suspected
or diagnosed. They include the physical separation of infected or colonized patients/residents from
other individuals and the use of barriers (e.g. gowns, gloves, masks) to prevent the transmission of the
infectious agent from colonized or infected individuals to those who are susceptible to infection or may
spread the infectious agent to others.

Alcohol-based Hand Rub (ABHR): A liquid, gel or foam formulation of alcohol (e.g. ethanol, isopropanol)
which is used to reduce the number of microorganisms on hands in clinical situations when the hands
are not visibly soiled.

Cleaning: The physical removal of foreign (e.g. dust, soil) and/or organic material (e.g. blood, secretion,
excretions) from items. Cleaning physically removes rather than kills microorganisms. It is accomplished
with water, detergents and mechanical action.

Cohorting: The assignment of a geographical area such as a room or a patient care area to two or more
patients who are either colonized or infected with the same microorganism. In some instances, staffing
assignments may be restricted to the cohorted group of patients/residents.

Contact Precautions: The type of Additional Precautions used to reduce the risk of transmitting
infectious agents via direct or indirect contact with an infectious person.

Contamination: The presence of an infectious agent on the hands or on a surface, such as clothing,
gowns, gloves, bedding, toys, surgical instruments, patient/resident care equipment, dressings or other
inanimate objects.

Diarrhea: Loose/watery bowel movements (conform to the shape of the container) and the bowel
movements are unusual or different for the patient.

Disinfection: The inactivation of disease producing microorganisms. Disinfection does not destroy
bacterial spores. Medical equipment /devices must be thoroughly cleaned before effective disinfection
can take place.

Endogenous flora: Microbial flora occupying niche(s) that are in or on the body of the host.

Exogenous flora: Microbial flora normally existing externally to the body of the host.

Hand Hygiene: A general term referring to any action of hand cleaning. Hand hygiene relates to the
removal of visible soil and removal or killing of transient microorganisms from the hands. Hand hygiene
may be accomplished using soap and running water or an alcohol-based hand rub.

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Healthcare-associated Infection: A term relating to an infection that is acquired during the delivery of
health care.

Healthcare Worker (HCW): Individuals who provide health care or support services such as nurses,
physicians , dentists , nurse practitioners, paramedics, allied health professionals, temporary workers
from agencies, unregulated health care providers, students , volunteers and workers who provide
support services (e.g. food, laundry, housekeeping).

High-Touch Surfaces: High-touch surfaces are those that have frequent contact with hands. Examples
include doorknobs, call bells, bedrails, light switches, and wall areas around the toilet and edges of
privacy curtains.

Hospital Grade Disinfectant: A disinfectant that has a drug identification number (DIN) from Health
Canada indicating approval for use in Canadian hospitals.

Personal Protective Equipment (PPE): Clothing or equipment worn for personal protection against
hazards.

NAP1 Strain: Refers to a hypervirulent epidemic strain of C. difficile, typed the NAP1/BI/027 strain.

Outbreak: An increase in the number of cases above the number normally occurring in a particular
setting over a defined period of time.

Patient/Resident Environment: The immediate space around a patient/resident that may be touched by
the patient and may also be touched by the healthcare worker when providing care. The patient
environment includes equipment, medical devices, furniture (e.g. bed, chair, bedside table), telephone,
curtains and personal belongings (e.g. clothes, books). In a multi-bed room, the patient/resident
environment is the area inside the individual’s curtain. In an ambulatory setting, the patient/resident
environment is the area that may come into contact with the patient within their cubicle.

Recurrence- Recurrence is the return of diarrhea and other symptoms of CDI after a symptom-free
period. Recurrence occurs in about 30% of cases. This may be due to relapse of the initial infecting strain
or due to reinfection with a new strain. Most recurrences present within one to three weeks after
discontinuing antibiotic therapy, although recurrences can occur as late as two to three months later.

Routine Practices: The system of infection prevention and control practices to be used with all patients
during all care to prevent and control transmission of microorganisms in all health care settings. Routine
Practices are based on the premise that all patients/residents are potentially infectious, even when
asymptomatic, and that the same safe standards of practice should be used routinely with all
patients/residents to prevent exposure to blood, body fluids, secretions, excretions, mucous
membranes, non-intact skin or soiled items and to prevent the spread of microorganisms.

Surveillance: The systematic ongoing collection, collation and analysis of data (e.g. infection rates) with
timely dissemination of information to those who require it in order to take action.

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Terminal Cleaning: The cleaning of a patient room or bed space following discharge or transfer, in order
to remove contaminating microorganisms that might be acquired by subsequent occupants. Terminal
cleaning methods vary, but usually include removing all detachable objects in the room. In some
instances, terminal cleaning might be implemented once some types of Additional Precautions have
been discontinued. In the prehospital setting, the term “deep clean” may be used. A deep clean refers to
the thorough cleaning and disinfection process that occurs on a regular schedule and in instances where
the transporting vehicle is grossly contaminated.

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2. General Assumptions

Best practices in this document are based on the assumption that healthcare settings and organizations
in Nova Scotia already have basic infection prevention and control measures in place. If this is not the
case, healthcare settings will find it challenging to implement the practices recommended for preventing
and managing Clostridium difficile infections. If healthcare settings do not have dedicated resources,
they are encouraged to seek assistance from resources such as IPCNS at the Nova Scotia Department of
Health & Wellness (DHW) and/or the Community and Hospital Infection Control Association Nova Scotia
(CHICA NS).

Best practices are also based on the following assumptions and principles:

1. Healthcare settings routinely implement best practices to prevent and control the spread of
infectious diseases, including Public Health Agency of Canada’s (PHAC) Routine Practices and
Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings (May
2013).

2. Healthcare settings devote adequate resources to infection prevention and control. Guidelines
and practice standards recommend that healthcare facilities have trained Infection Control
Practitioners (ICP) and resources to implement the Infection Prevention and Control (IPAC)
program that are proportional to the size, complexity, case mix and estimated risk of the
populations served by the health care facility. The minimum recommendations for staffing
should not be based exclusively on bed numbers. Guidelines for the required ratio of ICPs to
patient beds will vary according to the acuity and activity of the health care setting, geographic
considerations (e.g. multiple sites), and the volume and complexity of the ICP’s work. PIDAC
(2012a) Best Practices for Infection Prevention and Control Programs in Ontario in All Health
Care Settings outlines specific recommendations for staffing ratios based on a variety of
literature sources:
a) a minimum ratio of 1.0 FTE ICP per 115 acute care beds;
b) a minimum ratio of 1.0 FTE ICP per 100 occupied acute care beds if there are high risk
activities (e.g., dialysis);
c) it is recommended that an additional ratio of 1.0 FTE ICP per 30 intensive care beds
be considered where ventilation and hemodynamic monitoring are routinely performed;
d) 1.0 FTE ICP per 150 occupied long-term care beds where there are ventilated patients,
patients with spinal cord injuries and dialysis or other high acuity activities; and
e) 1.0 FTE ICP per 150-200 beds in other settings depending on acuity levels

3. District Health Authorities/IWK Health Centre IPAC programs should include a physician with
knowledge, expertise and training in infection prevention and control.

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4. Acute care facilities within the District Health Authorities/IWK Health Centre comply with the
regulations set forth under the Patient Safety Act in relation to public reporting and reporting to
the DHW rates of healthcare-associated Clostridium difficile infection.

5. Healthcare settings have effective working relationships with their local Public Health Services.
They maintain clear lines of communication, contact Public Health Services for information and
advice as required, and fulfill their obligations to report notifiable diseases and conditions as per
“It’s the Law: Reporting Notifiable Diseases and Conditions” . Link:
http://www.gov.ns.ca/hpp/publications/06026_ItsTheLawPoster_En.pdf

6. Healthcare settings have programs in place that promote good hand hygiene practices and
ensure adherence to guidelines for hand hygiene.

7. Healthcare settings devote adequate resources to environmental services/housekeeping that

include written procedures for cleaning and disinfection of patient/resident rooms and
equipment, education of new environmental services/housekeeping staff and continuing
education for all staff, regular auditing and an ongoing review of procedures and policy.

8. ICPs or designate provide regular education (including orientation and continuing education)
and support to help healthcare workers consistently implement appropriate infection
prevention and control practices. Education programs shall be flexible enough to meet the
diverse needs of the range of healthcare providers and other staff who work in the healthcare
setting. Effective education programs emphasize:

 The risks associated with infectious diseases and the benefits of case
finding/surveillance.
 The importance of proper and prudent use of antibiotics.
 Hand hygiene including the use of alcohol-based hand rub and hand washing.
 Principles and components of Routine Practices, including a point-of-care risk
assessment, and Additional Precautions.
 Assessment of the risk of infection transmission and the appropriate use of personal
protective equipment (PPE), including safe application, removal, and disposal.
 Appropriate cleaning and/or disinfection of healthcare equipment, supplies, surfaces, or
items in the healthcare environment.
 Individual staff responsibility for keeping patients/residents, themselves, and co-
workers safe.

