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. 

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

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.

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.

Isolation may be initiated prior to the onset of the 3^rd 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).

Isolation may be initiated prior to the onset of the 3^rd 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).

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.

Instructions on how to get Isolation Signs: https://infectioncontrol.ucsfmedicalcenter.org/resources

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.

To put on PPE:

1. Put on a new gown

2. Clean your hands

3. Put on clean gloves.

(CLICK HERE FOR VIDEO)

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)

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

No! Do not perform a “test of cure” as per the 2014 SHEA/ IDSA Practice Recommendations on Strategies to Prevent Clostridium difficileInfections 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.

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.

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.

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.

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 3^rd 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.

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.

Yes, a provider must order testing for CDI.

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.

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.

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.

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.

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.

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.

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

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

 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.

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.