derbyshire joint area prescribing committee (japc ...€¦ · start treatment for c diff if strong...

Produced: September 2009 Reviewed: June 2019 Next Review date: May 2022

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GUIDANCE ON THE MANAGEMENT OF CLOSTRIDIUM DIFFICILE INFECTION (CDI) IN PRIMARY CARE

This guideline deals with the diagnosis, monitoring, treatment and referral of patients having suspected or diagnosed Clostridium difficile infection in the community. This is based on the Public Health England document, ‘Updated guidance on the management and treatment of Clostridium difficile infection’ (May 2013) supported by available evidence and advice/guidance from microbiologists.

DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC)


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Content SUMMARY: Management of CDI in primary care

Document updates Date updated

Introduction…………………………………………………………………………………….. Page 4 Clinical Symptoms…………………………………………………………………………….. Page 4 Diagnosis………………………………………………………………………………………. Page 4 Management & Treatment…………………………………………………………………… Page 5 Monitoring……………………………………………………………………………………… Page 5 Management in GP Practice…………………………………………………………………. Page 6 Referral…………………………………………………………………………………………. Page 7 Recurrent infection……………………………………………………………………………. Page 7 Obtaining Vancomycin……………………………………………………………………….. Page 8 Fidaxomicin……………………………………………………………………………………. Page 8 Useful Patient Information leaflets on Clostridium difficile………………………………... Page 8 Contact details for Infection Prevention and Control teams……………………………… Page 8 References…………………………………………………………………………………….. Page 8 APPENDIX 1 Derby and Derbyshire CCG North Management of C. Diff infection……. Page 9 APPENDIX 2 Medicines that can produce diarrhoea……………………………………... Page 11 APPENDIX 3 Department of Health 2 stage testing algorithm for Clostridium difficile... Page 11 APPENDIX 4 Information leaflet for patient/carer………………………………………… Page 13 APPENDIX 5 IP&C requirements for Patients with C. difficile Infection in Their Own Home/ Residential or Care Home……………………………………………………………

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SUMMARY: Management of CDI in primary care: Please see Appendix 1 for Practices previously belonging to Hardwick and North

Derbyshire CCG

Please note - unless otherwise stated, doses are for adults

Consider C.diff infection if: Diarrhoea (Bristol Stool Chart type 5 - 7) plus one or more of the following

antibiotic exposure previous C diff over 65yrs of age protein pump inhibitor use recent hospital admission

Send liquid stool for testing ASAP do not wait 7 days before sending

Start treatment for C diff if strong clinical suspicion (don’t wait for results) Take bloods for white cell count and serum creatinine - Review all medications including

PPI - antibiotics - antimotility drugs i.e. Loperamide Record baseline observations (temperature, pulse and BP)

Monitor daily (via telephone if appropriate) 1

st episode - Commence oral Metronidazole 400mg TDS, 10 -14 days

Alcohol gel is not effective against C diff spores hand washing with soap and

water is essential. Gloves and aprons should be used for contact with the patient and environmental precautions in place.

Anti-motility agents should not be used in CDI in CDI

Symptoms of mild disease: (None of: WCC >15, acute rising creatinine, temp>38.5

oC

tachycardia >100 bpm and/or colitis continue Metronidazole(even if toxin negative but symptomatic)

Symptoms of severe or life threatening disease:

WCC >15, acute rising creatinine, temp>38.5

oC,

tachycardia >100 bpm and/or colitis

Symptoms improving - Diarrhoea should resolve in 1-2 weeks

Symptoms not improving or worsening Should not normally be deemed a treatment failure until day 7 of treatment. However, if evidence of severe CDI: WCC>15, acute

rising creatinine and\or signs\symptoms of colitis consider discussion with GI / microbiologist /switch to oral vancomycin

125mg 6 hourly 10-14 days

Symptoms resolved, monitor for reoccurrence,

samples not required for clearance

Daily Assessment either by the carer/patient or with the GP (e.g. by telephone)