9. Healthcare settings regularly assess and evaluate the effectiveness of their IPAC education
programs and their impact on practices, and use that information to refine their programs.

10. Healthcare settings promote collaboration and partnerships between professionals involved in
occupational health nursing, occupational health and safety, engineering/maintenance,
microbiology laboratory, environmental services and infection prevention and control in

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 implementing and maintaining appropriate infection prevention and control standards that
protect workers.

11. Healthcare settings have an established relationship between infection prevention and control
and the microbiology laboratory to support the infection prevention and control program. This
includes appropriate utilization of laboratory facilities, the ability to process screening
specimens in a timely fashion, timely notification of results and laboratory support during
outbreaks.

12. There is clear delineation of cleaning and disinfection responsibilities and practices among
healthcare workers (i.e. environmental services, nursing staff, unit aides and other support staff)
to ensure the safety and cleanliness of environmental surfaces and patient care equipment.

13. The prehospital care providers receive timely and appropriate information through the
Emergency Health Services (EHS) Communication Centre (dispatch) communicable disease
screening questions.

14. Healthcare settings have a process for evaluating Personal Protective Equipment (PPE) to ensure
it meets quality standards where applicable.

15. Healthcare settings have access to ongoing infection prevention and control expertise and
resources to offer advice, guidance to support staff, and resolve any uncertainty about the level
of precautions required in a given situation. Infection prevention and control expertise includes
IPCNS, CHICA-NS, Infectious Disease Physician trained in Infection Prevention & Control, and the
District Health Authorities/IWK Health Centre ICPs.

16. Healthcare settings have established procedures for receiving and responding appropriately to
all international, regional, and local health advisories. They also communicate health advisories
promptly to all staff responsible for case finding/surveillance and provide regular updates.
Current advisories are available from local Public Health Services, DHW, Health Canada and
Public Health Agency of Canada websites, and IPCNS.

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3. Introduction

Purpose and Goals

The goals of these guidelines are to minimize the impact of Clostridium difficile infection (CDI) on
individuals and reduce the transmission of Clostridium difficile in all settings where care is provided.

The purpose of these guidelines is to provide direction to healthcare workers on the management of
patients who have CDI. This document outlines infection prevention and control practices to:

 Assist healthcare providers in the management of patients and residents with CDI and outbreaks
related to CDI, and
 Prevent the transmission of C. difficile to other patients and residents.

It is recognized that each facility/practice setting delivers a specific set of services and has unique
challenges with physical layout and resources. Site specific policies and procedures are necessary to
address these unique challenges in each practice area. These best practices guidelines do not replace
site specific policies and procedures; rather should be integrated with existing infection prevention and
control programs, policies and processes and used as part of a comprehensive effort to maintain
accepted standards of infection prevention and control.

These guidelines are applicable to all patients and residents in acute care, continuing care (e.g.
long‐term care and other residential care facilities), and prehospital care.

Legislated Clostridium difficile Infection (CDI) Reporting Responsibilities in Nova Scotia

As of April 1, 2012, Clostridium difficile became a notifiable illness/disease in Nova Scotia under the
Regulations of the Health Protection Act. As per standard operating procedures for all notifiable
diseases, all cases of CDI will be reported to the district Public Health office. CDI cases must be reported
to Public Health by the next business day. As per normal process, outbreaks and outbreak-associated
cases of CDI are reported to local Public Health.

Healthcare-associated CDI rates are included in the mandatory reporting indicators as per the Act to
Improve Patient Safety and Health Systems Accountability (Patient Safety Act). All acute care hospitals
are required to report the number of cases of healthcare-associated CDI cases and the rate as outlined
within the provincial protocol. These district rates are publicly reported on the DHW website
(http://novascotia.ca/dhw/qps/public_reporting.asp) and through the District Health Authority
(DHA)/IWK Health Centre websites.

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4. Background

What is Clostridium difficile?

Clostridium difficile is a Gram-positive, spore forming, anaerobic bacillus. It is widely distributed in the
environment and colonizes up to 3-5% of healthy adults without causing symptoms (Bouza, 2005).
Between 2% and 70% of infants may be asymptomatically colonized with C. difficile. Rates of C. difficile
colonization decrease with age, falling to about 6% at age two years, while in children older than two,
colonization rates are similar to those in adults (approximately 3%) (APIC, 2008).

Disease-producing strains of C. difficile are characterized by their ability to produce two toxins: toxin A
and toxin B. The most common symptom of CDI is diarrhea. It is almost never grossly bloody and ranges
in consistency from soft unformed stools to watery or mucoid, and in frequency from 3 to 20 or more
bowel movements per day. Other symptoms include abdominal pain and cramping (22% of patients) and
fever (28% of patients). Some patients with severe CDI develop an ileus, and will therefore not have
diarrhea, and may not have bowel movements at all. Laboratory findings include leukocytosis in up to
50% of patients (PEI Health, 2010).

In recent years, there has been an increase in the rates of CDI across Canada, with a number of
outbreaks in many healthcare facilities in Quebec and Ontario. Some of these outbreaks have been due
to a hypervirulent epidemic strain of C. difficile, the NAP1/BI/027 strain. Characteristics of this strain
include the presence of a binary toxin; increased resistance to clindamycin and the fluoroquinolone class
of antibiotics; and the increased potential for severe adverse events (PIDAC, 2013). While this strain of
C. difficile causes more severe disease, the infection prevention and control practices for this strain are
the same as for other strains of C. difficile.

How is Clostridium difficile spread?

C. difficile spores are resistant to destruction by many environmental conditions and agents, including a
number of chemicals commonly used in disinfection. This enables C. difficile to survive for months in the
environment (in healthcare facilities as well as community settings). It is then spread by transfer of
spores directly from the contaminated environment to the patient or on the hands of healthcare
workers who fail to follow good hand hygiene and gloving practices. It can be acquired in prehospital,
facility and community settings. Proper control is achieved through the physical removal of the spores
from hands and the environment through consistent hand hygiene and thorough cleaning and
disinfection of the patient environment.

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What are the risk factors for Clostridium difficile infection?

 recent antibiotic use is the most important risk factor for developing CDI. Almost any antibiotic
can be associated with developing CDI, and it can occur after even one dose of antibiotic
 older age is the next most important risk factor for CDI
 bowel disease and surgery
 chemotherapy
 prolonged hospitalization
 non-surgical gastrointestinal procedures
 treatment with proton pump inhibitors; and,
 immunosuppressive therapy.

Risk factors that predispose people to develop more severe disease include:
 infection with the NAP1 strain of C. difficile
 increased age
 serious underlying illness or debilitation.

The rate of community‐acquired CDI (CA‐CDI) appears to be rising among persons previously thought to
be at low risk. Recent studies indicate that only two-thirds of CDI cases identified in the community are
actually linked to recent antibiotic therapy and prior hospitalization. Since these classic risk factors are
sometimes lacking in identified CA‐CDI cases, it may be prudent to test patients in the community with
unexplained diarrhea for C. difficile.

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5. Recommendations
A. Surveillance
Clostridium difficile is a notifiable disease as per regulations under the Regulations of the Health
Protection Act and is listed under “It’s The Law: Reporting Notifiable Diseases and Conditions for Nova
Scotia”. This means that all cases are reported to local Public Health.

Each facility should establish a mechanism/system for the early reporting of symptomatic patients to the
organization’s Infection Control Practitioner (ICP) or delegate. A system should also be established for
prompt notification of all patients testing positive for C. difficile to the ICP or delegate.

Surveillance should be conducted using accepted CDI case definitions (Table 1) and denominators to
determine the organization’s baseline rate and monitor changes in the CDI rate. This information should
be reviewed and analyzed on an ongoing basis to identify any clusters or outbreaks of CDI.

Table 1. Case Definition for CDI for Surveillance and Reporting

Clostridium difficile Infections (CDI)

A patient over the age of one year and;
 s/he has diarrhea or fever, abdominal pain and/or ileus, AND a laboratory
confirmation of a positive toxin assay or positive PCR for C .difficile
OR
 s/he has a diagnosis of pseudomembranes on sigmoidoscopy or colonscopy or
histological/pathological diagnosis of CDI
OR
 s/he is diagnosed with toxic megacolon (ADULT PATIENTS ONLY)

Diarrhea is defined as one of the following:

 6 or more watery stools in a 36 hour period
 3 or more unformed stools in a 24 hour period for at least 1 day and new or
unusual for the patient (ADULT PATIENTS ONLY)

Healthcare-associated CDI
 Patient’s CDI symptoms occur in a hospital ≥ 72 hours after admission
OR
 CDI is seen in a patient who had been hospitalized at your hospital and discharged
within the previous 4 weeks.
(CNISP, 2012)

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Only “Primary” cases will be included in surveillance. Primary cases can be defined as
 First episode of CDI experienced
OR
 A new episode of CDI which occurs > 8 weeks after the first toxin-positive assay.

