Clostridioides difficile

Infection Prevention and Control

Queensland Health Guideline – May 2024

Key Messages

• Clostridioides difficile infection is a serious gastrointestinal disease caused by

toxins which produce spore-forming bacterium Clostridioides difficile
(C. difficile).
• C. difficile infection usually occurs in the context of risk factors, such as repeated
hospitalisation, extensive antibiotic use, multiple co-morbidities, including
primary or secondary immunodeficiency, Hirschsprung disease, inflammatory
bowel disease, cystic fibrosis proton inhibitor use, presence of a gastrostomy
tube, and structural or postoperative intestinal disorders.
• C. difficile infection is easily spread via the faecal–oral route or via direct and
indirect contact by hands, devices, fomites, or the environment. Robust Infection
prevention and control practices should be in place to limit spread.
• Timely treatment is required to reduce the risk of complications of severe
disease which may give rise to clinical symptoms such as ileus, toxic megacolon,
or pseudomembranous colitis.
• Suspected and confirmed cases should be isolated in a single room with
standard and contact precautions until 48 hours after symptoms have ceased.1–3

Purpose
This guideline provides recommendations for best practice in the management of adult and
paediatric patients with C. difficile infection.

Scope
This guideline provides IPC advice for all Queensland Health Hospital and Health Service (HHS)
employees (permanent, temporary, and casual) and all organisations and individuals acting as its
agents (including Visiting Medical Officers and other partners, contractors, consultants, students,
and volunteers). This includes acute care, aged care, offender health and disability services that
are managed by Queensland Health. Queensland-licensed private health facilities may choose to
use this guideline. This guideline does not include clinical treatment advice, as this is managed by
a treating doctor or Infectious Diseases specialist.

Related documents
• Australian Guidelines for the Prevention and Control of Infection in Healthcare
• Health Facilities Communicable Disease Outbreak Preparedness, Readiness, Response and Recovery

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Clostridioides difficile - Queensland Health Guideline - May 2024
Published by the State of Queensland (Queensland Health), June 2024
This document is licensed under a Creative Commons Attribution 3.0 Australia licence.

To view a copy of this licence, visit creativecommons.org/licenses/by/3.0/au

© State of Queensland (Queensland Health) 2024
You are free to copy, communicate and adapt the work, as long as you attribute the State of Queensland
(Queensland Health).

For more information contact:

Queensland Infection Prevention and Control Unit
Queensland Health, GPO Box 48, Brisbane QLD 4001,
email [email protected]
An electronic version of this document is available at https://www.health.qld.gov.au/clinical-
practice/guidelines-procedures/diseases-infection/infection-prevention/management-advice/

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Contents

Key Messages 1

Purpose 1

Scope 1

Related documents 1

1 Quick reference guide for clinicians 4

2 Prepare 4

3 Readiness 4
3.1 C. difficile infection and mode of transmission 4
3.2 Early detection and SIGHT protocol 5
3.3 Diagnosis and Testing 6
3.3.1 Testing considerations 6

4 Response 7
4.1 Care of patient with suspected/confirmed C. difficile infection 7
4.2 Environmental cleaning 9
4.3 Discharge cleaning 10
4.4 Cleaning of patient equipment 10
4.5 Bedpans 11
4.6 Considerations for rehabilitation and outpatient settings 11
4.7 Considerations for paediatric settings 11
4.8 Considerations for residential long-term care facilities 11
4.9 Surveillance 12
4.10 Antimicrobial stewardship 12

5 Recovery 13
5.1 Outbreak cessation 13
5.2 Debrief and evaluation 13

6 Further information 13

7 References 14

Appendix 1 – Clostridioides difficile Quick Reference Guide 16

Document approval details 18
Document custodian 18
Approval officer 18

Version control 18

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1 Quick reference guide for clinicians
Appendix 1: Clostridioides difficile infection - Quick reference guide summarises key IPC
guidance for use by healthcare workers at the point of care.

2 Prepare
Consistent with the Health facility’s communicable disease outbreak preparedness, readiness,
response and recovery guideline, it is recommended that health facilities develop an outbreak
control plan. In the event of 2 or more cases of C. difficile infection in the same clinical area, 2
cases that can be linked to time, place and person, or an increase number of patients with
C. difficile infection above the usual number, should prompt an outbreak management team to
be convened, and the outbreak control plan activated. 4,5 Smaller facilities where C. difficile
infection is uncommon should consider one case significant.

3 Readiness
3.1 C. difficile infection and mode of transmission
C. difficile infection is a gastrointestinal disease with a clinical spectrum ranging from
asymptomatic colonisation, mild and self-limiting disease, to a severe life-threatening
pseudomembranous colitis (PMC), toxic megacolon, sepsis syndrome and death. 12 Disease-
causing C. difficile infection produces exotoxins, toxin A and toxin B. These toxins may cause
colitis, diarrhoea (sometimes bloody), mucosal damage, loss of intestinal barrier function,
colonocyte death and neutrophilic colitis.6 Complications such as ileus, hyper-inflammation,
peritonitis, bowel perforation, or necrosis of the gut lining may also occur. Recurrence of
infection is possible within 8 weeks of initial resolution of symptoms and infection.1,2
C. difficile infection usually occurs in the context of risk factors, such as repeated
hospitalisation, extensive antibiotic use, older age, or multiple co-morbidities: including primary
or secondary immunodeficiency, Hirschsprung disease, solid organ transplantation,
inflammatory bowel disease, cystic fibrosis, proton inhibitor use, presence of a gastrostomy tube
and structural or postoperative intestinal disorders.1–3
Asymptomatic colonisation in children <1 year is common, with C. difficile colonisation rates as
high as 50% in neonates, and 70% in infants <1 year of age. By the age of 2 years, reported
colonisation rates decrease to 35–46%. Acquisition of C. difficile in patients <2 appears to be
from the environment rather than maternal sources. C. difficile infection is rare in children
<2 years.1,2
Transmission of C. difficile infection in the healthcare setting is most likely a result of person-to-
person spread through ingestion of spores through the faecal–oral route. Direct and indirect
contact, where hands, devices, fomites, or the environment may become contaminated and
serve as a reservoir for C. difficile spores, are implicated in transmission.

