Clostridium Difficile Infection
Infection Prevention and Control Guidance for Management in Acute Care Settings
Public Health Agency of Canada has developed this document to provide
infection prevention and control guidance to healthcare organizations and healthcare
for the management of patients with Clostridium difficile (C. difficile) infection
in acute care settings. The content of this guidance document
has been informed by technical advice provided by members of the Public Health Agency of Canada’s Steering
Committee on Infection Prevention and Control Guidelines.
This guidance is
meant to be used in conjunction with relevant provincial/territorial and local legislation,
regulations, and organizational policies. The recommendations are based on
current, scientific evidence and best practices, and are subject to review and
change as new information becomes available.
Clostridium difficile (C. difficile) is a
Gram positive, spore-forming, anaerobic bacillus that causes infectious
diarrhea by producing two toxins - toxin A (an enterotoxin) and toxin B (a
cytotoxin). C. difficile is the most frequent cause of
healthcare-associated infectious diarrhea in Canada and other developed
The reported incidence of
healthcare-associated C. difficile infection in Canada has risen over the last decade and is
associated with increased morbidity and mortality. C. difficile infection can have a
variety of manifestations from uncomplicated diarrhea to life-threatening
pseudomembranous colitis, bowel perforation and sepsis. There has been an almost four-fold increase in the C. difficile infection attributable mortality
rate in Canadian hospitals from 1997 to 2005 (1.5% of cases to 5.7%,
respectively, p<.001). There are multiple reasons behind the
increase in C. difficile infection and C. difficile infection-related mortality rates in Canada but an important
contributor has been the spread of a more virulent strain, often referred to as
North American pulsed field (NAP) type 1.
The primary mode of transmission
for C. difficile within healthcare facilities is by person-to-person
spread through the fecal-oral route. The hands of healthcare workers
transiently contaminated with C. difficile spores, along with environmental
contamination play an important role in the transmission of C. difficile in healthcare settings.- Compared to other healthcare-associated
bacterial pathogens, environmental contamination around a C. difficile infection patient is
thought to be a relatively more significant factor in cross-transmission to
others. This is because C. difficile, being a spore-forming
microorganism, persists in the environment longer and resists routine
disinfection processes more than non-spore forming bacteria.
The degree to which C. difficile infection is endemic
within a healthcare facility is variable. Those responsible for infection
prevention and control within a facility should be aware of C. difficile infection epidemiology within
their organization and gauge their response accordingly. Consistent
and correct application of infection prevention and control measures has proven
effective in reducing the incidence of healthcare-associated C. difficile infection.,
As C. difficile infection is strongly associated with previous
antibiotic use, antimicrobial stewardship is believed to have a role in preventing
and terminating C. difficile infection outbreaks., While this guidance document is
focused on infection prevention and control measures to prevent C. difficile infection in acute
care settings, it should be acknowledged that the prevention of C. difficile infection also
requires appropriate use of antimicrobial therapy (i.e., antimicrobial stewardship).
Infection control professionals should advocate for both effective infection prevention
and control and antimicrobial stewardship programs as important strategies to
prevent C. difficile infection within their organizations.
Recommended Infections Prevention and Control Measures
following guidance is based primarily on recommendations in the Public Health Agency of Canada’s Routine Practices and Additional Precautions for Preventing
the Transmission of Infection in Health Care Settings guideline, except where indicated.
In addition to routine practices, patients suspected
or confirmed to have C. difficile infection in acute care settings should be placed on Contact Precautions.
risk assessment approach (Appendix A) should be used to guide decisions
regarding when to apply contact precautions.
The following topics are addressed in more detail in this
- Organizational Controls
- Engineering Measures
- Administrative Measures
- Laboratory Testing/Reporting
- Contact Precautions
- Personnel Restrictions
- Hand Hygiene
- Patient Placement and Accommodation
- Patient Flow/Activities
- Personal Protective Equipment
- Management of Fecal Matter
- Cleaning and Disinfection of Non-critical
Patient Care Equipment
- Environmental Cleaning
- Handling Linen, Dishes, Cutlery
- Duration of Precautions
- Handling Deceased Bodies
- Education of Healthcare Workers, Patients,
- Visitor Management
- Discharge Planning
- Outbreak Management
A major role of all healthcare
organizations is to minimize the risk of exposure to and transmission of
infections within healthcare settings. This can be achieved by having policies,
procedures and programs specifically for the prevention of C. difficile infection based on the
following engineering and administrative measures.
a) Engineering Measures
- Facility design should include
single rooms for the routine care of inpatients (with in-room private toilets,
designated patient sinks, alcohol-based hand rub dispensers and
designated staff hand washing sinks).