Symptoms not resolved, or increasing

severity consult microbiology

URGENT Surgery/GI/Micro/

ID Consultation

For further advice, contact Infection Prevention and Control: DDCCG North (Hardwick & NDCCG) – Tel. 01246 513 183 (Mon-Fri), 01246 277271 bleep 275

(weekends & bank hols). E-mail: [email protected] DDCCG South ( Erewash & SDCCG) – Tel. 0115 931 6226

E-mail: [email protected]


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Introduction The antimicrobial treatment guidelines in both primary and secondary care have been designed to reduce patient’s exposure to antibiotics (quinolones, cephalosporins, clindamycin, co-amoxiclav) most likely to cause Clostridium difficile associated diarrhoea (CDAD). Adherence to these guidelines is therefore an extremely important aspect of preventing infection. However, all antibiotics may cause CDAD and some cases will still occur. Early diagnosis and treatment prevents complications, hospital admissions and saves lives. Clinical Symptoms

Asymptomatic

Watery diarrhoea (type 5-7)

Fever

Loss of appetite

Abdominal pain/tenderness

Nausea

Stool has characteristic offensive smell /green appearance Diagnosis National guidance advises all cases of diarrhoea among people in the community aged 2 years or more should be investigated for CDI unless there are good clinical or epidemiological reasons not to1. If a patient has diarrhoea (Bristol Stool Chart types 5-7) that is not clearly attributable to an underlying condition or therapy (i.e. laxatives,) then it is necessary to determine if this is due to CDI3. A stool sample should always be collected if CDI is suspected. The possibility that the diarrhoea has an infectious cause should be considered, particularly where there is no clear alternative cause. See appendix 2 for medicines that can cause diarrhoea. Note: For patients on enteral feeding do not assume diarrhoea is due to therapy. Consider possibility of CDI as seen below. CDI should be suspected in patients with type 5-7 stools AND one or more of the following risk factors: o current or recent course of antibiotics (within last 4-12 weeks) o has a previous history of CDAD o > 65 years o has recently been a hospital inpatient (within last 3 months) o current anti-ulcer medication (e.g. omeprazole, lansoprazole & ranitidine) o nasogastric tube o immunocompromised (undergoing chemotherapy, cancer treatments, haematological diseases).

Stool samples should take the shape of the container (Bristol stool types 5-7), as soon as CDI suspected. NB: solid stools will not be tested for CDI by the laboratory

If a patient has a positive result for the CDI Toxin test and has symptoms of mild disease, they require prompt treatment with metronidazole, for 10-14 days, in primary care.

Please note that stool samples can be GDH (Clostridium difficile) antigen positive, but toxin negative. This means that the patient has no active C. difficile infection but is carrying the antigen which has the potential to develop into CDI. Clinical treatment is only indicated if the patient is symptomatic with diarrhoea. It is important to reduce exposure to risk of CDI such as usage of antibiotics, anti- ulcer medication etc. in these patients.

If the patient has diarrhoea and there is a strong clinical suspicion of CDI, treatment MUST be initiated without waiting for a positive toxin stool sample result. Further advice can be obtained from microbiology. Consider the clinical presentation.

Once the diagnosis has been made, repeat samples are not required unless specifically requested by microbiology.

Appendix 3 provides details of the Department of Health mandatory 2 stage testing procedure, and interpretation of results, for Clostridium difficile for more information.


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Management & Treatment For ALL patients on suspicion or confirmed CDI see below – please document any rationale for deviations from the advice outlined here.

Discontinue current ‘unnecessary’ antibiotics to allow normal intestinal flora to be re-established. If this is not possible, discuss alternatives with a Consultant Microbiologist.

Anti-motility drugs (e.g. codeine, loperamide) should be avoided in CDI (due to the risk of precipitating toxic megacolon – by slowing clearance of C difficile from intestine). Including those prescribed or bought over the counter.

Stoma patients who require anti-motility drugs to maintain a normal stoma output should be discussed with the gastroenterologist.

Review anti-ulcer drugs (e.g. PPIs & H2 antagonists) -stop or reduce dose if possible. Evidence indicates these are a risk factor for CDI (in particular PPIs). Consider the risk/benefit to the patient. If necessary Ranitidine may an alternative to PPI medication.

