What precautions should be taken to contain Clostridioides difficile (C. difficile) in a hospital setting?

Contact Precautions Are Most Appropriate for Clostridioides difficile Infection Containment

Contact precautions should be implemented immediately for this patient with confirmed Clostridioides difficile infection to prevent transmission within the hospital setting. 1

Rationale for Contact Precautions

The 86-year-old woman presents with classic signs of C. difficile infection (CDI):

• Fever (38.5°C/101.3°F)
• Abdominal tenderness
• Loose, watery stools
• Recent antibiotic exposure (started 3 days ago)
• Positive stool immunoassay for toxin B

C. difficile produces spores that are resistant to many disinfectants and can persist in the environment for months. The primary mode of transmission is via the fecal-oral route through direct contact with contaminated surfaces, equipment, or healthcare workers' hands.

Specific Contact Precaution Measures

1. Private Room Placement

   • Place patient in a private room with dedicated toilet facilities 1
   • If private rooms are limited, prioritize CDI patients with stool incontinence 1
   • If cohorting is necessary, only cohort with other CDI patients (not with patients having other multidrug-resistant organisms) 1

2. Personal Protective Equipment

   • Healthcare personnel must wear gloves when entering the room or caring for the patient (strong recommendation, high-quality evidence) 1
   • Healthcare personnel must wear gowns when entering the room or caring for the patient (strong recommendation, moderate-quality evidence) 1

3. Hand Hygiene

   • In CDI outbreak or hyperendemic settings, perform hand hygiene with soap and water rather than alcohol-based hand rubs due to superior spore removal 1
   • In routine settings, either soap and water or alcohol-based hand rub is acceptable before and after patient contact 1

4. Environmental Cleaning

   • Use sporicidal disinfectants for daily cleaning of the patient's room 1
   • Terminal cleaning with sporicidal agents should be performed after patient discharge 1
   • Ensure thorough cleaning of frequently touched surfaces 2

5. Equipment Management

   • Use disposable equipment when possible 1
   • Ensure reusable equipment is thoroughly cleaned and disinfected with sporicidal agents 1
   • Dedicate equipment such as commodes to the patient when possible 1

Duration of Precautions

• Continue contact precautions for at least 48 hours after diarrhea has resolved 1
• Consider extending contact precautions until discharge if facility CDI rates remain high despite standard infection control measures 1

Why Other Precautions Are Not Appropriate

• Airborne precautions: Not indicated as C. difficile is not transmitted via airborne route 1
• Droplet precautions: Not indicated as C. difficile is not transmitted via respiratory droplets 1
• Negative pressure: Not required as C. difficile is not transmitted via air 1
• Universal precautions: Insufficient; specific contact precautions are required for CDI 1

Common Pitfalls to Avoid

1. Delayed implementation: Place patients with suspected CDI on preemptive contact precautions while awaiting test results if results cannot be obtained on the same day 1

2. Improper hand hygiene: Alcohol-based hand rubs are less effective against C. difficile spores than handwashing with soap and water, especially during outbreaks 1

3. Inadequate environmental cleaning: C. difficile spores can persist for months in the environment; ensure proper sporicidal agents are used 1, 2

4. Premature discontinuation of precautions: Discontinuing precautions too early can lead to continued transmission 1

5. Failure to cohort appropriately: If private rooms are unavailable, cohort only with other CDI patients 1

By implementing these evidence-based contact precautions, healthcare facilities can significantly reduce the risk of C. difficile transmission and prevent further cases of this potentially serious infection.