B. Laboratory Testing/Reporting
A variety of tests are available to identify C. difficile or its toxins in the stools of patients with diarrhea.

Laboratory diagnosis of CDI includes the following methods:

 Glutamate dehydrogenase test (“C. difficile antigen test”) is sometimes used to screen stools
to indicate if the microorganism is present. It does not indicate if the strain is toxin-
producing, so is followed up with a test to detect toxin if the antigen test is positive.
 Toxin detection by enzyme-linked immunoassay (EIA)*
 Cytotoxicity neutralization assay using tissue culture*
 Nucleic acid amplification techniques (including real-time PCR assay)
 Histological examination of the colon.*
*Tests available from Nova Scotia hospital laboratories

1. A protocol and provisions for testing for CDI should be established.

2. Stool specimen collection for testing for C. difficile or its toxins is indicated as soon as possible
after the onset of acute diarrhea.
3. Only liquid specimens, “taking the shape of the container” (Stool Consistency= Bristol Stool Scale
Type 7, refer to Appendix A) should be submitted, sent in a dry sterile container and transported
at 4⁰ Celsius.
a. C. difficile toxin is unstable and can degrade within 2 hours if the specimen is left at
room temperature.
b. Testing for C. difficile should not be done on formed stool.
4. When test methods of lower sensitivity are performed, (e.g. EIAs), a single negative test for
patients/residents with acute diarrhea should not be relied on to rule out C. difficile. If the first
test is negative, a second test may be indicated.
5. Testing for C. difficile cytotoxin should not be done in children under the age of 1 year, as it is
considered normal flora in this age group.
6. If increases in CDI rates are observed, it is important to ensure they are not an artifact of
increased case detection resulting from the adoption of new test methods.
7. Laboratories should note that positive C. difficile results are notifiable to Public Health Services.
Laboratories should have a process to ensure all positive C. difficile results are reported to the
attending physician, and the Infection Prevention and Control Practitioner or designate at the
facility. Positive results should be reported promptly.

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Repeat Testing:
1. Repeat testing as a “test of cure” is not indicated and should not be done. Cytotoxin may persist
in stool for weeks and is not helpful in determining duration of treatment or required infection
control precautions. (Refer to Duration of Precautions).
2. Testing for C. difficile cytotoxin may be repeated if symptoms do not resolve despite treatment
or to diagnose a relapse of CDI following a period of time where symptoms were absent.

C. Duration of Precautions

Precautions for CDI should only be discontinued as outlined as per facility/organizational policy.
Consultation with the ICP or designate is recommended prior to discontinuation of precautions.

The following criteria are used when discontinuing precautions for CDI:

a) Patient with suspected CDI:

i) Patients/residents on Contact Precautions for suspected CDI may have the precautions
discontinued when appropriate testing is conducted and result(s) are negative and an
alternate diagnosis is likely (Refer to Laboratory Testing/Reporting). Contact Precautions
should be maintained until such evaluation has taken place or until CDI or other infectious
cause for diarrhea is ruled out.
ii) If CDI is still suspected, the clinician should evaluate the patient/resident and consider other
diagnostic modalities (e.g., colonoscopy/sigmoidoscopy).

b) Patient with confirmed CDI:

i) Contact Precautions may be discontinued when the patient has had at least 48 hours without
symptoms of diarrhea (e.g., formed or normal stool for the individual).
ii) Re-testing for C. difficile cytotoxin is not necessary to determine when precautions may be
discontinued.
iii) Contact Precautions should not be discontinued until the room/bed space has received
effective environmental cleaning for CDI (Refer to Environmental Cleaning).

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D. Infection Prevention and Control Measures

i) Initiation of Contact Precautions

Routine Practices are used for every patient regardless of disease status. In addition to Routine Practices
and point-of-care risk assessment (Appendix B), Contact Precautions should be initiated for any patient
in whom CDI is suspected at the onset of symptoms, even before CDI test results are available. Contact
Precautions should be initiated as soon as CDI is suspected.

Contact Precautions are initiated when:

a) There is a suspected or confirmed case of CDI;
b) There is diarrhea with risk factors for CDI;
c) There is toxic megacolon and pseudomembranous colitis even in the absence of a positive test
result for C. difficile

While the majority of patients with CDI have diarrhea, severe cases of CDI may exhibit presentations
that do not include diarrhea, such as toxic megacolon or pseudomembranous colitis, where the patient
may have no bowel movements at all.

As C. difficile or its spores can survive for months in the environment, HCWs should anticipate that
contact with any object in a room or bedspace of a patient with CDI may result in self-contamination
with C. difficile or its spores.

ii) Personal Protective Equipment

Contact Precautions require the use of personal protective equipment (PPE), specifically gloves and a
long‐sleeved gown. Refer to your district/facility or organizational policy for Contact Precautions for CDI.
The Continuum of Care Comparison Chart for Additional Precautions and Practices for C. difficile
(Appendix C) summarizes the PPE requirements based on the healthcare setting.

Acute care settings

PPE for Contact Precautions should be provided outside the room, cubicle or designated bedspace (or
when available, in the anteroom) of the patient suspected or confirmed to have CDI. Healthcare
workers, families and visitors should use the following PPE for patients suspected or confirmed to have
CDI:

a. Gloves
- Good quality vinyl gloves are generally sufficient for most tasks. Gloves that fit snugly around
the wrist are preferred for use with a gown because they will cover the gown cuff and
provide a better barrier for the arms, wrists and hands;

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 - Gloves are worn to enter the patient’s room, cubicle or designated bedspace during the care
of the patient and for contact with the patient’s environment;
- Gloves are removed and discarded into a no-touch waste receptacle and hand hygiene
performed upon exiting the patient’s room, cubicle or designated bedspace.

b. Gowns
- Gowns used as PPE should be cuffed and long-sleeved, and offer full coverage of the body
front, from neck to mid-thigh or below.
- A gown is worn if it is anticipated that clothing or forearms will be in direct contact with the
patient or with environmental surfaces or objects in the patient care environment;
- If a gown is to be worn it should be put on before entering the room, cubicle or designated
bedspace. The gown should be removed and discarded into a no-touch receptacle
immediately after the indication for use and hand hygiene should be performed before
leaving the patient’s environment.
The same PPE is not to be worn for more than one patient. If caring for more than one patient in
a shared room, PPE is changed and hand hygiene performed between contacts with each
patient/bedspace in the same room.

Long-term care settings

PPE for Contact Precautions should be provided outside the room or designated bedspace of the
resident suspected or confirmed to have CDI. Healthcare workers, families and visitors should use the
following PPE for residents suspected or confirmed to have CDI and include the following:

a. Gloves
- Good quality vinyl gloves are generally sufficient for most tasks. Gloves that fit snugly around
the wrist are preferred for use with a gown because they will cover the gown cuff and
provide a better barrier for the arms, wrists and hands;
- Gloves are worn if direct personal care contact with the resident is necessary, if direct
contact with frequently touched environmental surfaces is anticipated, if handling
contaminated objects/equipment, or if handling soiled linen;
- Gloves should be removed and discarded into a no-touch waste receptacle and hand hygiene
performed upon exiting the resident’s room or designated bedspace.

b. Gowns
- Gowns used as PPE should be cuffed and long-sleeved, and offer full coverage of the body
front, from neck to mid-thigh or below;
- A gown should be worn if it is anticipated that clothing or forearms will be in direct contact
with the resident or with environmental surfaces or objects in the resident’s environment;
- If a gown is to be worn it should be put on before entering the room or designated bedspace.
The gown should be removed and discarded into a no-touch receptacle immediately after the

18
 indication for use and hand hygiene should be performed before leaving the resident’s
environment.

The same PPE is not to be worn for more than one resident. If caring for more than one resident
in a shared room, PPE is changed and hand hygiene performed between contacts with each
resident/bedspace in the same room.

Prehospital Care
PPE for Contact Precautions should be provided for EHS personnel outside the room or designated
bedspace of the patient/resident suspected or confirmed to have CDI, and easily accessible within the
vehicle.

a. Gloves
- Good quality vinyl gloves are generally sufficient for most tasks. Gloves that fit snugly around
the wrist are preferred for use with a gown because they will cover the gown cuff and
provide a better barrier for the arms, wrists and hands;
- Gloves are worn upon entry to the patient/resident room or bedspace to prepare or assist
patient/resident and HCWs with transport;
- Gloves should be removed and discarded into a no-touch waste receptacle and hand hygiene
performed upon exiting the resident’s room or designated bedspace.

c. Gowns
- Gowns used as PPE should be cuffed and long-sleeved, and offer full coverage of the body
front, from neck to mid-thigh or below.
- A gown should be worn if it is anticipated that clothing or forearms will be in direct contact
with the patient/resident or with environmental surfaces or objects in the environment while
preparing or assisting with transport
- If a gown is to be worn it should be put on before entering the room or designated bedspace.
The gown should be removed and discarded into a no-touch receptacle immediately after the
indication for use and hand hygiene should be performed before leaving the resident’s
environment.

