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c. difficile
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c. difficile - April 11, 2008 8:03:52 AM
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rwillcott
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Hello. I work in private practice and had a 66 year old female patient book yesterday with c.difficile. She is being referred for a TKR, however she also has c. difficile.
I haven't worked in inpatients since my days in school. Is there anything I should know with regards to infection control? With the little I read, it seems that handwashing is enough to prevent the transmission. It does not require mask, gown, glove does it?
Any other things I should know?
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RE: c. difficile - April 11, 2008 9:35:19 AM
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jma
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I would exercise universal precautions with this patient but I would also definitely use gloves.
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RE: c. difficile - April 11, 2008 1:05:27 PM
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james079
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Get this woman out West for the cutting edge treatment of c difficile.
Why suffer when one administration will cure 90% of cases overnight! So don't POO POO this idea. All you need is a doner, usually a close relative, collect stools for a week and have them tested for anything untoward. Then it's into the blender and the enema is ready. Some groups baulk at blood transfusions but I don't think there is anything in the bible about poop.
Jim McGregor
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RE: c. difficile - April 11, 2008 2:44:49 PM
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Crevidence
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James,
That is the first I have heard of that treatment and I hope I never need it.
With the patient, I would use universal precautions and keep the gym equipment clean.
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RE: c. difficile - April 11, 2008 3:18:57 PM
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buckeye
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Gloves; protective gown for close contact; wash all equipment (chair, treatment table, bike, total gym, etc.) the patient contacts.
It is not vital - but consider scheduling the patient at a less active time in the clinic - it may help reduce risk of transmission but also may help reduce anxiety from the infected patient or other patients.
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RE: c. difficile - April 11, 2008 10:36:51 PM
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blast7
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quote:
ORIGINAL: buckeye
Gloves; protective gown for close contact; wash all equipment (chair, treatment table, bike, total gym, etc.) the patient contacts.
It is not vital - but consider scheduling the patient at a less active time in the clinic - it may help reduce risk of transmission but also may help reduce anxiety from the infected patient or other patients.
Agreed. I work in the inpatient setting and this is hospital's policy per infection control department. Also wiping down is done with Vyrex wipes.
< Message edited by blast7 -- April 11, 2008 10:39:29 PM >
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RE: c. difficile - April 12, 2008 6:58:14 AM
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SJBird55
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I had no idea what the heck c. difficile was or is.
Since the spread of c. difficile is by feces, I would actually take a different approach. How would "feces" get spread in your private practice? Immediately after she arrived I'd have her go wash HER hands for the length of time it took her to sing the alphabet 3 times! Then, as she begins whatever activity, I'd have someone in my office go back through the steps she just took and wipe down the door knobs, pen, chair... etc. (In my practice, the equipment is cleaned down between every patient, so the rest of the protocol would be normal protocol.)
I probably wouldn't wear gloves with this individual. I'd wash my hands with soap and water after treating her though.
If she's still having lots of episodes of diarrhea, she shouldn't be coming in to your clinic.
Here's info from the Mayo Clinic: http://www.mayoclinic.com/health/c-difficile/DS00736/DSECTION=9
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RE: c. difficile - April 12, 2008 3:04:24 PM
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Crevidence
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This is how I have seen it handled. When I was a student in a large hospital we used all the isolation precautions when the pt had it in the inpatient side. What happened when the same pt. came back for outpatient PT just a day or so latter just down the hall? We just treated like anyone else. Universal precautions and loads of HAND WASHING like SJ mentioned. Some of the therapists used gloves, but I think if you use gloves on that person why not use them on everyone?
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RE: c. difficile - April 13, 2008 11:35:36 AM
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rwillcott
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Is there a cleaning product that I can buy in a grocery store that would be effective in killing any spores?
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RE: c. difficile - April 13, 2008 12:45:28 PM
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jma
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I would look into those kind of products in a surgical supply store, however, it would help if it has bacteriostatic/sporicidal properties. Or a good hospital grade cleaner would do the job. Not usually found in a local grocery store but I could be wrong. The department orders from a surgical supply outlet.
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RE: c. difficile - April 13, 2008 3:26:05 PM
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SJBird55
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For products that are effective for c. difficile vegetative bacterium: http://www.epa.gov/oppad001/list_i_clostridium.pdf
Much more difficult to kill the spores. Apparently there are no EPA approved products for the spores. The CDC recommends a hypochlorite based product (bleach). http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_hcp.html#10
Infect Control Hosp Epidemiol. 2007 Aug;28(8):920-5. Epub 2007 Jun 15.
