CDI Frequently Asked Questions (FAQs)

Clostridium difficile Infection (CDI) FAQs

    

Click to Skip to the Following Topic

 

 

 

Top of page

Diarrhea Decision Tree (DDT) – General 

1. Q. Should the DDT be used for diarrhea management in general or only when CDI is suspected?

1. A The DDT has recently been revised to focus on patients with suspected or confirmed CDI. However, testing and initiation of contact isolation for other causes of infectious diarrhea should be performed if appropriate. Please refer to the HEIC isolation table for appropriate precautions for other causes of infectious diarrhea. Click here for the DDT

2. Q. I’ve seen the Bristol Stool Chart on my unit, but I don’t know how to apply it to my patient.

2. A Loose and/or watery stools that meet the diarrhea definition resemble Type 6 and Type 7 on the Bristol Stool Chart.

3. Q. Should I send a CDI test on any patient who meets the definition of diarrhea?

3. A No. Do not routinely submit specimens from:

1. Patients ≤ 12 months old; pediatric ID consult approval required if testing is desired

2. Patients who have received a laxative or stool softener in the previous 24 hours

3. Patients with a clear alternative explanation for diarrhea in whom infectious diarrhea is not a concern.

 

 

Top of page

Contact Isolation 

4. Q. When should I place a patient on Contact Isolation? Do I need an order to initiate Isolation?

4. A Contact Isolation should be ordered/initiated when a patient has had ≥ 3 loose stools in ≤ 24 hours and there is concern for infectious diarrhea. An order can be placed by the nurse, provider, or Infection Control Practitioner.

5. Q. Can I place a patient on Contact Isolation prior to the 3rd loose stool?

5. A Isolation may be initiated prior to the onset of the 3rd loose stool, but a test for C. difficile should not be sent until the patient meets the definition of diarrhea (≥ 3 loose stools in ≤ 24 hours and there is concern for infectious diarrhea).

6. Q. What signs need to be posted when I initiate Contact Isolation?

6. A Post Contact Isolation and C2 signs outside the patient’s room. Cover the alcohol-based hand rub (“ABHR” or “Alcohol Foam”) dispenser inside the room with a Wash Hands with Soap and Water sign so it cannot be easily used. If only one alcohol dispenser serves both entry and exit for the room, post the Wash Hands with Soap and Water sign as a reminder to wash on exit, so it does not impede use of the dispenser when entering the room.

7. Q. Where do I get the correct signage?

7. A Instructions on how to get Isolation Signs: http://infectioncontrol.ucsfmedicalcenter.org/faqs#Isolation

8. Q. What equipment do I need in place for Contact Isolation for CDI?

8. A Place a caddy stocked with gloves of different sizes and gowns outside the room. A tub of surface disinfectant wipes, a disposable stethoscope and a large trash bin should be placed in the room.

9. Q. What is the correct order to put on and remove PPE for a patient on Contact Isolation?

9. A To put on PPE:

1. Put on a new gown

2. Clean your hands

3. Put on clean gloves.

(CLICK HERE FOR VIDEO)
 

9. A To remove PPE:

1. Remove and discard PPE

2. Clean hands with soap and water

3. Use a clean paper towel to turn off faucet and open door to exit the room.

(CLICK HERE FOR VIDEO)

10. Q. I need to go into a Contact Isolation room just for a moment. Do I need to put on a gown and gloves?

10. A Yes! Anyone and everyone going into a Contact Isolation room needs to put on the proper personal protective equipment.

11. Q. Should repeat CDI testing be performed to guide discontinuing Contact Isolation?

11. A No! Do not perform a “test of cure” as per the 2014 SHEA/ IDSA Practice Recommendations on Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals. At UCSF Health we make decisions about discontinuing Contact Isolation for confirmed CDI based on two criteria:

1) Resolution of diarrhea for ≥ 48 hours and

2) The patient has been transferred to a clean room.

If the patient cannot be transferred to a clean room, s/he must remain in Contact Isolation. Contact Infection Control with questions regarding discontinuation of Contact Isolation.

12. Q. The patient I’m working with was positive for CDI, but for the last two days is having formed stools. Can I take him/her out of Contact Isolation?

12. A

  • Prior to discontinuing Contact Isolation:
  • Request a room transfer within 24hrs.
  • The MD may discontinue Contact Isolation in APeX, but the patient should be maintained on Contact Isolation until s/he is transferred to a clean room.
  • In APeX on the Bed Request screen, write in Comments section “CDI Isolation removed. Transfer to new room”
  • Bathe or shower the patient before moving him/her to a clean room.
  • Hospitality will use a sporicidal disinfectant to terminally clean the vacated room.
  • Leave the isolation caddy on the door until Hospitality has completed terminal cleaning.