Note: Additional information regarding the appropriate PPE for prehospital care staff during
transport of patient with CDI can be found in the section Patient/Resident Transfer.

Masks and Face protection are worn as per Routine Practices.

19
Putting on and taking off PPE:
HCWs must remove their PPE in a manner that minimizes the risk of self-contamination. HCWs should
be trained on the sequence for PPE removal. It may be helpful for HCWs to have visual tools placed at
the point of PPE removal. Refer to Appendix D for sample posters.
A) Sequence for Putting on PPE for Contact Precautions:
1) Perform Hand Hygiene
2) Put on Gown
3) Put on Mask (as per Routine Practices)
4) Put on Protective eyewear (as per Routine Practices)
5) Put on Gloves

B) Sequence for Removing PPE for Contact Precautions:

1) Remove Gloves
2) Remove Gown
3) Perform Hand Hygiene
4) Remove Eye Protection (if worn as per Routine Practices)
5) Remove Mask (if worn as per Routine Practices)
6) Perform Hand Hygiene

iii) Hand Hygiene

Effective hand hygiene is essential to limit the spread of C. difficile. While performing hand hygiene with
soap and water may be theoretically beneficial while caring for patient/residents with CDI, dedicated
staff hand hygiene sinks may not be readily available.

Hand hygiene should be performed frequently with the following considerations:

1) Hand hygiene should be performed frequently using effective techniques as per the Four
Moments of Hand Hygiene (Canadian Patient Safety Institute). Link:
http://www.handhygiene.ca/English/Documents/Tools%20and%20Templates/Your%204%20Mo
ments%20for%20Hand%20Hygiene%20(Poster).pdf
2) Hand washing with liquid soap and water should be performed at the point-of-care and at a
designated staff hand washing sink. If a designated staff hand washing sink is not available at the
point-of-care, alcohol based hand rub (ABHR) should be used and hand hygiene with liquid soap
and water should be performed as soon as a staff hand washing sink is available.
3) Hand wipes (impregnated with plain soap, antimicrobials, or alcohol) may be used as an
alternative to liquid soap and water when a designated staff hand washing sink is not
immediately available (e.g. prehospital care, ambulance), or when the hand washing sink is
unsuitable (e.g. contaminated sink, no running water, no soap) under the following conditions:
i. When hands are not visibly soiled; and

20
 ii. When hands are visible soiled. ABHR should be used after the use of hand wipes, and
hands should be washed with liquid soap and water once a suitable staff hand washing
sink is available.
4) Hand hygiene should be performed at a designated staff hand washing sink and not carried out
at a patient/resident sink as this will re-contaminate the HCWs hands.
5) Education should be provided to the patient/resident on the need and procedure to be used for
hand hygiene; patients/residents who are unable to perform hand hygiene independently
should be assisted by the healthcare worker or a family member/friend.

iv) Accommodation
Acute care settings
1. Patients with suspected or confirmed CDI should be placed in a single room with dedicated
toileting facilities, either a private washroom or a dedicated commode and a designated patient
sink.
2. The door to the patient room may remain open.
3. Contact Precautions Signage should be visibly displayed at the entrance to the patient’s room,
cubicle or designated bedspace (See Appendix E for sample Contact Precautions signage).
4. When single rooms are limited:
• Patients who are faecally incontinent and soiling the environment should have priority
for single rooms.
• A point-of-care risk assessment should be performed to determine patient placement
and/or suitability for cohorting.
5. If a single room is not available, patients with laboratory- confirmed CDI may be cohorted;
however each patient should have a designated toilet or commode assigned.
6. In a shared room:
• A dedicated toilet or commode chair should be dedicated to each patient/resident with
diarrhea.
• Roommates should be selected on their ability and their visitors’ ability to comply with
the necessary precautions.
• Personal protective equipment should be easily accessible.
• A laundry hamper and waste receptacle should be placed as close to the
patient/resident’s bedspace as possible for discarding of PPE following use.
• ICP or designate should be consulted when cohorting is considered.
7. If cohorting of patients with confirmed diagnosis of CDI is not available and a cubicle or
designated bedspace is used in a shared room, privacy curtains should be drawn between beds
at all times, and a designated commode provided.

Long-term care settings

1. A point-of-care risk assessment (Appendix B) should be done to determine resident placement
and removal from a shared room, the potential of infection risks to other residents in the room,

21
 the presence of risk factors that increase the likelihood of transmission and the potential
psychological impact on the symptomatic resident. The ICP or delegate should be consulted.
2. In a shared room:
 A resident suspected or confirmed to have CDI should not share a toilet or commode
with another resident.
 A dedicated toilet or commode should be assigned to each individual resident with
diarrhea.
 Privacy curtains should be drawn between beds at all times, if feasible.
3. The door to the resident’s room may remain open.
4. Contact Precautions signage should be placed at the entrance to the resident’s room or
designated bedspace.

v) Handling Linen, Dishes and Cutlery

1. No special precautions are required for linen. Routine practices are sufficient and include the
following:
a. Soiled linen should be handled in the same way for all patients, regardless of their
infection status.
b. Soiled linen should be placed in a no-touch receptacle at the point of use.
c. Soiled linen should be handled with a minimum of agitation to avoid contamination of air,
surfaces and persons.
d. Soiled linen should be sorted outside of the patient care areas and
e. Heavily soiled linen should be rolled or folded to contain the heaviest soil in the centre of
the bundle. Solid fecal matter that can be removed with a gloved hand and toilet tissue
should be placed into a bedpan or toilet for flushing.

2. No special precautions are required for dishes or cutlery; routine practices are sufficient.
a. In areas where dietary staff distribute trays, they may enter the patient/resident room
wearing a clean pair of gloves, place the tray in the room and then remove the gloves and
dispose of them in the waste receptacle at doorway in the room before leaving, and
perform hand hygiene.
b. Dietary staff can pick up trays from a patient/resident’s room wearing a clean pair of
gloves, bring the tray outside the room, place the tray on the cart and then remove the
gloves and dispose of them in the nearest waste can. Perform hand hygiene. No other
activities are to be performed by the dietary staff when in the patient/resident room. If
the patient requires assistance, a nurse is to be notified.

22
v) Patient Flow/Activities
1. The symptomatic patient/resident suspected or confirmed to have CDI should be allowed out of
the room only as indicated in the care plan or for medical reasons.
2. The patient/resident suspected or confirmed to have CDI should be provided with clean clothes
and should perform hand hygiene, with supervision/assistance as necessary, before leaving the
room.
3. Instructions/assistance with hand hygiene should be provided to patients suspected or
confirmed to have CDI after using the toilet facilities and prior to leaving their room.
4. If diarrhea cannot be contained and/or if hand hygiene compliance is inadequate,
patients/residents suspected or confirmed to have CDI should be restricted to their room until:
a. Diarrhea has resolved; or
b. Diarrhea can be contained; or
c. Hand hygiene compliance is adequate.
5. In long-term care facilities, participation in group activities should be restricted when diarrhea
cannot be contained and adherence to hand hygiene is not possible.

vi) Patient/Resident Transfer

Suspected or confirmed CDI does not preclude a patient/resident from being transferred within the
healthcare system when medically appropriate (e.g. essential diagnostics and therapeutic
tests/treatment) provided that the receiving unit/department/facility is able to comply with
requirements for accommodation and Contact Precautions. Otherwise, transfers should be minimized.
When booking an ambulance for any purpose for a patient/resident with known or suspected CDI,
notification of the diagnosis should be done at the time of booking, prior to the transfer.

a) Transfers to Other Hospitals or Healthcare Facilities

1. When considering the transfer of any patient with CDI to another facility, discharge planning and
communication must begin in time to ensure proper communications and arrangements for the
transfer have been made.
2. It is the responsibility of the transferring team to inform the receiving facility of the CDI
diagnosis in advance to allow for appropriate placement of the patient.
3. The transferring service, receiving unit, or facility should be advised of the necessary
precautions for the patient being transported;
4. A request to have the patient promptly seen to minimize time in waiting areas should be
considered;
5. The patient should be provided with clean clothes and bedding as necessary, diarrhea should be
contained (i.e., with incontinent products) as necessary, and instruction/assistance with
performing hand hygiene should be provided.