- Facility design should include
surfaces that are constructed of materials that can be easily and effectively cleaned
at the point of use.
- Appropriate number of bedpans and
commodes should be available.
- To avoid contamination of the
environment with C. difficile spores, systems should be in place to
manage the disposal of fecal matter when bedpans or commodes are required. Some
options for consideration are:
- Installation of
bedpan washers/disinfector systems on patient units;
- Utilization of disposable
bedpans for patients with acute diarrhea and the installation of macerator
systems for the disposable bedpans.
- Appropriate supply of and accessibility to personal protective equipment should be available.
- Appropriate number of accessible
no-touch waste receptacles for disposal of paper towels, tissues, gloves, etc.
should be available.
- Appropriately functioning, accessible dispensers for
hand hygiene products (soap, lotion, paper towels and alcohol-based hand rub) should be
- Appropriate number of designated staff hand washing
sinks should be available.
- Appropriate number of point-of-care
alcohol-based hand rub dispensers should be installed.
- If laundry chutes are used, they should
be properly designed, maintained and used in a manner to minimize dispersion of
aerosols from contaminated laundry.
b) Administrative Measures
- Policies and procedures should be
developed and implemented for the prevention and control of C. difficile infection, including the
application of contact precautions, and outbreak recognition, reporting and
expert human capital (e.g., hospital epidemiologist, infection control
professionals) and financial allocation to ensure an effective infection prevention and control program
appropriate to the organization’s mandate should be provided.
control professionals or delegates should be actively involved in the selection
of new patient care equipment and devices that require cleaning, disinfection
- Policies and procedures should be
developed and implemented for environmental cleaning to ensure sufficient
staffing, routine scheduled environmental cleaning, procedures for assigning
responsibility and accountability for cleaning as indicated by the level of
patient contact and degree of soiling, and include event-related cleaning of
environmental surfaces and increased cleaning as per additional precautions.
- Education and training programs
should be developed and implemented for those responsible for environmental
cleaning. Evaluation of policies, procedures and practices, including audits,
should be performed to determine effectiveness of environmental cleaning and
- Policies and procedures, including
assigning responsibility, should be developed and implemented for cleaning and
disinfection of all non-critical patient care items (e.g., mobile devices,
multi-use electronics, intravenous poles, toys and electronic games, etc.) that
are and are not moved in and out of patient care areas.
- A facility-wide, adequately resourced antimicrobial stewardship
program should be established.
- Monitoring, auditing and reporting of hand hygiene
compliance and environmental cleaning procedures should be established.
- A surveillance
system should be established that includes systematic collection, analysis,
interpretation and dissemination of C. difficile infection rates by unit in the facility (refer to
item 4, Surveillance).
2. Triage - Emergency Departments and Acute
Patients with an acute diarrheal
illness should be placed into a single examining room with a dedicated toilet
or commode whenever possible and as soon as possible.
- Patients with diarrhea or other
symptoms (e.g., nausea ± vomiting, fever, abdominal
pain/tenderness) suspected to be C. difficile infection should be assessed in a timely manner. A
stool specimen should be taken for laboratory testing for C. difficile (refer
to item 5, Laboratory Testing/Reporting), and the patient placed on contact precautions
(refer to item 6, Contact Precautions).
- Clinical assessment of symptomatic patients
and, where necessary, initiation of antimicrobial therapy according to clinical
practice guidelines, should occur promptly.
- Asymptomatic patients should not be
tested for C. difficile.
- Routine environmental testing for C.
difficile is not useful and should not be done.
- Testing of asymptomatic
staff is not advisable. Symptomatic staff should be referred to the
organization’s occupational health and safety personnel or their personal
physician for evaluation.
- A system should
be established for the early reporting of symptomatic patients to the
organization’s infection control professional or delegate.