Efficacy of hospital cleaning agents and germicides against epidemic Clostridium difficile strains.
Fawley WN, Underwood S, Freeman J, Baines SD, Saxton K, Stephenson K, Owens RC Jr, Wilcox MH.Department of Microbiology, General Infirmary, Old Medical School, Leeds, United Kingdom.
OBJECTIVE: To compare the effects of hospital cleaning agents and germicides on the survival of epidemic Clostridium difficile strains. METHODS: We compared the activity of and effects of exposure to 5 cleaning agents and/or germicides (3 containing chlorine, 1 containing only detergent, and 1 containing hydrogen peroxide) on vegetative and spore forms of epidemic and non-epidemic C. difficile strains (3 of each). We carried out in vitro exposure experiments using a human fecal emulsion to mimic conditions found in situ. RESULTS: Cleaning agent and germicide exposure experiments yielded very different results for C. difficile vegetative cells, compared with those for spores. Working-strength concentrations of all of the agents inhibited the growth of C. difficile in culture. However, when used at recommended working concentrations, only chlorine-based germicides were able to inactivate C. difficile spores. C. difficile epidemic strains had a greater sporulation rate than nonepidemic strains. The mean sporulation rate, expressed as the proportion of a cell population that is in spore form, was 13% for all strains not exposed to any cleaning agent or germicide, and it was significantly increased by exposure to cleaning agents or germicides containing detergent alone (34%), a combination of detergent and hypochlorite (24%), or hydrogen peroxide (33%). By contrast, the mean sporulation rate did not change substantially after exposure to germicides containing either a combination of detergent and dichloroisocyanurate (9%) or dichloroisocyanurate alone (15%). CONCLUSIONS: These results highlight differences in the activity of cleaning agents and germicides against C. difficile spores and the potential for some of these products to promote sporulation.
Lancet. 2000 Oct 14;356(9238):1324.
Comment in:
Lancet. 2000 Dec 16;356(9247):2098-9.
Hospital disinfectants and spore formation by Clostridium difficile.
Wilcox MH, Fawley WN.Evidence is lacking on how best to decontaminate the hospital environment of Clostridium difficile. We compared sporulation levels in the UK epidemic C. difficile strain (P24), another clinical isolate (B31), and an environmental strain (E4) cultured in faecal emulsion containing subinhibitory concentrations of one of five hospital cleaning agents. The epidemic strain produced significantly more spores than the non-prevalent strains, and sporulation was further enhanced when this strain was cultured in faeces exposed to non-chlorine-based cleaning agents. The choice of cleaning agent can have a substantial effect on the persistence of C. difficile spores in the hospital environment.
Infect Control Hosp Epidemiol. 2003 Oct;24(10):765-8.
Activity of three disinfectants and acidified nitrite against Clostridium difficile spores.
Wullt M, Odenholt I, Walder M.Department of Infectious Diseases, Lund University, Malmö University Hospital, Malmö, Sweden.
OBJECTIVE: To identify environmentally safe, rapidly acting agents for killing spores of Clostridium difficile in the hospital environment. DESIGN: Three classic disinfectants (2% glutaraldehyde, 1.6% peracetyl ions, and 70% isopropanol) and acidified nitrite were compared for activity against C. difficile spores. Four strains of C. difficile belonging to different serogroups were tested using a dilution-neutralization method according to preliminary European Standard prEN 14347. For peracetyl ions and acidified nitrite, the subjective cleaning effect and the sporicidal activity was also tested in the presence of organic load. RESULTS: Peracetyl ions were highly sporicidal and yielded a minimum 4 log10 reduction of germinating spores already at short exposure times, independent of organic load conditions. Isopropanol 70% showed low or no inactivation at all exposure times, whereas glutaraldehyde and acidified nitrite each resulted in an increasing inactivation factor (IF) over time, from an IF greater than 1.4 at 5 minutes of exposure time to greater than 4.1 at 30 minutes. Soiling conditions did not influence the effect of acidified nitrite. There was no difference in the IF among the 4 strains tested for any of the investigated agents. Acidified nitrite demonstrated a good subjective cleaning effect and peracetyl ions demonstrated a satisfactory effect. CONCLUSIONS: Cidal activity was shown against C. difficile spores by glutaraldehyde, peracetyl ions, and acidified nitrite. As acidified nitrite and peracetyl ions are considered to be environmentally safe chemicals, these agents seem well suited for the disinfection of C. difficile spores in the hospital environment.