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b) Transfers to Long-Term Care
1. When considering the transfer of any patient/resident with CDI to a long-term facility, discharge
planning and communication must begin in time to ensure proper communications and
arrangements for the transfer have been made.
2. It is the responsibility of the transferring team to inform the receiving facility of the
patient/residents diagnosis in advance to allow for appropriate placement of the patient.
3. The transferring service, receiving unit, or facility should be advised of the necessary
precautions for the patient being transported;
4. The patient should be provided with clean clothes and bedding as necessary, diarrhea should be
contained (i.e., with incontinent products) as necessary, and instruction/assistance with
performing hand hygiene should be provided.

c) Patient Transfer of Care to Emergency Health Services (EHS):

If the patient/resident is being transported by an ambulance the following procedure should take
place by the EHS personnel:
1. Don appropriate PPE prior to entering the patient/resident room. EHS personnel should refrain
from touching or using any unnecessary equipment.
2. Once the patient is transferred to the stretcher, the patient should be wrapped sufficiently
(cocooned if possible) and educated on not to reach or touch items/equipment while they are
being transported. This will help mitigate patient injury and prevent microorganism
transmission.
3. Patient belongings should be bagged.
4. The parts of the stretcher that were touched during the bed transfer (i.e. hand rails, head of
stretcher, foot of stretcher and raising/lowering mechanism) and any equipment touched up to
that point, are cleaned and disinfected prior to leaving the patient/resident environment.
5. EHS personnel shall dispose of all PPE as they are leaving the patient/resident room. Hand
hygiene shall be performed immediately after the PPE is properly disposed.
6. PPE shall not be worn through the healthcare facility while transferring the patient on the
stretcher to the ambulance.
7. Appropriate PPE should be worn within the patient compartment of the vehicle during transport
8. The paramedic/first responder responsible for operating the vehicle should discard any
unnecessary PPE and perform hand hygiene prior to entering the cab to drive in order to avoid
inadvertent contamination of this area.
9. EHS staff will follow Routine Practices and Contact Precautions at the receiving facility.
10. The transport personnel will remove and dispose of their PPE and perform hand hygiene prior to
transporting patients into the healthcare facility.
11. The transport EHS personnel should put on clean personal protective equipment, if necessary, to
handle the patient during transport and at the transport destination.
12. All equipment and horizontal surfaces that may have become contaminated should be cleaned
and disinfected.
13. Any used linen should be handled as per Routine Practices.

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viii) Management of Patient/Resident Care Equipment
1. Dedicated equipment (e.g., wheelchairs, blood pressure cuffs, thermometers) should be
provided for each suspected or confirmed patient /resident with suspected or confirmed CDI.
2. In the event that reusable non-critical equipment is shared, thorough cleaning and disinfection
must occur before use on or with another patient/resident.
3. A disinfectant product with sporicidal claim should be used provided it is approved for use on
the patient care equipment item by the manufacturer.
4. Unused supplies from the rooms of patients with CDI that cannot be cleaned and disinfected
should be discarded.
5. Temperatures should not be taken rectally. Rectal thermometers have been linked with the
spread of CDI.
6. All equipment and supplies should be stored in a manner that prevents use for/by other patients
until it is appropriately cleaned and disinfected. Organizations should ensure that a system for
clearly identifying clean vs. soiled items is in place and is communicated to all HCWs.
7. Toys, electronic games, personal effects should be dedicated to the use of the patient/resident
with suspected or confirmed CDI. If appropriate for reuse by another patient, it is cleaned and
disinfected prior to reuse.

xi) Environmental Cleaning & Disinfection

Effective cleaning and disinfection of the environment around patients who have CDI is essential in
limiting the acquisition and spread of C. difficile. It is the manual effort of scrubbing that is most
effective at spore removal. After cleaning with your facility’s usual detergent solution, disinfect all
surfaces using a sporicidal product.

The following disinfectants, appropriate for environmental cleaning, have been shown to be effective
against C. difficile spores:

1. Hydrogen peroxide enhanced action formulation (4.5%)

2. Sodium hypochlorite (1,000-5,000 parts per million)
3. Peracetic acid (0.26%)

Choosing a Product: When choosing a sporicidal product for the facility or organization, consideration
should be given to ease of use and time requirements, the ability of the product to achieve the required
wet-contact time (e.g. gel versus liquid formulations), its compatibility with equipment being cleaned,
and cost.

25
Table 1: Dilution of Household Bleach (Sodium Hypochlorite) to Achieve Desired Chlorine Levels

Dilution* Preparation Level of available chlorine Contact time for

activation of C. difficile
% chlorine #ppm spores

1:100 1 part bleach +99 parts water 0.05% 500ppm N/A

1:50 1 part bleach + 49 parts water 0.1% 1, 000ppm 30 minutes

1:10 1 part bleach + 9 parts water 0.5% 5,000ppm 10 minutes

** Dilution of household bleach containing 5% sodium hypochlorite with 50,000 parts per million (ppm) available chlorine

Always follow the manufacturer’s directions for use to ensure that disinfectants are properly prepared
and applied, and that there is sufficient contact time on items/surfaces.

Decontamination, cleaning and disinfection of environmental surfaces must be thorough and

incorporate the following:
a) Prepare a checklist of surfaces and equipment that need to be cleaned and disinfected during an
outbreak. Using a checklist promotes consistency in cleaning among staff, and helps identify
opportunities for improvement.
b) In keeping with the recommended practice of moving from clean to dirty for all cleaning, the
rooms of patients without CDI should be cleaned first.
c) For patients/residents with suspected or confirmed CDI, all high‐touch surfaces and all items and
surfaces within the patient’s reach must be cleaned and disinfected twice daily and when soiled.
High touch surfaces can include bathrooms, light switches, light cords, hand/bed rails, bedside
tables, wheelchair/ walker etc.
d) De-clutter the patient/resident room to facilitate cleaning and disinfection.
e) A pre-cleaning step to remove visible soiling/organic material is completed prior to using a
sporicidal product. If using a QUAT product for cleaning, through rinsing before applying a
hydrogen peroxide enhanced action formulation agent is required.
f) Always work from clean items/surfaces to dirty ones.
g) Successful cleaning and disinfection requires manual scrubbing followed by application of the
disinfectant to the surface for the appropriate wet-contact time. Achieving the recommended
wet-contact time may be a challenge on some surfaces given the viscosity of some disinfectant
products (gel versus liquid formulation). Sporicidal kill will only be achieved by the appropriate
wet-contact time.
h) Do not use spray bottles to apply disinfectants. All cleaning and disinfectant solutions must be
applied directly to the cloth. Saturating several clean cloths in a pail of solution and using one at

26
 a time is the safest way to clean and disinfect. After use, reusable cloths must go directly into
the laundry.
i) Disposable wipes can be used for cleaning and disinfection of smaller surface areas only to
ensure the wet-contact time is achieved. Once used, wipes are placed in the regular waste
receptacle.
j) Cloths and mop heads must not be double-dipped and must be changed after use in the
patient’s/resident’s room. This practice reduces contamination of clean cloths, mops and the
disinfectant solution, and prevents transferring bacteria to other rooms and equipment.
k) Housekeeping staff shall adhere to Contact Precautions.

Communication Processes: Ensure clear communication with housekeeping/environmental services

with respect to cleaning protocols for C. difficile.
 Consider developing a checklist for housekeeping/environmental services that provides clear
expectations of cleaning and disinfection processes.
 Ensure a process for notification and scheduling of C. difficile cleaning of a specific patient
room/isolation area is established.
 An audit tool should be used to monitor the cleaning and disinfection of areas where CDI is
present.
Environmental Cleaning upon Discontinuation of Precautions: A discharge/terminal cleaning should be
done upon discontinuation of precautions, transfer of the patient/resident to another room, or
discharge from the healthcare facility. In cases where precautions are being discontinued (refer to
Duration of Precautions), patients/residents could be temporarily removed from the room while
terminal cleaning is done. The patient/resident should be bathed and dressed in clean bed‐clothes or
personal clothing before re‐admission to the room.
The following additional procedures may be incorporated into your organization’s discharge/terminal
cleaning and disinfection procedure for CDI:
a) Contact precautions should remain in effect until discharge cleaning has taken place.
b) All privacy, shower and window curtains, which undergo frequent handling, should be taken
down and sent for laundering.
c) All disposable items including paper towels, toilet paper, glove boxes and dedicated toilet
brushes should be discarded.
d) Clean and disinfect all dedicated equipment in the patient’s room upon discharge or
transfer.

Environmental Cleaning and Disinfection of Emergency Vehicles: Services should have clear, evidence-
informed policies and procedures detailing the indications for cleaning and disinfection of emergency
transport vehicles paying particular attention to frequency, processes, and materials in the event a
vehicle is contaminated with C. difficile.

27
 1. A risk assessment should occur after the completion of a transfer of a patient who has
suspected or confirmed CDI to determine the need to complete a terminal cleaning or “deep
clean” of the vehicle.
2. When a terminal cleaning/deep clean has been deemed necessary, a sporicidal product must be
used.
3. PPE is worn during the process of cleaning and disinfection.
4. Cleaning should occur from cleanest to dirtiest areas. These areas may vary depending on the
type of call and the degree of contamination in the treatment area.