- A system should
be established for early notification of all patients testing positive for C.
difficile to the infection control professional or delegate.
surveillance using accepted C. difficile infection case definitions and denominators should be established to determine the organization’s baseline rate and to
monitor changes in the C. difficile infection rate. By adopting a recognized provincial or national case
definition (i.e., the Canadian Nosocomial Infection Surveillance Program, Case Definitions for Communicable
Diseases under National Surveillance, Case Definition and Minimum Data Set for the Surveillance of Clostridium
difficile Infection in Acute Care Hospitals across Canada) organizations will be able to
benchmark their C. difficile infection and C. difficile infection-related mortality rate against other Canadian
5. Laboratory Testing/Reporting
- A variety of tests
are available to identify C. difficile or its toxins in the stools of
patients with diarrhea. These tests vary significantly in sensitivity.
Infection control professionals should review local testing methods and
algorithms with their clinical or medical microbiologist. If increased C. difficile infection
rates are observed, it is important to ensure that they are not an artifact of
increased case detection resulting from adoption of new test methods or
- A protocol and provisions for
testing for C. difficile infection should be established.
- Stool specimen collection for the testing
of C. difficile or its toxins should be done as soon as possible after
onset of diarrhea.
- A process should be established for
prompt notification of all positive tests to the attending physician and
infection control professional or delegate, as well as regional,
provincial/territorial public health authorities as required.
- When test methods of lower
sensitivity are performed (e.g., enzyme-linked immunoassays) a single negative
test for patients with acute diarrhea should not be relied on to rule out C.
difficile. If the first test is negative, a second test may
- Testing for C. difficile or
its toxins should only be performed on unformed, diarrheal stool (i.e. loose,
- Repeat testing during the same
episode of diarrhea or follow-up for “test of cure” should not be done.
- Testing of infants under one year
of age should not be done as they are not susceptible to C. difficile infection.,
6. Contact Precautions
- Contact precautions should be
implemented empirically, at onset of diarrhea, for patients with acute
diarrhea, suspected or confirmed to be C. difficile infection, and not otherwise explained.
- Patients suspected or confirmed to
have C. difficile infection should be placed on contact precautions, preferably in a single room,
until the diarrhea is resolved or its cause is determined not to be infectious
(refer to item 9, Patient Placement and Accommodation).
- If availability of single rooms is
limited, preference for single rooms should be given to patients with uncontrolled
- Cohorting of multiple laboratory
confirmed patients is acceptable.
- Signage should be placed at the
entrance to the patient’s room, cubicle, designated bedspace or other visible
location to identify contact precautions.
- Refer to items
below for further details relating to contact precautions.
- Healthcare workers should
stay away from work when infectious with a communicable disease, including, but
not limited to, gastroenteritis with vomiting and/or diarrhea.
immediate supervisor/occupational health personnel should be informed if the healthcare worker
worked when symptomatic/infectious.
- Hand hygiene should be performed frequently
using effective techniques (as recommended in the Public Health Agency of Canada Hand Hygiene
Practices in Health Care Settings guideline) and include:
- After patient care;
- After contact with the patient’s
- After removing gloves at point-of-care
and just prior to leaving the patient’s room, cubicle or designated bedspace;
- After handling fecal matter; and
- After handling bedpans and commodes.
- Soap and water in preference to ABHR
should be used in settings with C. difficile infection transmission and during C. difficile infection outbreaks, for
the physical and mechanical removal of spores (refer to item 21, Outbreak
- Hand hygiene with 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 (with an alcohol concentration between 60% and 90%) should be used and
hand hygiene with soap and water should be performed as soon as a staff hand
washing sink is available.
- Hand wipes (impregnated with plain
soap, antimicrobials, or alcohol) may be used as an alternative to soap and
water when a designated staff hand washing sink is not immediately available,
or when the hand washing sink is unsuitable (e.g., contaminated sink, no
running water, no soap), for the following conditions:
- When hands are not visibly soiled; and
- When hands are visibly soiled. Alcohol-based hand rub should be used after the use of hand wipes, and hands should be washed with soap and water once a suitable staff hand washing sink is available.
Placement and Accommodation
- Patients suspected or
confirmed to have C. difficile infection should be placed into a single room with a private toilet
(or designated commode if there is no toilet in the room) and a designated
- The room door may
- When single patient
rooms are limited, a point-of-care risk assessment (Appendix A) should be
performed to determine patient placement and/or suitability for cohorting.