Avoid prokinetic agents (e.g. metoclopramide, domperidone) as these may increase diarrhoea.

Laxatives (e.g. lactulose, senna) are rarely indicated long term - stop in acute CDI.

Non-steroidal anti-inflammatory drugs (e.g. ibuprofen, diclofenac) should be stopped in acute CDI.

Review use of diuretics (e.g. furosemide, bendroflumethiazide, spironolactone) and ACE inhibitors/A2RAs (e.g. ramipril, lisinopril, losartan, valsartan) during acute CDI and withhold if appropriate due to acute kidney injuries. Remember to review ongoing need once infection has cleared. See AKI leaflet here.

Review the lithium dosage during CDI (as diarrhoea can increase the lithium level) - obtain advice from the consultant psychiatrist, as appropriate.

Replace fluid & electrolyte losses. Encourage eating and drinking.

Assess nutritional risk & manage appropriately. Give all patients & carers patient information about C difficile infection via https://www.nhs.uk/conditions/c-difficile/

Avoid prescribing cephalosporins, quinolones, clindamycin or co-amoxiclav / amoxicillin in future to patients who have had an episode of CDI.

Discuss alternatives with a Consultant Microbiologist, if needed.

Drug Treatment of mild-moderate CDI Where there is a strong clinical suspicion of CDI, start treatment: metronidazole 400mg three times a day for 10-14 days, as it has been shown to be as effective as oral vancomycin in mild to moderate CDI. Note. Patients with mild disease may not require specific C. difficile antibiotic treatment.2 Monitoring Regular assessment of the patient is essential to determine the severity of the infection, ensure effectiveness of treatment and early recognition of complications e.g. dehydration. Table 1: Assessment of severity of CDI

Mild CDI Not associated with a raised WCC; it is typically associated with 50% increase above baseline) or a temperature of >38.5°C, or evidence of severe colitis (abdominal or radiological signs). Note. The number of stools may be a less reliable indicator of severity. A low serum albumin can be useful to detect profound protein loss / malnutrition in recurrent CDI or prolonged symptoms.

Life-threatening CDI

Includes hypotension, partial or complete ileus or toxic megacolon, or CT evidence of severe disease.

Note. A conservative WCC threshold of 15 109/L has been chosen (to indicate severe CDI), as higher cut-off values may miss severe cases and relative immune paresis is common in the frail elderly who are most at risk of severe CDI. Elevated blood lactate >5 mmol/L is associated with extremely poor prognosis, even with colectomy.2

http://www.derbyshiremedicinesmanagement.nhs.uk/clinical-guidelines/chapter_6/https://www.nhs.uk/conditions/c-difficile/


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Management in GP Practice – developed from national guidance On presentation / diagnosis (Day 1): Face to face assessment by clinician (ideally in patients home to minimise cross infection)

determine severity of symptoms

ensure carers/relatives/patient are able to cope at home with symptoms

identify risk factors for complications/dehydration C. difficile infection is usually spread on the hands of healthcare staff and other people who come into contact with infected patients or with environmental surfaces (e.g. floors, bedpans, toilets) contaminated with the bacteria or its spores. Spores are produced when C. difficile bacteria encounter unfavourable conditions, such as being outside the body. They are very hardy and can survive on clothes and environmental surfaces for long periods (HPA).

Record baseline observations i.e. temperature, pulse and blood pressure,

Arrange Blood test for white cell count & serum creatinine.

Provide Patient information and infection prevention and control advice.

Severe disease and the potential need for hospital admission are indicated if any of the following parameters are met: (See Table 1 on page 5) o >38.5oC; o Evidence of severe colitis (abdominal or

radiological signs); o BP 100bpm o WCC >15 109/L; o SCr >50% increase above baseline

Provide Appendix 4 – This leaflet (for patients and carers) includes: The Bristol Stool Chart for monitoring type of bowel movements; information on hand washing, hygiene, cleaning; and patient information about C difficile and when to contact the GP / doctor. Provide Appendix 5 - IP&C information for Patients with C. difficile Infection in their own home / care home Appendix 4 & 5 adapted for use from Derbyshire Community Health Services NHS Trust, IPC team.

