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Preventative measures for C. difficile are essentially the same as for other nosocomial infections (NI's). C. difficile however, poses a particular problem because it generates spores that are resistant to several regular disinfectants. These spores can survive for weeks, even months in the hospital environment.
Three types of measures should be implemented:
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1. General precautionary measures that apply to all patients regardless of whether they are C. difficile carriers.
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2. Additional precautionary measures when infections occur.
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3. Strict control of antibiotics for all patients regarding treatment.
A) General precautions to be taken with all patients
(C. difficile carriers or not)
1) Objectives:
- Protect patients against C. difficile and all other infections such as SARMS (Methicillin resistant staphylococcus aureus).
- Protect health care workers from patient's germs.
- Inform the public that a patient can be a carrier of C. difficile or other potentially harmful bacteria without exhibiting symptoms. The patient therefore becomes a potential source of contamination.
2) General precautionary measures:
Health care workers need to disinfect their hands with an alcohol-based solution before and after contact with a patient. If hands are soiled, they need to be washed with soap and water before being disinfected.
If there is risk of contact with patient's blood or bodily fluids, health care workers should wear latex gloves, a protective outer gown and, if necessary, a surgical mask. Hands must be disinfected before and after wearing gloves.
These measures are required in order to avoid accidental contamination caused by cuts or pricks.
The same approach is recommended when handling hospital garments, disposing of medical waste, or performing routine maintenance tasks.
B) Additional Precautionary Measures
These measures apply to all patients exhibiting symptoms such as diarrhea, and to all carriers of a toxic strain:
The patient should be quarantined in a private hospital room. Patients must be forbidden to share personal hygiene articles such as soap etc. Patients should also have their own commode. When it is not possible to isolate infected patients in individual rooms, it is recommended that infected patients be kept together in the same hospital room or ward.
- - Patient's movements outside hospital rooms must kept to a minimum.
- - Should there be an outbreak, patients exhibiting symptoms must be quickly isolated. These measures should be implemented as soon as symptoms such as diarrhea appear. This can be done even before receiving confirmation of an outbreak from the hospital laboratory.
Given the length of time it takes for a relapse to occur, these additional measures need to be maintained for seven to ten days after treatment. Should patients exhibit symptoms such as diarrhea, precautionary measures should be implemented immediately and without waiting for lab results to confirm that an outbreak has occurred.
After patients are removed from isolation, the hospital room has to be thoroughly disinfected before admitting another patient to the same room.
Individual protective equipment: gloves and long sleeved protective gowns must be reserved for the care of each patient. They should be replaced immediately after use or if they have been soiled. It is recommended that gloves and gowns be used not only for treatment but also for any contact whatsoever with the patient's environment. It is also recommended that health care workers disinfect their hands as soon as they remove their gloves and gown.
When several patients are isolated in the same room or unit, gloves, gowns, and other protective equipment should be removed and hands disinfected after treating each patient.
Hand cleanliness: up to 59% of health care workers can be contaminated by direct contact with C. difficile infected patients. The most frequently contaminated areas of the hand are the fingertips, the under part of the fingernails, the palms of hands, and the area of the finger directly underneath a ring. Washing one's hands with soap and water is necessary to eliminate bacteria that are resistant to alcohol-based solutions. Recent studies (2005) demonstrate that chlorhexidine
gluconate is particularly effective.
Cleaning and disinfecting the general hospital environment:
Within 24 hours of the appearance of symptoms such as diarrhea, all surfaces in the patients room become contaminated and remain contaminated for weeks, even months in some cases.
Using a disinfectant when performing daily maintenance tasks helps reduce contamination. Unfortunately, very few types of disinfectant have proven to be effective. Chlorinate derivatives such as sodium hypo-chlorinate, and hydrogen peroxide seem to be the most effective[i]. The choice of product is important because some non-chlorinate based disinfectants contribute to the formation of bacterial spores that are resistant to many disinfectants. These bacteria can survive for extended periods in the hospital environment. In order to be effective, chlorinate-based products must remain in contact with the surface being cleaned for ten minutes.
Disinfecting the hospital environment must include a specific list of tasks carried out in a systematic manner. It is also necessary to follow a specific procedure whereby the cleanest surfaces are disinfected first and the dirtier surfaces after that. The bathroom and toilets should be cleanest last.
Any surface frequently touched by patients must be regularly cleaned and disinfected. These high-touch surfaces include tables, night tables, bed bars, door handles, buzzers, and telephones.
Any scrub pads, brushes, or anything else used to clean hospital rooms should be put in plastic bags and disposed of. Under no circumstances should they be reused to clean other rooms.
It is highly recommended that all maintenance staff wear gloves, a protective gown, and follow proper hand-cleanliness protocol.
Cleaning and disinfecting should be done at least once a day and, in certain situations, every few hours. Particular attention must be paid to bathrooms and toilets.
Whenever a patient is released from the hospital, or when special precautionary measures are lifted, the room must be thoroughly disinfected and any objects or materials that couldn't be properly disinfected disposed of.
All medical equipment and instruments also have to be disinfected.
Quarantined patients are required to stay in their rooms and should be provided with their own medical instruments such as thermometers, and stethoscopes etc. All instruments have to be disinfected immediately after use.
When possible, it is best to use disposable towels and facecloths. Otherwise, cloth towels etc. must be disinfected and replaced daily.
Handling eating utensils: After meals, orderlies and nurses should wear gloves when removing serving trays. On serving carts used to transport meals, the trays of infected patients should not come into contact with other patient's trays. Kitchen workers have to pay particular attention to hand cleanliness.
Moving quarantined patients: Infected patients must wear protective clothing outside their hospital room. Should a patient require a wheel chair, a sheet should cover it. Afterwards, the chair has to be cleaned and disinfected. Hospital staff in charge of moving infected patients would have to follow the same procedure. Such situations usually arise when infected patients have to be treated outside their hospital room, or when diagnostic equipment such as an x-ray machine is required.
Visitors, of course, would have to follow the same protective hygiene measures as hospital staff. Furthermore, visitors would required to disinfect their hands when leaving a patients room, and under no circumstances should they be allowed to use a patient's toilet. It is preferable that they leave the hospital immediately after visiting an infected patient.
C) Controlling the use of antibiotics:
C. difficile accounts for 15% to 25% of all cases of diarrhea occurring after a patient has been given antibiotics, and for more that 95% of pseudo-membranous colitis cases. Even in a healthy patient, the digestive tract is colonized by billions of bacteria belonging to four hundred different categories. Thirty to forty percent of these types of bacteria account for most intestinal fluids and form an ecosystem necessary for one's good health. Some of these bacteria, known as probiotics, are beneficial.
Using antibiotics to treat an infected patient frequently causes an imbalance in this delicate ecosystem and favors the development of pathogenic bacteria such as C. difficile. Preventing C. difficile therefore requires strict control of antibiotics.
Although the role of probiotics is still not clearly defined, an increasing number of studies have demonstrated that using them in conjunction with antibiotics is an effective means of preventing infection, in particular, C. difficile.
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