- Only patients with laboratory-confirmed
C. difficile infection should be cohorted, however, each patient should have a designated toilet
or commode assigned. In a shared room, a patient with diarrhea should not
share a toilet with another patient. A dedicated toilet or commode should be
assigned to each individual patient with diarrhea. Roommates should be
selected on their ability and their visitors’ ability to comply with the
- The infection control professional
or delegate should be consulted when cohorting is considered.
- If cohorting of
patients with confirmed diagnosis of C. difficile infection is not possible 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.
- Infection control signage should be
placed at the entrance to the patient’s room, cubicle or designated bedspace indicating
contact precautions are required upon entry.
- The chart/record of the patient
suspected or confirmed to have C. difficile infection should not be taken into the patient’s room,
cubicle or designated bedspace.
10. Patient Flow/Activities
- The symptomatic patient suspected
or confirmed to have C. difficile infection should be allowed out of the room only as indicated in
the care plan, providing diarrhea can be contained and hand hygiene compliance
- The patient suspected or confirmed
to have C. difficile infection should be provided with clean clothes and should perform hand
hygiene, with supervision/assistance as necessary, before leaving the room.
- Instructions/assistance with hand
hygiene should be provided to patients suspected or confirmed to have C. difficile infection after
using the toilet facilities and prior to leaving their room.
- If diarrhea cannot be contained
and/or if hand hygiene compliance is inadequate, patients suspected or
confirmed to have C. difficile infection should be restricted to their room until:
- Diarrhea has
- Diarrhea can
be contained; or
- Hand hygiene
compliance is adequate.
- Transfer of patients suspected or
confirmed to have C. difficile infection within and between facilities should be avoided unless
medically indicated (e.g., for essential diagnostic and therapeutic tests/treatment).
If a medically indicated transfer is necessary:
transferring service, receiving unit, or facility should be advised of the
necessary precautions for the patient being transported;
- A request to
have the patient promptly seen to minimize time in waiting areas should be
- 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;
- The transport
personnel should remove and dispose of their personal protective equipment (refer to item 11, Personal
Protective Equipment) and perform hand hygiene prior to transporting patients;
- The transport
personnel should put on clean personal protective equipment, if necessary (refer to item 11, Personal
Protective Equipment), to handle the patient during transport and at the
11. Personal Protective Equipment
Personal protective equipment
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 C. difficile infection. Healthcare workers, families and visitors should use the
following personal protective equipment for patients suspected or confirmed to have C. difficile infection:
- Gloves should be 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 should be removed and
discarded into a no-touch waste receptacle and hand hygiene (refer to item 8,
Hand Hygiene) should be performed upon exiting the patient’s room, cubicle or
- A long-sleeved gown should be 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
- 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
The same personal protective equipment should not be worn for
more than one patient. Personal protective equipment should be changed and hand hygiene should be performed
between contacts with each patient in the same room.
of Fecal Matter
- When bedpans
and commodes are required:
- Bedpans and
commodes should be handled in such a way as to avoid contamination of the
environment with C. difficile spores;
bedpans should be considered; and
- Spray wands for
cleaning bedpans and commode pans/buckets should not be used.
- Toilet bowl
brushes should be dedicated to one specific toilet and not be reused.
Disposable toilet bowl brushes should be considered.
13. Cleaning and Disinfection of
Non-critical Patient Care Equipment
- All equipment/supplies should be
identified and stored in a manner that prevents use by or for other patients.
- Reusable non-critical equipment
(blood pressure cuffs, stethoscopes, pulse oximeters, commodes, bedpans, walkers,
etc.) should be dedicated to the use of the patient suspected or confirmed to
have C. difficile infection, and should be cleaned and disinfected (with a chlorine-containing
cleaning agent (at least 1,000 parts per million [ppm]) or other sporicidal
agent before reuse with another patient.
- Electronic rectal thermometers
should not be used.
- Single-use devices should be discarded
in a no-touch waste receptacle after use.
- Toys, electronic games, personal
effects, etc. should be dedicated to the use of the patient suspected or
confirmed to have C. difficile infection, and should be cleaned and disinfected before reuse by
- All horizontal and
frequently touched surfaces in the room, cubicle or designated bedspace of the patient suspected or
confirmed to have C. difficile infection should be cleaned at least twice daily and when soiled, paying particular attention to
“high touch” areas/items (patient bathroom, bathing facilities, toilet/commode/bedpan,
light switches, light cords, bed/hand rails, bedside tables and other furniture,
wheelchair, walker, etc.).