Discuss ongoing monitoring with patient/carers to include keeping a daily diary recording frequency / type of bowel movements, deterioration in the patient’s condition or decrease in fluid intake. This monitoring could be completed by the carer/patient or by telephone with the GP.

Signs of deterioration include: fever; abdominal distension or tenderness/pain; and increased diarrhoea. These should be reported to the GP as a formal medical review is needed. Please note that diarrhoea can reduce in severe CDI. Deterioration may be more likely in the frail elderly, in whom there should be a low threshold for formal review.

Refer Where a patient shows signs of deterioration, or worsening disease is suspected, patients must be referred to hospital.

Advise symptomatic patients to remain off work and minimise contact with others until the diarrhoea symptoms have ceased due to the risk of cross infection.

Between days 4 and 6 of treatment An assessment of response to treatment should be made:

Clinician to assess patient either by telephone or in person to ensure symptoms are resolving and patient is coping with the infection at home.

If the symptoms are not reduced, the patient management should be discussed with the microbiologist

Monitoring should continue as above until treatment course completed

3 days after completion of treatment (or as soon afterwards as possible):

A final assessment to be done by clinician to assess patient (either by telephone or face to face - as clinically appropriate) to ensure patient symptoms fully resolved and no other issues present

Discuss with patient/carer actions to be taken should symptoms return Note: Further assessments may be needed, if clinically indicated by the patient's condition


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Referral Urgent admission is required when:

A patient show signs of severe or life-threatening disease

A patient show signs of deterioration or worsening disease is suspected. Tel. microbiologist for advice when: [01332 340131 or 01246 277271 ask for microbiologist on-call]

A current (pre-disposing) antibiotic cannot be stopped.

Oral route of administration is not possible / usual

Symptoms are unresolved despite a 14 day course of treatment

Second (subsequent) episode of infection occurs

Antibiotic treatment is required for a patient with previous CDI [Broad spectrum antibiotics should be avoided in patients who have had a previous episode of CDI - see details above].

Symptoms are not resolving & strong clinical suspicion of CDI remains despite negative stool sample (discuss further testing with microbiologist).

Contact gastroenterologist for advice when: [via consultant connect/ email; or 01332 340131 or 01246 277271 ask for gastroenterology]

Symptoms are not resolving and advised by microbiology to involve gastroenterology

Stoma patients require management

Diarrhoea persists despite 20 days of treatment, the patient is stable and frequency of stools (type 6-7) has decreased.

Note. If WCC is normal and there is no abdominal pain or distension, the persistent diarrhoea may be due to post-infective irritable bowel syndrome.

Re-starting anti-motility agents. These should NEVER be initiated by a GP. For any advice on infection prevention & control, see contact details on p3 summary. Recurrent infection Recurrence occurs in about 20% of patients, treated initially with either metronidazole or vancomycin. It is more common in elderly patients, with risk of further recurrence of nearly 50%. Any patients who recover and then relapse within 28 days should be treated as Clostridium difficile positive and the control measures re-introduced. Further samples should not be sent unless more than 28 days have passed. Treatment must be started promptly on clinical symptoms – do not lose time waiting for results. Note. A variable proportion of recurrences are reinfections due to a new strain (20-50%) as opposed to relapses due to the same strain; relapses tend to occur in the first two weeks after treatment cessation. After a first recurrence, the risk of another infection increases to 45–60%.2

Treatment of mild, recurrent infections may be done in the community; patients with signs of moderate-severe disease should be referred for admission. If symptoms return after initial treatment (i.e. first recurrence), oral vancomycin (125mg 6 hourly for 10-14 days) is the recommended treatment2 The same management and monitoring should be performed (including reviewing and discontinuing any precipitating antibiotic, antimotility drugs, and anti-ulcer drugs where possible, etc.)

For second and subsequent recurrences, contact microbiologist for advice on appropriate antibiotic treatment. The same management and monitoring should be performed as outlined above.