Deep Clean refers to the thorough cleaning and disinfection process that occurs on a regular schedule
and in instances whereby the vehicle is grossly contaminated. A deep clean includes the following:
A) Driver’s compartment
 Removal of all equipment from the front of the vehicle
 Clean and vacuum floor,
 Clean and disinfect all interior surfaces, including walls, doors, radio equipment, dash and
windows.
B) Patient compartment
 Remove stretchers, clean and disinfect including mattress and belts; check for wear or
damage
 Remove wall suction, clean and disinfect area (if applicable)
 Remove contents of cupboards and shelves; clean and disinfect all surfaces
 Clean, disinfect and dry all hard surface items before returning to cupboard or shelf; inspect
for damage and expiration dates; repair/replace as needed
 Sweep, vacuum, clean and disinfect floor
 Clean and disinfect chairs, bench seats, seat belts
 Clean and disinfect all interior surfaces, including ceiling and walls and remove scuff marks
 Check interior lighting
 Empty, clean and disinfect waste containers
 Clean interior windows
C) Equipment storage compartment
 Remove all equipment and sweep out compartment
 Clean and disinfect compartment and restock

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x) Disposal of Fecal Matter
The safe disposal of fecal matter is of critical importance in preventing contamination of the worker’s
hands, clothing, and the health care environment. HCWs must wear appropriate PPE during the disposal
process.
When bedpans and commodes are required:
1. Handle bedpans and commodes in such a way as to avoid contamination of the environment
with C. difficile spores.
2. Do not empty bedpans/commodes into sinks or toilets. Cover the bedpan or commode
pan/bucket for transport to the soiled utility room. Solidifiers may be used to minimize risk of
spills.
3. Do not clean bedpans manually.
4. Bedpans or commode pan/buckets should be emptied into a hopper or, if available, use a
flusher/disinfector or macerator system.
5. Do not use spray wands for cleaning bedpans and commode/buckets.
6. If a bedside commode is being used, dedicate it to the patient and clean and disinfect it twice
daily and when soiled.
7. If applicable, flusher or washer/disinfectors should be installed, and maintained according to the
manufacturer’s directions. To ensure that the equipment is operating properly, preventive
maintenance and verification of the machine’s operational parameters should be performed
regularly. The manufacturer should be contacted to determine if adjustments can be made to
the flusher/disinfector to achieve conditions that will effectively eliminate spores.
8. Use of hygienic bags may be considered for patients with CDI or in the event of an outbreak.
9. If used, dedicate toilet bowl brush to one specific toilet and do not reuse. Disposable toilet bowl
brushes should be considered.
10.When precautions are discontinued, clean and disinfect or sterilize the commodes and bedpans
using a sporicidal agent (refer to Environmental Cleaning& Disinfection) before use by another
patient.

xi) Education of Patients, Families and Visitors

1. Visitors should receive verbal or written information/ education from the patient/resident’s
healthcare worker on precautions required to prevent transmission of C. difficile. (Refer to
Appendix F for a sample information sheet for Patients, Resident and Family Information about
Clostridium difficile).
2. Families and visitors who are participating in direct patient/resident care should be instructed
healthcare worker by the about the indications for appropriate use of PPE.
3. Families and visitors who assist with patient/resident care should use the same PPE as HCWs.
This may not be necessary for parents carrying out usual care of young children.

29
xii) Visitor Management
1. Visitors should be instructed to speak to nursing staff before entering the room, cubicle or
designated bedspace of a patient with suspected or confirmed CDI to evaluate the risk to the
health of the visitor and the ability to comply with precautions.
2. All visitors should be educated by the appropriately trained staff about the importance of hand
hygiene and how and when to properly carry this out. This should be done at the time of the
visitor’s initial visit.
3. If a visitor is providing care for the patient/resident or having significant contact with the
patient/resident’s immediate environment, PPE should be worn similar as for the HCWs. The
visitor should receive instruction from the patient/resident’s health care worker on the correct
use of the PPE.
4. Visitors should be restricted to visiting only one patient who is on contact precautions. If the
visitors must visit more than one patient, the visitor should be instructed to remove the PPE
between visits to different patients and perform hand hygiene before going to visit the next
patient/resident.
5. Visitors should not use the patient/resident’s bathroom.

E. Patient Discharge
After discharge, patients with CDI pose minimal risk to other family members as person-to-person
transmission within the home setting is uncommon. Additional precautions that are in place in the
healthcare setting are not necessary once the patient is discharged to the community. Good personal
hygiene and hand washing with soap and water is recommended for both individuals with CDI and their
caregivers while the individual has diarrhea. Special attention should be paid to cleaning and disinfecting
the bathroom used at home. An information sheet such as the one provided in Appendix F: Information
Sheet: Patient, Resident and Family Information about Clostridium difficile outlines information for what
to do at home.

F. Recurrence of Symptoms
Recurrence refers to the return of the symptoms of CDI after a symptom-free period. Recurrence of CDI
occurs either due to relapse (i.e., endogenous persistence of the same strain of C. difficile) or re-
infection (i.e. acquisition of a new strain of C. difficile from an exogenous source). Recurrence of CDI can
occur in about 30% of cases. If diarrhea and/or symptoms of CDI recur within 8 weeks of the last
infection, the case should be counted as a relapse.
If diarrhea recurs, the patient should be immediately placed on Contact Precautions and an appropriate
medical assessment conducted to determine if a recurrence has occurred. This may include re-testing
for C. difficile cytotoxin.

30
G. Outbreak Management
Institutions or facilities should have written policies and procedures for managing outbreaks. These
policies should include mitigation strategies such as the formation of a multidisciplinary outbreak team,
lines of communication, staff and patient education, review of environmental and equipment cleaning
practices, review and audit of infection prevention and control strategies such as hand hygiene
adherence monitoring.
a. Outbreaks are reported to local Public Health as per legislative requirements.
b. Efforts to identify the source of the outbreak should be done through a comprehensive
investigation and review. Refer to Appendix H for a sample C. difficile outbreak line listing form.
b. Notification to the facility microbiology lab/provincial lab that an outbreak is suspected to
ensure awareness of potential for increased number of specimens, need for increased
turnaround time and immediate reporting of positive cases.
c. The multidisciplinary team with expertise in outbreak management should assist in determining
the course of action for admissions, discharges, cancellations of service and internal and
external communication.
d. Depending on the outbreak setting, Public Health Services, the Infectious Disease Physician, or
Infection Control Practitioner or designate has the authority to declare the outbreak over.
e. An outbreak report, which includes lessons learned, shall be completed and submitted by the
Outbreak team of the facility. The report should be shared with the facility senior leadership
team, Infection Prevention and Control Committee, and the district Medical Officer of Health or
designate at the Communicable Disease Control program at Public Health Services.

When there is evidence of continued transmission of C. difficile within a facility or when the incidence
rate for C. difficile is higher than the facility’s baseline rate, the following heightened measures should
be implemented;
a) Place signage at entrances to the affected unit(s) to direct families and visitors;
b) Place all patients/residents with acute diarrhea illness on contact precautions;
c) Report the outbreak to local Infection Prevention and Control personnel, and to public health
officials as per provincial reporting requirements;
d) Decontaminate and clean rooms or designated bedspace of patients/residents suspected or
confirmed to have CDI with a sporicidal agent (Refer to Environmental Cleaning)
e) Increasing the frequency of cleaning, including bathing and toileting facilities, recreational
equipment, all horizontal surfaces in the patient/resident’s room or designated bedspace and, in
particular, areas/items that are frequently touched (e.g., hand and bedrails, light cords, light
switches, door handles, furniture, etc.), common areas, nursing stations, staff washrooms, etc.,
on the affected unit(s);
f) Cohort staff to patients/residents;
g) With associated high burden of illness, particularly with higher than expected attributable
mortality, there may be a role, in consultation with Infectious Diseases/Microbiologist and/or

31
 Public Health and Provincial Public Health Laboratory , to characterize the strain type and
clonality of C. difficile isolates;
h) Perform audits on the affected unit/area. This may include auditing adherence to hand hygiene
practices, PPE use by staff, cleaning/disinfecting shared non-critical equipment, and
environmental cleaning;
i) Review the process for disposal of fecal matter (Refer to Disposal of Fecal Matter);
j) Consider closing affected unit(s) to admissions if initial control measures are ineffective in
controlling the spread of C. difficile;
k) Reviewing antimicrobial prescribing practices including indications for prescribing and specific
agents used. In some settings, it may be helpful to restrict the use of specific antimicrobial
agents; and
l) Consulting provincial IPCNS or public health expertise in outbreak management for ongoing
outbreak situations.

