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

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

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

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

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

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

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

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

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

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

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

12. Antibiotic Stewardship
 Reduce overuse and inappropriate selection of
antibiotics
 Shorter duration of treatment
Cohen S et al. Infect Control Hosp Epidemiology, 2010; 31(5), 431-
12 455.

13. Components of an Infection
Control & Prevention Plan
 An early detection system
 Interruption of person-to-person spread
 Elimination of environmental contamination
 Education, and
 Monitoring
13

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

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

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

17. Interruption of Horizontal
Transmission
 Implement soap and water
for hand hygiene
 Hand hygiene for patients
 Personal protective
equipment
 Use of dedicated non-
critical medical equipment
 Visitor
requirement/restrictions
17

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

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

20. Supplemental Measures for High
–Risk Units
 High loads of C. difficile spores or outbreaks of
CDI will necessitate daily cleaning with Clorox
ultra-germicidal bleach wipes containing 6.15
percent sodium hypochlorite.
 Orenstein (2011) showed daily use of these wipes
on a high-risk unit “effectively reduced the
acquisition rates of CDI by one-third and time
between cases from 8 to 80 days.”
Orenstein R et al. Infect Control Hosp Epidemiology
2011;32(11), 1137-9.
20

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

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

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

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

25. Monitoring (continued)
Track monthly compliance with infection control
measures including hand hygiene and PPE use
Track number of CDIs per 1,000 patient days
Effectiveness of environmental cleaning by
housekeeping staff
25

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

27. Quantum Leadership Theory
 Shared decision making
 Coaching
 Mentoring
 Employee empowerment
27

28. Successful and Effective Leader
 Constructs effective teams
 Shared vision
 Believes every employee is unique and important
(Ercetin and kamaci, 2008)
28

29. Communication
 Necessary for successful decision making and
implementing change
 Active listening essential
 Leader must be able to acknowledge and
respond to staff emotions
(Porter-O’Grady & Malloch, 2011)
29

30. Communication (continued)
 Important to have effective plan of early
communication to implement a change
 Everyone affected by proposed plan of change
should be involved
 Imperative to provide as much information as
possible
30

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

32. Proposed CDI Plan
 Hold in-service for all medical staff
 Educate staff regarding what C.diff is and the mode of
infection transmission
 Explain importance of rapid identification to place patient
in isolation
 Precautions explained on the use of personal protective
equipment (PPE)
 Staff to be taught proper procedure to put on and remove PPE
 Staff to be taught how to dispose of PPE appropriately
32

33. Implementation of Contact
Precautions Protocols
 Staff expected to demonstrate proper way to put
on and remove PPE
 Point person assigned to units to assure PPE
readily available
 Point person to ensure staff compliance
 Point person will keep surveillance forms and
send to infection control committee
33

34. Hand Hygiene Education
 Critical element of plan
 Essential to eliminating CDI
outbreaks
 Only acceptable method is
soap and water
 Quizzes given to staff to
ensure understanding
34

35. Implementation of Hand Hygiene
Protocols
 Hands to be washed for at least 15 seconds before
and after entering a patient’s room
 Point person assigned to perform hand washing
checks
 Monitor use of soap and water
 Use skill validation check list
 Use check list as a tool to counsel staff as needed
 Staff encouraged to ask each other about hand
washing
35

36. Environmental Cleaning
 Transmission of contaminated patient surfaces and
medical equipment is significant if not cleaned
properly
 Important to educate housekeeping on cleaning high touch
areas to eliminate spread of infection
 Daily cleaning of high touch areas vital
 Educate staff to use 10% chlorine bleach solution or bleach
wipes.
 Educate importance of cleaning bathrooms twice a day
 Educate importance of dedicated cleaning equipment to be
kept in patient’s bathroom
36

37. Implementation of Environmental
Cleaning Hygiene
 Environmental manager in charge of monitoring
appropriate chemicals being used
 Environmental manager will utilize Digiglo light to
evaluate proper disinfecting
 Digiglo will be used to decide if further education
is needed regarding cleaning is required
37

38. Conclusion
 Not one strategy alone can eradicate or lower CDI
 Combination of antibiotic control, good hygiene and
environmental cleaning
 Hold staff accountable with help of management and
infection control committee
 Regular education of staff is an important driving force
behind lowering CDI rates
 Have staff demonstrate competency
 Most important factor behind implementing change is
patient safety
38

39. References
 Allen, S., & Nones-Cronin, S. (2012). Improving staff compliance with
isolation precautions through use of an educational intervention and
behavioral contract. Dimensions of Critical Care Nursing, 31(5), 290-
294. Retrieved from CINAHL database.
 Bobulsky, G., Al Nassir, W., & Riggs, M. (2008). Clostridium difficile skin
contamination in patients with C. difficile-associated disease. Clinical
Infectious Diseases, 46, 447–450.
 Carboneau, C., Benge, E., Mary T. Jaco, M., & Robinson, M. (2010). A
lean six sigma team increases hand hygiene compliance and reduces
hospital-acquired MRSA infections by 51%. Journal for Healthcare
Quality, 34(4) 61-70. Retrieved from CINAHL database.
 Cohen, S., Gerding, D., Johnson, S., Kelly, C., Loo, V., McDonald, L.,
Pepin, J., & Wilcox, M.(2010). Clinical practice guidelines for C. difficile
infection in adults: 2010 update by the Society for Healthcare
Epidemiology of America and the Infectious Diseases Society of
America. Infection Control and Hospital Epidemiology, 31(5), 431-455.
Retrieved from CINAHL database.
39

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

41. References (continued)
 Hacek, D., Ogle, A., Fisher, A., Robicsek, A., Peterson, L. (2010).
Significant impact of terminal room cleaning with bleach on reducing
nosocomial Clostridium difficile. American Journal of Infection Control,
38(5), 350-3.
 Healthcare-Associated Infections (HAI) Report: Q+A. (2011). Retrieved
from
http://www.portal.state.pa.us/portal/server.pt/community/healthcare_ass
ociated_infections/14234
 Keske L. A. & Letizia, M. (2010). Clostridium difficile infection: Essential
information for nurses. MEDSURG Nursing, 19(6), pp. 329-333.
Retrieved from CINAHL EBSCO Host database.
 Murphy, C., Avery, T., Dubberke, E., & Huang, S. (2012). Frequent
hospital readmissions for Clostridium difficile infection and the impact on
estimates of hospital-associated C. difficile burden. Infection Control
and Hospital Epidemiology, 33(1), 20-28. Retrieved from CINAHL
database.
41
 Orenstein, R., Aronhalt, K., & McManus, J. (2011). A targeted strategy
to wipe out Clostridium difficile. Infection Control and Hospital

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

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