Note. If a relapse of CDI occurs more than 28 days after the date of the specimen collection (for the first toxin positive result), then it is classed as a new case of infection. An episode of CDI is 28 days, with day 1 being the date of specimen collection.


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Obtaining Vancomycin If a patient has a prescription for vancomycin that pharmacy cannot obtain in a timely manner, patients could have their prescription dispensed at the pharmacy at local hospitals. UHDB: https://www.uhdb.nhs.uk/service-pharmacy Emergency situations only. There is a hospital pharmacist on duty 24 hours per day for 7 days per week, so this can be dealt with at any time. At weekends and evenings, please ask switchboard to bleep the on-call pharmacist. Chesterfield Royal Hospital: GP prescriptions (FP10) for vancomycin can be dispensed at the Pharmacy, Chesterfield Royal Hospital which is open on: Mon-Fri 8.30am-6pm; Sat 9am-1.30pm; Sun 10am-12 noon. This Pharmacy can also prepare an oral solution from Vancomycin injection (see Vancomycin injection Summary of Product Characteristics) if a patient is unable to swallow capsules. Fidaxomicin Fidaxomicin at dose 200mg twice daily for 10 days is the reserved treatment option on consultant microbiologist advice only (NICE/PHE Summary of antimicrobial prescribing guidance 2019). It is only used in severe CDI who have not responded to vancomycin or in patients with multiple comorbidities who are receiving concomitant antibiotics or for recurrence of CDI. Stock is not usually kept at community pharmacies although it may be obtained from wholesalers. To avoid delay in obtaining fidaxomicin follow same advice for obtaining vancomycin above. Useful Patient Information leaflets on Clostridium difficile:

Further information about Clostridium difficile is available at https://www.nhs.uk/conditions/c-difficile/

There is also a leaflet on p15 of this guidance: 'Information on Clostridium difficile Infection' Contact details for further advice from Infection Prevention and Control teams:

Derby and Derbyshire CCG Practices in the North (previously Hardwick & NDCCG)

Tel. IPC (at CRH) on 01246 513 183 (Monday-Friday).

01246 277271 bleep 275 (weekends & bank holidays).


Derby and Derbyshire CCG Practices in the South (previously Erewash & SDCCG)

Tel. 01332 258190


References 1.Clostridium difficile : how to deal with the problem. December 2008(Department of Health / Health Protection Agency) Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/340851/Clostridium_difficile_infection_how_to_deal_with_the_problem.pdf 2. Section on Clostridium difficile Infection from Notts APC ‘Antimicrobial Prescribing Guidelines for Primary Care (by microbiologists) 2017. Available from: http://www.nottsapc.nhs.uk/media/1044/antimicrobial-guidelines.pdf 3. Clostridium difficile: updated guidance on diagnosis and reporting March 2012 (Department of Health) Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/215135/dh_133016.pdf

https://www.uhdb.nhs.uk/service-pharmacyhttps://www.nhs.uk/conditions/c-difficile/mailto:[email protected]:[email protected]://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/340851/Clostridium_difficile_infection_how_to_deal_with_the_problem.pdfhttps://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/340851/Clostridium_difficile_infection_how_to_deal_with_the_problem.pdfhttp://www.nottsapc.nhs.uk/media/1044/antimicrobial-guidelines.pdfhttps://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/215135/dh_133016.pdfhttps://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/215135/dh_133016.pdf


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APPENDIX 1 Derby and Derbyshire CCG North* MANAGEMENT OF CLOSTRIDIUM DIFFICILE INFECTION * Previously North Derbyshire and Hardwick CCGs) All results that require clinical intervention and treatment will be notified promptly (SAME WORKING DAY) to the G P practice in hours or DHU out of hours by the Infection Prevention & Control Team (IP&CT) at Chesterfield Royal Hospital (CRH). The GP or DHU will ensure that the patient is assessed and commenced on appropriate therapy.

