In my last post we discussed the increased incidence of the c diff infection and its causes. This post will cover how it is transmitted and how we as nurses can effect change and promote safety in the transmission and care of patients with c diff.
One of the reasons why c diff is transmitted easily is the fact that the bacterium develops spores. If you remember back to microbiology, some bacteria, including c diff can form a type of cell (a spore) that has all of the cellular parts needed for reproduction, but develops a hard “shell.” The cell hibernates until the environment becomes more favorable and then begins again, to reproduce. Spores of c diff are found on fomites (inanimate objects) around the environment of an infected person. Think, bed linens, side rails, toilet seats and handles, and even light switches.
Health care professionals, family members and visitors all touch these areas and if they do not follow proper hand-washing procedures, the spores find themselves either on another fomite or in the GI tract. The spores are acid resistant, which is why people on long-term PPIs can be more susceptible to c diff. All of a sudden, the spore is in a favorable environment and if the conditions are right, they will start another overgrowth of c diff.
By now all of us know the answer to this question but we are still not following through, so I will ask it again. What do you think is the most frequent way the c diff organism and spores are transmitted?
Yes, that is correct, through health care workers.
Which brings us to the most important part of the posts on c diff. Nurses, who are at the bedside in the hospital 24/7 and are the coordinator of patient care in long term facilities and in the home are in a unique position to decrease the transmission of this organism. This can be accomplished by proper precautions and by teaching the patient and those around them the importance of stopping the spread of transmission.
The initial most important treatment in managing c diff is to discontinue current antibiotic treatment. Nurses are in a position to monitor their patients on antibiotic therapy for any signs of diarrhea and ask specific questions of the pt and family regarding this sign. Report this to the prescribing HCP immediately.
If a patient develops diarrhea the nurse should also observe for changes in WBC, vital signs and hydration status.
Meticulous skin care, especially in immobile patients, is a must.
When collecting a stool specimen for c diff, certain rules must be observed. The specimen should not be mixed with urine, water or toilet tissue. To collect a specimen, place saran wrap or a chux over the back half of the toilet seat or commode. Remove the specimen from the chux and place it in a clean container.
Time is another important factor in collecting a specimen. The c diff toxins degrade within 4 hours at room temperature. Therefore a stool specimen must get to the lab to be refrigerated in a timely manner, not sit at room temperature at the nurses station until someone is available to transport it. I wonder what effect this practice has on the false negative results?
The patient with C diff will be placed in Contact Precautions to reduce transmission of the bacteria. Nurses must not only abide by these precautions but also enforce their use with anyone who enters the room. Spores can persist for 4 weeks on dry surfaces. Gowns and gloves should be worn when coming in contact with any part of the patient or equipment that can be contaminated in the room. When you hang an IV antibiotic, do you touch the side rail with your scrubs? Do you set the IV pump? How do you know another nurse didn’t lay the IV bag down on the bed linens and then set the machine? The answer is you don’t so take the proper precautions.
C diff cannot be eradicated with the normal alcohol based antiseptics or soap and water. A diluted bleach solution must be used. How about when a patient with c diff is discharged? Does housekeeping take down the curtains and put up a new set? They should. Think of how many times parts of those curtains could be contaminated with c diff spores.
Soiled linens and personal items should not come in contact with hands or surfaces. Take that statement and visualize how many situations you can come up with that violate this.
Antiperistaltic, antidiarrheals and opiates are contraindicated in patients with c diff because they predispose the patient to toxic megacolon. One of the first things we want to do is to get an order for one of these, to stop the persistent diarrhea. Avoid the impulse. The best way to control the diarrhea is to discontinue the current antibiotic.
Ironically, the treatment for C diff is another antibiotic. The two used are metronidazole (Flagyl) and Vancomycin. An oral course of either of these two drugs for 10-14 days is standard treatment. Flagyl is less expensive and Vancomycin has it’s own issues, which we will cover in another post. Patients often complain of nausea and a metallic taste from the Flagyl.
For moderate to severe diarrhea the patient should be placed on a clear liquid diet until the diarrhea resolves. Studies have shown probiotics are not effective in the prevention of c diff.
Teaching is a must in dealing with patients, care givers and family members.
Nurses are in a unique position to be patient advocates, teachers and infection control practitioners in the treatment of c diff.
Center for Disease Control 2011
Curry,Jennifer. 2009. Pseudomembranous Colitis. Medscape Reference.
Grossman, S. and Mager, D. (May/June 2010) Clostridium difficile: Implications for Nursing. MEDSURG Nursing The Journal of Adult Health.