Executive Summary Checklist

In  order  to  implement  a  program  to  eliminate  Clostridium  difficile  infection  (CDI)  the  following  implementation plan  will  require  the  actionable  steps.  The  following  checklist  was  adapted  from  the  core  prevention  strategies recommended by the CDC \cite{00015}.

The Performance Gap

Clostridium difficile (C. diff) is a spore-forming, Gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B \cite{00016}. It is a common cause of antibiotic-associated diarrhea (AAD), and it accounts for 15-25% of all episodes of AAD. Various diseases result from C. diff infection (CDI), including: pseudomembranous colitis (PMC), toxic megacolon, perforations of the colon, sepsis, and death (rarely).  The clinical symptoms include watery diarrhea, fever, loss of appetite, nausea and abdominal pain/tenderness.   Certain patient populations are at an increased risk for C. diff, including patients with: antibiotic exposure, proton pump inhibitors, gastrointestinal surgery/manipulation, long length stay in healthcare settings, a serious underlying illness, immunocompromising conditions and advanced age.
Clostridium difficile is shed in feces.  Any surface, device, or material that becomes contaminated with feces may serve as a reservoir for the C. diff spores.  The spores are primarily transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item.  It is important to note that C. diff spores are not killed by alcohol-based hand rubs \cite{Oughton_2009},\cite{Jabbar_2010},\cite{18177221}. The WHO recommends washing hands with soap and water before gloving and after degloving \cite{00017}. CDI will resolve within 2-3 days of discontinuing the antibiotic to which the patient was previously exposed in approximately 20% of patients.  The infection can usually be treated with an appropriate course (about 10 days) of antibiotics. After treatment, repeat C. diff testing is not recommended if the patients’ symptoms have resolved, as patients may remain colonized.  The differences between C. diff colonization and infection are important to note:
Common laboratory tests used to diagnose C. diff infection include stool culture, molecular tests, antigen detection for C diff, toxin testing (tissue culture cytoxicity assay or enzyme immunoassay). The toxin is very unstable and degrades at room temperature, and may be undetectable within 2 hours after collection of a stool specimen. False-negative results occur when specimens are not promptly tested or kept refrigerated until testing can be done.

Leadership Plan

Practice Plan

Establish  and  consistently  implement  Clostridium  difficile  infection  (CDI)  prevention  guidelines  that  focus  on  the education  of  healthcare  providers,  patients,  and  families,  surveillance,  hand  hygiene,  contact  and  isolation precautions,  and  establishment  of  an  antimicrobial  stewardship  program \cite{00016},\cite{00017}. An  example  of  an  evidence-based approach  is  the  Association  for  Professionals  in  Infection  Control  and  Epidemiology  Guide  to  Preventing Clostridium difficile Infections. This Guide can be accessed online \cite{00018}.
We have also listed key elements of CDI prevention below:

Technology Plan

Suggested practices and technologies are limited to those proven to show benefit or are the only known technologies with  a  particular  capability.  As  other  options  may  exist,  please  send  information  on  any  additional  technologies, along with appropriate evidence, to info@patientsafetymovement.org

Metrics

Topic:

Healthcare-associated Clostridium Difficile Infection Rate (CDiff)
Rate of patients with a healthcare associated CDI per 1,000 patient days

Outcome Measure Formula:

Numerator: Number of healthcare associated CDI based on CDC NHSN definitions \cite{00020}
Denominator: Total number of patient days based on CDC NHSN definitions
*Rate is typically displayed as Infections/1000 Patient Days

Metric Recommendations:

Direct Impact:
All hospitalized patients