1st line – Oral Metronidazole 400mgs TDS 10 – 14 days (Unless previously prescribed and treatment failed then use 2nd line)

2nd line – Oral Vancomycin 125mgs QDS ( 10 – 14 days )

The GP will undertake a full medication review:

Discontinue current antibiotic if clinical condition allows. If unable to discontinue discuss with a Consultant Microbiologist at Chesterfield Royal Hospital 01246 277271 bleep 512

Anti- motility drugs should be avoided (Loperamide or codeine phosphate) should be avoided. Exceptions include patients who require these drugs to maintain a normal stoma output. If patient requires codeine for analgesia switch to tramadol , but if they have greater opioid needs refer to acute pain team for advice

Avoid laxatives and prokinetic agents (metoclopramide, domperidone) as these may worsen diarrhoea

PPI’s and H2 antagonists should be reviewed and stopped or dose reduced if possible

NB- Probiotics must not be used during the acute phase of CDI or in immunocompromised patients

The following should be checked in all patients to monitor response to treatment

Monitoring checklist How these should be monitored

By whom Indicator of severe disease

Number. and type of stools

Bristol stool Chart

Issued to patient and monitored by Infection Control Team CRH

Number of stools may be a less reliable indicator of severity

FBC for Hb and WBC Initially and then as clinically indicated

Initial Bloods taken by GP practice ,results reviewed by GP / Practice Nurse

If further tests required escalated by infection control team CRH

Hb < 10g/dL WBC > 15 x 109/L

Serum albumin Initially then as necessary

Initial Bloods taken by GP practice ,results reviewed by GP Practice

If further tests required escalated by infection control team CRH

50% above baseline

Serum lactate Consider if suspect very severe case

> 2.2 and rising


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Heart rate / Blood pressure

On 1st visit then as clinically

indicated by GP Practice

Bp 100 bpm

Temperature Checked by GP practice on 1

st visit

Advise patient on 1st visit if

Temperature requires monitoring

Will be monitored and escalated by

Infection Control Team CRH if clinically indicated

>38.5oC

Signs/symptoms of abdominal distension

Assess on initial review advise patient to seek urgent advice if symptoms present ( abdo xray if present)


Infection Control Team CRH if required

Yes, & see criteria for urgent surgical above

CRP Twice weekly if severe Bloods done by GP practice

>45

Urine output Advise patient to monitor and contact practice t for advice if urine output reduces

Encourage to eat and drink


Infection Control Team CRH if required


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APPENDIX 2 Medicines that can produce diarrhoea1

Diarrhoea is a common adverse drug reaction (ADR) with many medicines. Antimicrobials account for about 25% of drug-induced diarrhoea though most cases are benign.

While diarrhoea has been seen with most medicines, the ones most commonly implicated are: • acarbose; • leflunomide; • antimicrobials; • magnesium preparations, eg antacids; • biguanides; • metoclopramide; • colchicine; • misoprostol; • cytotoxics; • NSAIDS, e.g. aspirin, ibuprofen; • dipyridamole; • olsalazine; • gold preparations; • orlistat; • iron preparations; • proton pump inhibitors; and • laxatives; • ticlopidine. Alternative diagnoses for the diarrhoea are important; therefore, careful attention should be paid to the temporal relationship between the time that the medicine is first taken and when the diarrhoea first appears.

APPENDIX 3 Department of Health Mandatory 2 stage testing for Clostridium difficile Link to Department of Health information: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132927

This method aims to provide more effective and consistent diagnosis across the NHS. The 2 stages include: Stage 1 – A test to detect the presence of C. difficile Stage 2 – a more specific test for detecting toxin A&B produced by C. difficile infection. Test information (see algorithm below for results explanation) C. difficile is an opportunistic anaerobic bacteria present in the intestines. It can produce toxins which results in infection. Some strains do not produce toxins but the bacteria being present can mean that the patient has the potential to excrete it and have an increased risk of developing the infection. This method will differentiate between patients who have active CDI and those that could be at risk of becoming infected (excretors). GDH: Glutamate dehydrogenase (GDH) is an enzyme produced in large amounts by both toxin and non-toxin producing C. difficile. Toxin A&B: C. difficile can produce 2 toxins A and B. They are responsible for causing infection. CDI: C. difficile infection Test ordering All electronic requestors will now see the test on ICM as: Faeces (C. difficile screen only) The test previously used: Faeces (Clost diff toxin only) will no longer be available Laboratory testing times Please ensure the sample arrives in the laboratory (Chesterfield or Derby):

9:30am or 12:30pm Monday – Friday

9am on Saturday and Sunday. If the sample arrives after this time it will be tested the next day. Note. Chesterfield Royal Hospital advise that if the test is needed to be done quickly, it may be possible to organise it with the laboratory and have the sample arrive by 2pm. It is recommended to keep faecal samples cool (4C).