- Measures should be taken
to limit contamination of cleaning and disinfecting solutions by changing cleaning cloths and mop
- During continued transmission of C. difficile infection, the
rooms or bedspace of patients suspected or confirmed to have C. difficile infection should be
decontaminated and cleaned with a chlorine-containing cleaning agent (at least
1,000 parts per million [ppm]) or other sporicidal agent.
cleaning measures or frequency may be warranted in outbreak situations (refer
to item 22, Outbreak Management), or when there is continued transmission of C. difficile infection.
- When the
patient suspected or confirmed to have C. difficile infection is moved to a single room at the
onset of acute diarrhea, or transferred out of the room for other reasons, or
when contact precautions are discontinued, terminal cleaning of the room, cubicle or designated bedspace and bathroom,
changing the privacy curtains, discarding the toilet bowl brush, and cleaning
and disinfecting, or changing the string/cloth call bells or light cords should
be done (refer to Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings guideline, Appendix VII, for details on
- Contact precautions
should be maintained until terminal cleaning of the room, cubicle or designated
bedspace is completed.
Linen, Dishes, Cutlery
- No special
precautions are required for linen; routine practices are sufficient and
include the following:
- Soiled linen
should be handled in the same way for all patients without regard to their
- Soiled linen
should be placed in a no-touch receptacle at the point of use;
- Soiled linen
should be handled with a minimum of agitation to avoid contamination of air,
surfaces and persons;
- Soiled linen
should be sorted and rinsed outside of patient care areas; and
- 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 using a gloved hand and
toilet tissue should be placed into a bedpan or toilet for flushing.
- No special
precautions are required for dishes or cutlery; routine practices are
16. Duration of
- Contact precautions
should be maintained until:
- C. difficile infection is ruled out, and/or diarrhea
is determined as not infectious; or
- If C. difficile infection is confirmed,
until diarrhea has resolved;
- According to provincial/territorial
guidelines or the organization’s policy.
of contact precautions should be made in conjunction with the infection control
professional or delegate.
- Routine practices, properly and consistently applied, should be used in
addition to contact precautions for handling deceased bodies, preparing them
for autopsy, or transferring them to mortuary services.
specified communicable disease regulations should be followed.
18. Education of
Healthcare Workers, Patients, Families, Visitors
- Healthcare Workers
- All healthcare workers should receive education
on C. difficile, including measures to control its spread and on their role
in identifying and acting on new onset diarrhea; and
- Education should reinforce that routine
practices, contact precautions, and safe work practices, (e.g., no eating or
drinking in patient care areas) protect healthcare workers from acquiring C. difficile infection in the
- Patients, Families, Visitors
- Patients, families, and
visitors should be educated about the precautions being used; the duration of
precautions, as well as the prevention of transmission of infection to others,
with a particular focus on hand hygiene;
- Families and visitors
who are participating in direct patient care should be instructed about the
indications for and appropriate use of personal protective equipment; and
- Families and visitors
who assist with patient care should use personal protective equipment as healthcare workers. This may not be necessary
for parents carrying out their usual care of young children.
should be instructed to speak with a nurse before entering the room, cubicle or
designated bedspace of a patient on contact precautions to evaluate the risk to
the health of the visitor and the ability of the visitor to comply with
- The number
of visitors for a patient on contact precautions should be minimized to
essential visitors (e.g., immediate family member/parent, guardian or primary
should be restricted to visiting only one patient who is on contact precautions.
If the visitor must visit more than one patient, the visitor should be
instructed to use personal protective equipment as healthcare workers and perform hand hygiene before going to the next
patient’s room, cubicle or designated bedspace.
patients with C. difficile infection or recovering from C. difficile infection for discharge, the patients should be
provided with information/education about the following:
medications they are to take at home;
- Reminders on
the importance of washing their hands with soap and water after using the
toilet, handling used linen, and before preparing and/or eating food;
- That special
handling of dishes, bed linen and waste is not necessary (whether symptomatic
or not). Solid fecal matter that can be removed using a gloved hand and toilet
tissue should be placed into a bedpan or toilet for flushing;
frequency of recurrence of C. difficile infection; and
their physician if acute diarrheal symptoms recur.