Am J Infect Control. 2005 Aug;33(6):320-5.
Activity of selected oxidizing microbicides against the spores of Clostridium difficile: relevance to environmental control.
Perez J, Springthorpe VS, Sattar SA.Centre for Research on Environmental Microbiology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
BACKGROUND: Clostridium difficile is an increasingly common nosocomial pathogen, and its spores are resistant to common environmental surface disinfectants. Many high-level disinfectants (eg, aldehydes) are unsuitable for environmental decontamination because they need several hours of contact to be sporicidal. This study tested the potential of selected oxidative microbicides to inactivate C. difficile spores on hard surfaces in relatively short contact times at room temperature. METHODS: The spores of a clinical isolate of C. difficile were tested using disks (1 cm diameter) of brushed stainless steel in a quantitative carrier test. The spores of C. sporogenes and Bacillus subtilis, common surrogates for evaluating sporicides, were included for comparison. The clostridia were grown separately in Columbia broth (CB), and B. subtilis was grown in a 1:10 dilution of CB. Each disk received 10 microL test spores with an added soil load, and the inoculum was dried. One disk each was placed in a glass vial and overlaid with 50 microL test formulation; controls received an equivalent volume of normal saline with 0.1% Tween 80. At the end of the contact time the microbicide was neutralized, the inoculum recovered from the disks by vortexing, the eluates were membrane filtered, and the filters placed on plates of recovery medium. The colony-forming units (CFU) on the plates were recorded after 5 days of incubation. The performance criterion was > or = 6 log(10) (> or = 99.9999%) reduction in the viability titer of the spores. The microbicides tested were domestic bleach with free-chlorine (FC) levels of 1000, 3000, and 5000 mg/L; an accelerated hydrogen peroxide (AHP)-based product with 70,000 mg/L H2O2 (Virox STF); chlorine dioxide (600 mg/L FC); and acidified domestic bleach (5000 mg/L FC). RESULTS: Acidified bleach and the highest concentration of regular bleach tested could inactivate all the spores in < or = 10 minutes; Virox STF could do the same in < or = 13 minutes. Regular bleach with 3000 mg/L FC required up to 20 minutes to reduce the viability of the all the spores tested to undetectable levels; chlorine dioxide and the lowest concentration of regular bleach tested needed approximately 30 minutes for the same level of activity. CONCLUSIONS: Acidified bleach, Virox STF, and regular bleach (3000-5000 mg/L FC) could inactivate C. difficile spores on hard environmental surfaces in approximately 10 to 15 minutes under ambient conditions. All of these products are strong oxidizers and should be handled with care for protection of staff, but acidified and regular bleach with high levels of FC also release chlorine gas, which can be hazardous if inhaled by staff or patients.
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RE: c. difficile - April 30, 2008 9:51:01 AM
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Dr.Wagner
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If I were you...and the patient had ACTIVE C-Dif, I don't think I would want that patient in the clinic.
But my guess is that the stool have slowed and she is either on oral Metronidazole or Vanc. So likely you are ok, non the less, wear gloves, wash hands with soap and water and I would treat in a private treatment room.
< Message edited by Dr.Wagner -- April 30, 2008 9:56:16 AM >
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RE: c. difficile - April 30, 2008 12:23:40 PM
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rwillcott
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From: Canada
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Thanks for all the great info. I know a lot of it is common sense hwever, I just wanted to be safe and have a clean environment for my patients.
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RE: c. difficile - May 6, 2008 7:03:59 PM
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hmgross
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I was just reading about this a couple days ago, and it looks like it is getting to be quite a problem
http://www.msnbc.com/id/24407803/
search c.difficile
(hope that works, I am not very good at this)
< Message edited by hmgross -- May 6, 2008 7:10:59 PM >
_____________________________
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RE: c. difficile - May 7, 2008 8:36:39 PM
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gshumrak
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Also, keep in mind c. diff is not killed by purell (unlike MRSA or VRE). You must wash with soap in water. In our hospital and inpt rehab, the patient is to wash hands prior to treatment and also any equipment used by the patient is wiped down with cavi wipes. (they kill just about everything, you even must wer gloves when using it.) I believe a bleach solution can also be used.
Even though it is spread by feces, think about all those reports about what organisms are found on public surfaces (stair railings, elevator buttons). Many people don't wash there hands.
And pt's who are immunocompromised are more at risk, hence why it usually a hospital acquired infection.
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