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132927


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Algorithm - two stage C difficile testing & interpreting results on ICM:

C. difficile GDH antigen test:

Not detected DETECTED

C. difficile Toxin A&B test

‘Clostridium difficile infection unlikely to be

present’

Not detected DETECTED

‘Clostridium difficile infection is likely to be present’ PPV= 91.4%

‘Potential Clostridium difficile excretor’

Stage 1: All samples

tested for GDH

Stage 2: All GDH positive samples will be tested for toxin A&B

This is NOT a C. difficile infection i.e. the patient is negative for infection but has the potential to become positive.

However, if the patient has diarrhoea & there is a strong clinical suspicion of CDI, treatment MUST be initiated without waiting for a further stool sample result. Further advice can be obtained from microbiology. The clinical condition of the patient should always be considered.

This is confirmation of C. difficile infection –

treatment is needed

C. difficile is very

unlikely to be present


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APPENDIX 4 Information leaflet for patient/ carer

How To Recognise Clostridium difficile Infection. Once normal stools have ressumed the infection has resolved, however medication prescribed for treatment of the infection must be completed. Some people may relapse up to a week after treatment and start with diarrhoea again. If this happens contact the doctor and discuss the need for more treatment. Keeping a diary of bowel movement will help the doctor to decide what treatment is needed.


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Infection Prevention and Control Hand washing

Household members, visitors and community staff should wash their hands in soap and water after contact with the affected individual, their bedding, clothing or equipment

Household members should be encouraged to wash their hands before and after preparing or serving food

The importance of hand hygiene should be discussed with the patient, especially after using the toilet and before meals

Please note that alcohol hand rubs are not effective against this infection General Practice

Supplies of gloves, aprons, incontinence pads, clinical waste bags etc will be needed. These will be arranged either by the carers or via the district nurse team

Where possible a flush toilet should be used by the affected individual

Disposable gloves should be worn by carers when handling urinals, bedpans, commodes, soiled linen or clothes or incontinence pads

Soiled clothing/bed linen can be washed in a domestic machine on a ‘hot’ cycle

If items are heavily soiled the faecal matter should be flushed away in running water, preferably into the toilet bowl

Further soaking in disinfectant is not required

Incontinence pads and gloves contaminated with faeces should be disposed of as clinical waste i.e. in a yellow bag

Cleaning

Where possible a disposable cloths should be used

Household detergent and water should be used to remove faecal matter, followed by a bleach based household cleaner if possible

Flush handles, wash hand basin taps and toilet door handles should be cleaned daily or when contaminated with faeces

Toilet seats should be wiped after use

The toilet should be cleaned after use with a sanitising solution e.g. bleach based household cleaner

Bedpans, commodes and urinals should be emptied into the toilet bowl and washed with disinfectant or bleach solution

These infection control precautions can be stopped once the diarrhoea has stopped and the individual has completed their treatment. If diarrhoea starts again these precautions must be restarted.


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What is Clostridium difficile? It is a bacterium found in the large bowel that produces toxins which can irritate the lining of the bowel. What does it cause? The toxins can cause explosive and watery diarrhoea. Some people also experience nausea, stomach ache, fever and loss of appetite. Who is at risk of this infection? The people who are most at risk of getting clostridium difficile infections are the elderly who have recently been on antibiotics and have some other underlying illness or condition. Other people who may be at risk are those who have repeated hospital admissions, those whose immune system is affected by illness and/or treatment and those who have had recent surgery. How do I get it? 3% of the population have Clostridium difficile in their bowel. When these individuals are given certain antibiotics the normal bacteria in the gut are reduced and Clostridium difficile is able to reproduce more easily, producing more toxins. Sometimes the bacteria can be picked up on your hands from surfaces that have not been cleaned properly. How do we reduce the risk of germs spreading?