- 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 considered:
- Placing signage at
entrances to the affected unit(s) to direct families and visitors;
- Placing all patients with
acute diarrhea on contact precautions;
- Reporting the outbreak
to local public health officials as per regional, provincial/territorial
and cleaning rooms, cubicles or designated bedspaces of patients suspected or
confirmed to have C. difficile infection with a chlorine-containing cleaning agent (at least 1,000
parts per million [ppm]) or other sporicidal agent;
- Increasing the frequency of
cleaning, including bathing and toileting facilities, recreational equipment, all
horizontal surfaces in the patient’s room and, in particular, areas/items that
are frequently touched (hand and bedrails, light cords, light switches,
door handles, furniture, etc.), common areas, nursing stations, staff washrooms,
etc., on the affected
- Cohorting of
staff to patients (i.e., assigning staff to work exclusively with C. difficile infection-positive
- With associated high burden of illness, particularly
with higher than expected attributable mortality, there may be a role, in
consultation with a microbiologist and public health, to characterize the
strain type and clonality of C. difficile isolates;
- Auditing adherence to hand hygiene practices (refer
to item 10, Hand Hygiene), personal protective equipment use by staff (refer to item 11, Personal
Protective Equipment), cleaning/disinfecting shared non-critical equipment
(refer to item 13, Cleaning and Disinfection of Non-critical Patient Care
Equipment), and environmental cleaning procedures (refer to item 14,
- Reviewing the process
for disposal of fecal matter (refer to item 12, Management of Fecal Matter);
- Closing affected unit(s)
to admissions if initial control measures are ineffective in controlling the
spread of C. difficile;
- 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
provincial/territorial and/or national public health expertise in outbreak
management for ongoing outbreak situations.
- An outbreak should be declared
over when there is no further transmission and there has been a return to the
organization’s baseline C. difficile infection rate.
- Healthcare workers - Individuals who provide
health care or support services, such as nurses, physicians, dentists, nurse
practitioners, paramedics and sometimes emergency first responders, allied
health professionals, unregulated healthcare providers, clinical instructors
and students, volunteers and housekeeping staff. Healthcare workers have
varying degrees of responsibility related to the health care they provide,
depending on their level of education and their specific job/responsibilities.
- Acute care settings - A healthcare facility
where a variety of inpatient services is provided that may include
surgery and intensive care. For the purpose of this document, acute care also
includes ambulatory care settings such as hospital emergency departments, and
free-standing ambulatory (day) surgery or other day procedures (e.g.,
- A thorough evaluation on the efficacy of bed pan
disinfector systems for use on patient units should be done prior to
procurement with a continuous quality improvement process in place for
monitoring and evaluating performance.,
- An operational definition is suggested by some
experts to continue contact precautions for at least 48 hours after diarrhea
has resolved as relapse of diarrhea is common. However, there is currently no
data to support isolation of asymptomatic patients.
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Surveillance - 2009 CCDR Volume 35s2, November 2009. Available at:
- Public Health
Agency of Canada and Canadian Patient Safety Institute. Case Definition and
Minimum Data Set for the Surveillance of Clostridium difficile Infection (CDI)
in Acute Care Hospitals across Canada. December 2008.
H, DeBaere T, Claevs G, et al. Evaluation of six commercial assays for the
rapid detection of Clostridium difficile toxin and/or antigen in stool
specimens. Clin Microbiol Infect
E, Gerding N, Classen D, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29:S81-S92.
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Clinical recognition and diagnosis of Clostridium difficile infection.
Clin Infect Dis 2008;46:S12-S18.
Health Agency of Canada, Hand Hygiene Practices in HealthCare Settings. 2012. PHAC release pending.
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Lamsdale A. Forrester L, et al. Bedpan washer disinfectors: An in-use
evaluation of cleaning and disinfection. Am J Infect Control 2011;39:566-570.
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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,
- 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,
- 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.);
- 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.
- 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.php
To obtain an electronic copy of the report, send your request to:
Centre for Communicable Diseases and Infection Control
Public Health Agency of Canada
100 Eglantine Driveway
Ottawa, ON K1A 0K9