Declaring an Outbreak Over: Criteria for declaring an outbreak over should be determined
collaboratively by the facility and local public health unit or Infection Prevention and Control Team as
part of the Outbreak management team process.

Factors to consider in declaring an outbreak over include:

 Control measures have been implemented and validated through an audit process.
 There has been a return to unit/ward or facility baseline from normal CDI. For a facility wide
outbreak, this should be a minimum period of one month.
 Reservoir of colonized patients or residents in the facility has been discharged.
 Facilities past experience with CDI outbreaks demonstrates ability to bring them under control.

H. Guidance for Health Care Workers

Healthcare workers (HCW), including when they are receiving antibiotics, are generally not at risk of
acquiring CDI occupationally. HCWs should not work when experiencing diarrhea, unless there is a
known underlying non-infectious cause. HCWs with diarrhea OR HCWs who have suspected or
confirmed CDI may return to work once symptoms of diarrhea have resolved for 48 hours and do not
need a negative stool sample. HCWs should be advised to continue with frequent hand hygiene and to
complete antibiotics as prescribed.

i) Education
HCWs should receive education on C. difficile, including measures to control its spread and on their role
in identifying and acting on new onset diarrhea. (Refer to Appendix G Information Sheet: Clostridium
difficile for Healthcare Workers). Education should reinforce Routine Practices, point-of-care risk
assessment, the use of Contact Precautions when caring for patients with suspected or confirmed CDI
and safe work practices such as not consuming food or beverages in patient/resident care areas.

32
ii) Hazard Assessment
The Nova Scotia Occupational Health and Safety Act and applicable regulations set out the legal
requirements that employers, you, and your co-workers must meet to protect the health and safety of
both yourself and others. These are minimum requirements:

Employers
Under Section 13(1) (f) of the Occupational Health and Safety Act, every employer shall take every
precaution that is reasonable in the circumstance to conduct the employers’ undertaking so that
employees are not exposed to health and safety hazards as a result of the undertaking. For instance:
- Assess a work site and identify existing or potential hazards.
- Prepare a written and dated hazard assessment, including the methods used to control or
eliminate the hazards identified. A properly completed checklist is acceptable for a written
hazard assessment.
- Involve workers in hazard assessment.
- Make sure workers are informed of the hazards and the methods used to control the hazards.

Employee
Under Section 17 (1) (a) of the Occupational Health and Safety Act, every employee, while at work, shall
take every reasonable precaution in the circumstances to protect the employee’s own health and safety
and that of others persons at or near the workplace.

It is the responsibility of each HCW to comply with additional precautions and use of PPE as outlined in
the Occupational Health and Safety legislation. Hazard Assessment in healthcare settings can include a
comprehensive assessment conducted with the joint occupational health and safety committee (JOHSC).
The risk assessment will include a review of C. difficile in your facility and the measures to protect
employees and patients/residents. The assessment should review availability of approved PPE,
compliance with infection prevention and control practices and policies concerning C. difficile, including
a current or organizational infrastructure-related assessment to identify issues which may pose infection
prevention and control risks for the employee. This includes but is not limited to sink availability and
locations, location of soiled utility rooms and practices for waste management/transport.

33
6. References
Association for Professions in Infection Control (APIC) (2008). Guide to the elimination of Clostridium difficile in
healthcare settings. Washington, DC.

Bouza, E., Munoz, P. & Alonzo, R. (2005). Clinical manifestations, treatment and control of infections caused by
Clostridium difficile. Clinical Microbiology and Infection, 11 (4), 57-64.

Canadian Nosocomial Infection Surveillance Program (CNISP). (2011). 2012 Surveillance for Clostridium
difficile‐associated infection (CDI) within healthcare institutions. Public Health Agency of Canada, (Revised
December 2011). Ottawa ON.

Community and Hospital Infection Control Association (CHICA) Canada: Prehospital Interest Group (2013).
Recommendation for environmental disinfection for emergency vehicles. Release pending.

Cohen, S.H., Gerding, D. N., Johnson, S. , Kelly, C. P., Loo, V.G., McDonald, L.C., Pepin, J. and Wilcox, M.H. (2010).
Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare
Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA), Infection Control and
Hospital Epidemiology 31,(5): 431‐455.

Hookman, P. & Barkin, J. S. (2009). Clostridium difficile associated infection, diarrhea and colitis. World Journal of
Gastroenterology, 15(13):1554-80.

Nova Scotia Communicable Disease Control Manual (2012) Chapter 8: Clostridium difficile. Retrieved from,
http://www.gov.ns.ca/hpp/publications/cdc_manual.pdf

Prince Edward Island Department of Health and Wellness (2010). Provincial infection prevention and control
Clostridium difficile guideline.

Provincial Infectious Diseases Advisory Committee (PIDAC) (2012a). Best practices for infection prevention and
control programs in Ontario in all health care settings (3rd ed.). Toronto, ON: Ontario Ministry of Health.

Provincial Infectious Diseases Advisory Committee (PIDAC) (2012b). Best practices for environmental cleaning for
nd
prevention and control of infections in all health care settings (2 ed). Toronto, ON: Ontario Ministry of Health.

Provincial Infectious Diseases Advisory Committee (PIDAC) (2013). Annex C: Testing, Surveillance and Management
of Clostridium difficile in All Health Care Settings. In Routine Practices and Additional Precautions. Toronto, ON:
Ontario Ministry of Health and Long Term Care.

Public Health Agency of Canada (2012). Clostridium difficile Infection: Infection Prevention and Control Guidance
for Management in Long-Term Care Facilities. Ottawa, ON.

Public Health Agency of Canada (2012). Clostridium difficile Infection: Infection Prevention and Control Guidance
for Management in Acute Care Settings. Ottawa, ON

Public Health Agency of Canada (2012). Hand Hygiene Practices in HealthCare Settings. Ottawa, ON

Public Health Agency of Canada (2012). Routine practices and additional precautions for preventing the
transmission of infection in healthcare settings. Ottawa, ON.

Saskatchewan Ministry of Health. (2010) Guidelines for the management of Clostridium difficile infection (CDI) in all
healthcare settings.

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Appendix A: Bristol Stool Chart

Reference: Heaton K.W. Reader in Medicine at the University of Bristol.

35
Appendix B: Point-of-Care Risk Assessment
Prior to any patient/resident/client interaction, all healthcare workers have a responsibility to always
assess the infectious risk posed to themselves and to other patients/residents/clients, families, visitors,
and healthcare workers. This risk assessment is based on professional judgment about the clinical
situation and up-to-date information on how the specific healthcare organization has designed and
implemented engineering and administrative controls, along with the availability and use of personal
protective equipment.

The point-of-care risk assessment is an activity performed by the healthcare worker before every
patient/resident/client interaction, to:

1. Evaluate the likelihood of exposure to the infectious agent:

 from a specific interaction (e.g., performing/assisting with aerosol-generating medical
procedures, other clinical procedures/interaction, non-clinical interaction [admitting,
teaching patients/residents/clients and families], transporting patients/residents/clients,
direct face-to-face interaction with patients/residents/clients, etc.);
 with a specific patient/resident/client (e.g., infants/young children,
patients/residents/clients not capable of self-care / hand hygiene, have poor compliance
with respiratory hygiene, copious respiratory secretions, frequent coughing/sneezing,
diarrhea, etc.);
 in a specific environment (e.g., single rooms, shared rooms/washrooms, hallway,
assessment areas, emergency departments, public areas, therapeutic departments,
diagnostic imaging departments, housekeeping, etc.);
 under available conditions (e.g., air exchanges in a large waiting area or in an airborne
infection isolation room, patient/resident/client waiting areas, etc.);

AND

2. Choose the appropriate actions/personal protective equipment needed to minimize the risk of the
patient/resident/client, healthcare worker, other staff, family, visitor, contractor, etc. of exposure
to the infectious agent.