You will need to take special care with hand washing. Wash hands in soap and water after using the toilet or bedpan and before eating

It is also important that all carers and visitors wash their hands with soap and water when they visit or provide care for you.

Carers should wear aprons and gloves when they come in to care for you or when they clean the toilet or bathroom areas.

What else can be done to help? You need to ensure that you drink plenty of water to prevent dehydration from the diarrhoea. Ideally at least one drink after every episode of diarrhoea If you keep a diary of your bowel movements this will help carers and the doctor assess what treatment you need and when to stop your medication Your carers and the district nursing team will help you cope with the diarrhoea and ensure that the environment is kept clean. If you have any concerns please talk to your doctor or district nursing team When should I contact my GP? If your symptoms have not improved after 5 days of treatment, or you have stomach pain/swelling or high temperature (fever), or if you have any other concerns, contact your GP or doctor promptly.

Can I give Clostridium difficile to my family and friends? Healthy people who are not taking antibiotics are at very low risk of getting this germ. Their best protection against even a small risk is to wash their hands after visiting you and follow the precautions as outlined above.

Information on Clostridium difficile Infection


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APPENDIX 5 IP&C requirements for Patients with C. difficile Infection in Their Own Home/Residential or Care Home

Monitoring Treatment Hand Decontamination Standard Precautions Cleaning

GP teams will need to support the family/carers

Ask patient or family to keep diary of bowel frequency and type of stool

Observe for signs of dehydration - encourage good oral intake

Monitor for signs of complications e.g. passing blood, abdominal distension, hypotension, fever, tachycardia

Blood tests will be needed for WCC & Serum Creatinine

Hospital admission should be considered if diarrhoea worsens, there are signs of colitis or dehydration or the family are not coping at home

NB 25-40% of patients relapse, ongoing monitoring may be needed

Send stool sample to confirm diagnosis – no further stool specimens required

State any recent antibiotic history, frequency of diarrhoea, stool type e.g. Type 7, date of onset of diarrhoea

Avoid antimotility drugs or other medication causing constipation

Review current antibiotics and stop if possible

Review use of proton pump inhibitors and use alternative

Consider IV fluids if patient dehydrated. Sub-cutaneous fluids not recommended for moderate to severe dehydration

Follow treatment flow chart

Probiotics should not be used in the acute phase or in immunocompromised patients

NB If a patient is asymptomatic i.e. does not have diarrhoea but has a positive C. difficile sample - contact microbiology for advice re treatment and continue to monitor bowel pattern

Alcohol hand rubs / hand sanitisers are not effective against C. difficile

Discuss good hand hygiene and personal hygiene with the individual affected especially after using the toilet and before meals

Household members, visitors and community staff should wash their hands with soap and water after contact with patients, their bedding, clothing or equipment

Household members should wash their hands before and after preparing or serving food

Gloves, aprons, incontinence pads, clinical waste bags etc. to be supplied by District Nurse team

Disposable gloves should be worn by carers when handling urinals, bedpans, commodes, soiled linen or clothes or incontinence pads

Soiled clothing/bed linen can be washed in a domestic machine on a ‘hot’ cycle

If possible a flush toilet should be used by the affected individual

Disposable items contaminated with faeces to be disposed of as clinical/infectious waste

NB Individuals in care/residential homes will need their own room and toilet facilities, whilst symptomatic with diarrhoea

Where possible a disposable cloth should be used for cleaning

General cleaning to be done with household detergent and water followed by a chlorine based solutions e.g. bleach, Milton

The toilet should be cleaned after each use, as above

Flush handles, wash hand basin taps and toilet door handles should be cleaned, as above, daily or when contaminated with faeces

Bedpans, commodes and urinals should be emptied into the toilet bowl and cleaned as above

derbyshire joint area prescribing committee (japc ...€¦ · start treatment for c diff if strong...

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