NOTE: If a clean room is not available when symptoms resolve, Contact Isolation must be maintained until the patient can be transferred to a clean room.

13. Q. I initiated Contact Isolation for my patient with diarrhea. The test came back negative but my patient is still having frequent loose stools. Can I discontinue Contact Isolation?

13. A Contact Isolation may be discontinued if:

1) A non-infectious cause of diarrhea is deemed likely OR

2) Other potential infectious causes of diarrhea that require Contact Isolation have been ruled out.

If norovirus is still in the differential, the C2 sign should remain in place with Contact Isolation until results return.

14. Q. The Isolation Table on the Infection Control website says to maintain Isolation until “diarrhea has resolved for 48 hours…”. How is “diarrhea resolved” defined?

14. A Diarrhea resolution is defined as normal, formed stools for 48 hours in the absence of anti-motility agents. For patients who have loose stool or increased frequency at baseline, diarrhea resolution is defined as return to baseline stool. Please contact Infection Control with questions regarding whether Contact Isolation may be discontinued.

15. Q. When should I send a test for CDI?

15. A Testing for CDI should be considered when a patient meets the definition of diarrhea (≥ 3 loose stools in ≤24 hours) and there is concern for infectious diarrhea. Although isolation may be initiated prior to the 3rd loose stool, the test should not be ordered under most circumstances until the patient meets the criteria for diarrhea ( ≥ 3 loose stools in ≤ 24 hours). Please contact the Adult or Pediatric Infectious Diseases Consult service to discuss earlier testing for concerning patients who do not meet criteria for diarrhea.

16. Q. Should I send a CDI test on any patient who meets the definition of diarrhea?

16. A No. Do not routinely submit specimens from:

1. Patients ≤ 12 months old; pediatric ID consult approval required if testing is desired

2. Patients who have received a laxative or stool softener in the previous 24 hours

3. Patients with a clear alternative explanation for diarrhea in whom infectious diarrhea is not a concern.

17. Q. Does there need to be a provider order for a CDI test?

17. A Yes, a provider must order testing for CDI.

18. Q. Should repeat CDI testing be performed to guide discontinuation of Contact Isolation?

18. A No! A test of cure should not be performed as per the 2014 SHEA/ IDSA Practice Recommendations on Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals. At UCSF Health we make decisions about discontinuing Contact Isolation for confirmed CDI based on two criteria:

1. Resolution of diarrhea for ≥ 48 hours

2. Patient has been transferred to a clean room.

If the patient cannot be transferred to a clean room, s/he must remain in Contact Isolation. Contact Infection Control with questions regarding discontinuation of Contact Isolation.

19. Q. My patient recently tested negative, but we would like to check again. Can I send another test?

19. A Repeat tests submitted within 7 days of a previous order will be rejected by the laboratory as repeat testing has a low yield and patients with an initial negative test should not routinely be retested. If the patient has a clinical change that raises concern for CDI in a shorter interval, contact the Microbiology Lab at 415.353.1268 for approval.

20. Q. How should I refill the water pitcher for my patient on Contact Isolation for C. difficile?

20. A Pitchers may be filled in the patient room. If the pitcher must be filled outside the patient room (e.g. patient requests ice water), discard the used water pitcher in the patient’s room (recycle if bin is present, trash if not) and get a new pitcher from storage. Because a new pitcher costs the same as a pitcher liner, liners are not used at UCSF.

 

 

Top of page

General Patient Considerations 

21. Q. A patient was just admitted and during the admission history he reported having diarrhea for the last few days. Do I need to wait for anything before placing him on Contact Isolation?

21. A No! Immediately place patient in Contact Isolation. Discuss with provider regarding placing an order for CDI test. Although the patient may not yet have had 3 loose stools, a recent history of diarrhea prior to admission should prompt Contact Isolation and consideration of testing to limit further transmission and ensure appropriate attribution as community-onset CDI.

A positive test on days 1-3 of admission is considered a community-onset case while a positive test collected on or after day 4 of admission is considered a hospital-onset case, regardless of when symptoms started. If the patient is not stooling, maintain vigilance for onset of loose stool and submit specimen for testing when available.

22. Q. If a patient has an order for CDI test, but is not stooling, what should I do?

22. A In general, it is appropriate to cancel the order (providers) or request that the order be cancelled (nurses) if the patient is not having diarrhea.

23. Q. On my unit there are two patients with CDI. Is that considered a cluster and should I alert anyone about this?

23. A Two patients on a unit with the same disease at the same time may be considered a cluster. Please contact Infection Control to review these cases and investigate further.