The point-of-care risk assessment is not a new concept, but one that is already performed regularly by
healthcare workers many times a day for their safety and the safety of patients/residents/clients and
others in the healthcare environment. For example, when a healthcare worker assesses a
patient/resident/client and the situation to determine the possibility of blood or body fluid exposure or
chooses appropriate personal protective equipment to care for a patient/resident/client with an
infectious disease, these actions are both activities of a point-of-care risk assessment.
Reference: Public Health Agency of Canada. Prevention and Control of Influenza during a Pandemic for All Healthcare Settings.
Annex F of the Canadian Pandemic Influenza Plan for the Health Sector. Available at: www.phac-aspc.gc.ca/cpip-pclcpi/index-
eng.ph

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Appendix C:
Continuum of Care Comparison Chart for Additional Precautions for Clostridium difficile Infection (CDI)
Precautions Hand Hygiene Gloves Gowns Masks Patient Patient/Resident Cleaning Laundry Garbage Patient Dietary
for CDI by and face placement care equipment transport
Setting protection

Acute Care Hand hygiene Worn to Worn if it is As per Single room with Dedicate use of Cleaning and Handle laundry Double bagging not Notify area Disposable
with soap enter the anticipated Routine dedicated toileting equipment for the frequently as per Routine required. Garbage receiving patient dishes not
and water patient’s that clothing Practices facilities patient when possible touched Practices. handled as per of precautions. required.
Before and room, or forearms preferred. Refer - If it is not dedicated, areas twice - Gloves and Routine Practices - Patient must - Trays will be
after contact cubicle or will be in to guidelines if clean and disinfect daily with a gown should and in accordance perform hand treated as normal
with patient or bedspace direct single room is not equipment before and disinfectant be worn and with the hygiene. and placed
patient’s contact with available. after use on another that will kill hand hygiene Nova Scotia/ district/ on the cart to be
environment, patient or Consult Infection patient spores. performed. hospital waste brought to
before aseptic patent’s Prevention & - When possible use management kitchen.
procedure, environment Control team if single-use items protocols
after body alternate -Minimize supplies in
fluid exposure arrangements room as these
- 4 Moments need to be made. supplies will be
of Hand discarded upon patient
Hygiene discharge
Long-Term Hand wash Worn to Worn if it is As per Single room with Dedicate use of Cleaning and Handle laundry Double bagging not Notify area Disposable
with soap enter the anticipated Routine dedicated toileting equipment for the frequently as per Routine required. Garbage receiving patient dishes not
Care and water Practices facilities patient when possible touched Practices. handled as per of precautions. required.
patient’s that clothing
Before and preferred. Refer - If it is not dedicated, areas twice - Gloves and Routine Practices - Patient must - Trays will be
room, or forearms
after contact to guidelines if clean and disinfect daily with a gown should and in accordance perform hand treated as normal
with resident/ cubicle or will be in single room is not equipment before and disinfectant be worn and with the hygiene and placed on the
resident bedspace direct available. after use on another that will kill hand hygiene Nova Scotia/ district/ cart to be brought
environment, contact with Consult Infection patient with a spores performed hospital waste to kitchen.
before aseptic patient or Prevention & disinfectant that will kill management
procedure, patent’s Control or spores. protocols
after body environment designate if - When possible use
fluid exposure alternative single-use items
and leaving arrangements -Minimize supplies in
resident need to be made room as these
environment ( 4 supplies will be
Moments discarded upon
of Hand discontinuation of
Hygiene) precautions.

Prehospital Clean hands with Worn Worn when As per Ambulance Clean and disinfect all Conduct a risk Handle laundry Double bagging Notify area If applicable, offer
soap and water when in in contact Routine should not be equipment between assessment as per Routine Garbage handled as receiving patient patient/resident
Care (e.g. (preferred) or an contact with patient Practices shared with patients. following Practices. per Routine of precautions. hand hygiene
EHS) ABHR if sink not with or patient another transport of - Gloves and Practices and in assistance prior
readily available patient or environment patient/resident patient and if gown should accordance with the to eating or

37
and wash hands patient applicable, be worn and Nova Scotia/ district/ drinking
at next available environme perform deep hand hygiene hospital waste
sink. If hands are nt clean as per performed. management
visibly soiled, and protocol using protocols.
sink is a disinfectant not required.
unavailable, use that will kill
pre-moistened spores.
hand wipes
followed by
ABHR.

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Appendix D: Sample Posters for Putting On and Removing Personal
Protective Equipment

39
40
Appendix E: Sample Contact Precautions Signage

41
Appendix F: Sample Information Sheet: Patient, Resident and Family
Information about Clostridium difficile

42
43
Appendix G: Information Sheet: Clostridium difficile for Healthcare
Workers

The Issue
Clostridium difficile, commonly called C. difficile, is a bacterium that causes diarrhea and other serious
intestinal conditions. It is the most common cause of infectious diarrhea in hospitalized patients in the
industrialized world.

Background
C. difficile is one of the most common infections found in hospitals and long-term care facilities.
C. difficile bacteria are found in feces. This microorganism is a spore-forming, Gram-positive, anaerobic
bacillus that causes diarrhea and colitis in humans and in a number of animal species. Its spores can survive
outside the human body for weeks to months on environmental surfaces and devices, including bedrails,
commodes, thermometers, improperly sterilized endoscopes, bathing tubs, etc. People can become infected
if they touch items or surfaces that are contaminated with fecal traces, and then touch their mouth.
Healthcare workers can spread the bacteria to other patients or contaminate surfaces through hand contact.
The use of antibiotics increases the chances of developing C. difficile diarrhea because antibiotics alter the
normal levels of good bacteria found in the intestines and colon. When there are fewer good bacteria, C.
difficile can thrive and produce toxins that can cause an infection. These toxins then cause diarrhea and
others symptoms of infection. In hospital and long-term care settings, the combination of a number of people
receiving antibiotics and the presence of C. difficile can lead to frequent outbreaks.

Transmission of C. difficile
Transmission of C. difficile occurs when the microorganism or its spores are ingested orally (fecal-oral route).
This may occur because of direct contact, person to person spread on hands, or from the environment.
Healthcare-associated transmission has been well documented, and outbreaks have been reported in both
hospitals and long-term care facilities.

Symptoms of C. difficile infection

The symptoms of C. difficile infection include:
 watery diarrhea (at least three bowel movements per day for two or more days)
 fever
 loss of appetite
 nausea
 abdominal pain or tenderness

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Diagnosis of C. difficile
Lab confirmation of a suspected case of C. difficile infection consists of a positive result of one of the
following tests:
• endoscopy for colonic pseudomembranes
 stool culture for C. difficile with toxin production
 stool enzyme immunoassay for either Toxin A or Toxin B
 stool cytotoxicity assay positive for Toxin B

Health Risks of C. difficile

Healthy people are not usually vulnerable to C. difficile. Seniors and people who have other illnesses or
conditions being treated with antibiotics and certain other stomach medications are at the greatest risk of
infection.
Most commonly, the infection causes diarrhea, which can lead to serious complications including
dehydration and colitis. The spectrum of clinical outcomes can range from asymptomatic colonization of the
colon, to the more severe manifestations of C. difficile infection, such as pseudomembranous colitis, toxic
megacolon, and colonic perforation. In rare cases, it can be fatal.
For people with mild symptoms, no treatment may be needed. The symptoms usually clear up once the
patient stops using antibiotics. In severe cases, medication and even surgery may be needed.

Minimizing Risk
Hospitals and long-term care facilities appear to be the major reservoirs for C. difficile. The microorganism
can be cultured from patient/residents with and without diarrhea, from the environment of infected
patients/ residents, from patient care equipment (e.g. bedpans, bedrails, bedside commodes, wheelchairs)
and from the hands of healthcare workers caring for these patients/residents.
The spores from C. difficile can survive for weeks and months in the environment. Cleaning and disinfection
protocols for C. difficile are very important in preventing the spread of infection.
Patients and residents with active diarrhea are much more infectious than those who are asymptomatic.
Performing hand hygiene often is your best defense against C. difficile. Hand washing with liquid soap and
water should be performed at the point-of-care and at a designated staff hand washing sink. If a designated
staff hand washing sink is not available at the point-of-care, alcohol-based hand rub (ABHR) should be used
and hand hygiene with liquid soap and water should be performed as soon as a staff hand washing sink is
available.

Adapted from: Prince Edward Island Department of Health and Wellness (2010). Provincial infection prevention
and control Clostridium difficile guideline.

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 Appendix H: Sample Clostridium difficile Infection (CDI) Outbreak Line Listing Form
Facility Name: _______________________________
Notification Date to Public Health (dd/mm/yy):__________________ Outbreak Number: _____________________________

Case Identification Risk Factors Symptoms & Case Definition Complications Stool Specimens/ Status
( Example: A & D) (Y/N) Tissue Sample
Case Patient Name Unique DOB Unit/ Date of A. Antibiotic Usage Onset date of Initiation of Symptoms (Y/N) Date of Date and Date
# Patient Floor/ Admission B. Bowel Surgery symptoms Contact specimen Results Resolved,

Diarrhea/Bloody Diarrhea
Identifier (dd/mm/yy) Room (dd/mm/yy) C. Chemo/Immunosuppresive Tx Precautions (Pos/Neg) Discharged or
D. Prolonged Hospitalization (dd/mm/yy) (dd/mm/yy) Died (specify)

Pseudomembranes
Abdominal Cramps
E. Increased Age (dd/mm/yy) (dd/mm/yy)

Toxic Megacolon
F. Underlying illness (dd/mm/yy)

Hospitalization

ICU Admission
G. Non-surgical gastrointestinal
procedures (e.g. frequent

Surgery
enemas or NGs)

Death
Fever
H. Treatment with Proton Pump
Inhibitors

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