 

 

Top of page

Special Patient Populations 

24. Q. Should I send a CDI test on any patient who meets the definition of diarrhea?

24. A No. Do not routinely submit specimens from:

1. Patients ≤ 12 months old; pediatric ID consult approval required if testing is desired

2. Patients who have received a laxative or stool softener in the previous 24 hours

3. Patients with a clear alternative explanation for diarrhea in whom infectious diarrhea is not a concern.

25. Q. When should I isolate my patient who has a colostomy, ileostomy, or rectal tube?

25. A If infectious diarrhea is suspected, initiate Contact Isolation. For patient with colostomy, these parameters may indicate diarrhea: > 1.5 L / day OR an increase of ≥ 50% above baseline. For further questions, contact Infection Control.

26. Q. When should CDI testing be done for someone with an ileostomy, colostomy or rectal tube?

26. A CDI testing should only be performed if there is a clinical suspicion for CDI.

27. Q. My patient’s baseline stool pattern is more than 3 loose stools over 24 hours. Should I test for CDI?

27. A No. CDI testing should only be performed if there has been an increase in frequency or change in consistency of stooling compared to baseline and there is a clinical suspicion for CDI.

28. Q. Are there special considerations for patients with chronic diarrhea due to Crohn’s or IBS?

28. A Monitor patients with chronic diarrhea for a change in stool volume or consistency. Order CDI testing only if a patient has a significant change in stool volume and/or consistency and there is a clinical suspicion for CDI.

29. Q. My patient has a rectal tube. They don’t need to be on in Contact Isolation, right?

29. A Wrong! If a patient has enough loose stool to require a rectal tube they definitely need to be in Contact Isolation until you determine whether or not they have CDI. A rectal tube is not a closed system and C. difficile spores can still get on the patient and environmental surfaces.

30. Q. If a post-partum mom is diagnosed with CDI, can her baby room in with her?

30.  A Yes, the baby can room in with the mother with CDI. The risk of the mother transmitting CDI to the neonate is not concerning. Some newborns are colonized with CD spores without evidence of the disease.

31. Q. Does the post-partum mom diagnosed with CDI need a longer length of stay?

31. A No, the mom can be discharged with a diagnosis of CDI when she meets her post-partum goals. She should also be assessed for hydration and the ability to care for her newborn with new toileting needs.

32. Q. Can a mother with suspected or confirmed CDI infection whose infant is a patient in the UCSF Intensive Care Nursery (ICN) visit the ICN and breastfeed?

32. A 

  • The mother may visit the ICN and breastfeed her infant if she:
  • Showers daily
  • Puts on clean gown just prior to visiting the infant
  • Washes hands with soap and water after using the bathroom
  • Washes hands with soap and water before and after handling the infant
  • Uses ONLY the bathroom in her room for toileting OR Uses a community restroom in the ICN that is cleaned immediately afterwards by Hospitality with a sporicidal cleaner.

 

 

Top of page

Specimen Collection / Laboratory 

33. Q. What is the correct way to send a stool sample if urine was mixed with the stool?

33. A Stool contaminated with a small amount of urine is acceptable for CDI testing. The primary issue with the assay would be if the stool were too dilute to detect CDI due to a large amount of urine present.

Suggestion: When you collect a sample, scoop out stool or pour off urine to minimize dilution.

34. Q. What is the appropriate specimen to collect from a patient in whom ileus secondary to C. difficile is suspected?

34. A A rectal swab can be obtained and tested directly by PCR. The goal of the swab is to get a small bit of stool for testing in patients with ileus, so the swab should be visibly soiled. Any sterile swab type (cotton, nylon, flocked) is acceptable. Place the rectal swab in a sterile tube. Ordering a C. difficile with rectal swab is similar in APeX, except the provider must check “other” for specimen type, then type in “rectal swab”. If you have questions on how to do this, call the Micro lab: 353-1268.

35. Q. Why was the stool sample rejected by the lab?

35. A There are several reasons for the laboratory to reject a stool specimen for CDI testing:

  1. The sample may have been too old to process
    1. An unformed stool sample can be processed up to 24 hours after collection for CDI toxin and assay.
    2. If the same stool sample is used for ova & parasite, bacteria, or fecal WBC, the specimen must be processed within 3 hours, or must be placed in a preservative.
  2. The sample sent may have been formed stool:
    1. Remember, only loose stool or watery should be submitted for C. difficile testing.
    2. “If it ain’t loose, the test is of no use!”
  3. The sample may have been sent within 7 days of the last stool sample sent.
    1. The lab will only process one sample in a 7 day time frame.

36. Q. When are specimens picked up for transport to the Micro lab?

36. A 
Mount Zion
: First pick up is at 6:30am, last pick up at 10:15pm.
Parnassus and Mission Bay: First pick up is at 7:00am, last at 10:45pm.