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A prior room occupant with C. difficile infection is a significant risk factor for transmission and
acquisition for a subsequent patient if the risk is not identified and the room is adequately
cleaned in between.4,6,7
The period between initial colonisation with C. difficile organism and the occurrence of C.
difficile infection (known as the incubation period) is estimated to be a median of 2–3 days
however this timeframe can be longer. C. difficile exists in a spore form in the environment and
enters a vegetative state in the intestine. It is only in the vegetative state that C. difficile can
produce toxins.6
The formation of spores poses unique challenges for hand hygiene and environmental
disinfection practices. This is because C. difficile spores are resistant to the bactericidal effects
of alcohol and commonly used hospital disinfectants, and may live on surfaces for months.3,7
C. difficile spores are not killed by alcohol-based hand rub. There is evidence to suggest that
alcohol-based hand rubs (ABHR) have activity against vegetative forms of C. difficile. Vegetative
forms of C. difficile are found in greater numbers than spores in stools. The mechanical action of
washing and scrubbing with soap and water will not kill C. difficile spores but will physically
assist in the removal of spores from the hands, reducing the risk of transmission. If gloves are
worn, and there is no breach of glove integrity and hands are not visibly soiled, a lower density
of contamination of the hands is expected and ABHR may be used for hand hygiene.4–6

3.2 Early detection and SIGHT protocol

Clinicians suspecting C. difficile infection should isolate and test any hospitalised patient who
develops diarrhoea where there is no clear alternative cause for diarrhoea (particularly those on
antibiotics or immunosuppressive therapy). 1–4,6,7 Consideration should also be given to testing
for other diarrhoeal-causing pathogens. Where C. difficile infection is suspected, the SIGHT
protocol should be initiated. See Table 1.8,9
Diarrhoea is defined as the passage of three or more loose or liquid stools in 24 hours (or more
frequent passage than is normal for the individual and taking into consideration loose stools
caused by laxatives and/or stool softeners/antibiotics/total parenteral nutrition (TPN).
C. difficile infection should also be suspected, the patient isolated, and testing undertaken
when:

• pseudomembranous colitis is seen during endoscopic examination or surgery;

or
• pseudomembranous colitis is seen during colonic histopathological examination;
or
• when unexplained large intestine distension, colonic wall thickening, fat stranding, or ascites
are apparent on imaging.1

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 Suspect C. difficile infection for any patient who develops diarrhoea with no clear
S cause, particularly those who have been prescribed antibiotic or
immunosuppressive therapy in the last 12 weeks
Isolate the patient/resident in a single room with its own bathroom. Consult with
I the infection prevention and control team where available while determining the
cause of the diarrhoea
Apply standard and contact precautions. Gloves and aprons must be used for all
G
contacts with the patient/resident and their environment
Hand hygiene with alcohol-based hand rub (ABHR) following glove removal, or
H soap and water if hands are visibly soiled or when there is a breach in glove
integrity, should be carried out as per the 5 Moments of Hand hygiene

T Test the stool for Clostridium difficile toxin, by sending a specimen immediately

Table 1: Department of Health Ireland

3.3 Diagnosis and Testing

Laboratory detection of C. difficile A and/or B toxins in faeces, rectal swabs, or bowel contents
by enzyme immunoassay (EIA), PCR (polymerase chain reaction) or other laboratory means
performed on an unformed stool specimen. 10 If there is high clinical suspicion that the patient
has an ileus and faeces are not available for testing, discussion with the clinical microbiologist is
required to determine whether PCR and/or culture testing on a rectal swab is appropriate. 2
A diagnosis of C. difficile infection requires A + (B or C).
A. Clinical features suggestive of C. difficile infection (diarrhoea, ileus, toxic megacolon);
and
B. Microbiological evidence of toxin-producing C. difficile;
or
C. Pseudomembranous colitis demonstrated on colonoscopy.1

3.3.1 Testing considerations

• The stool sample taken should conform to the specimen container. (Type 6-7 Bristol stool
chart).4
• Stool specimens should be obtained from patients in, or admitted to, healthcare settings as
soon as possible after the onset of diarrhoea.
• All specimens should be kept refrigerated, below 4C but not frozen, until testing can be
done. C. difficile toxin is unstable and the toxin degrades at room temperature.11 Specimens
kept unrefrigerated for periods greater than 2 hours should be discarded and a new
specimen collected.
• If the first test is negative, but there is a strong suspicion of C. difficile infection, consult with
infectious diseases clinician or microbiologist as further testing may be necessary. Other
pathogens should also be considered during this time if not already tested (for example
Norovirus).

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• Notify the laboratory of any wards/units that are experiencing a period of increased number
of patients with diarrhoea.
• It is not recommended to test for C. difficile infection in children under 2 years of age.
Children are commonly asymptomatic carriers of the C. difficile organism. Only test in this
age group if significant clinical suspicion of C. difficile infection. Testing should only be
performed in consultation with a paediatrician.
• Routine screening of patients and testing of stool specimens from asymptomatic patients is
not recommended.3
• Repeat testing for C. difficile infection to determine clearance before removing patients from
isolation is not recommended.1,2,4,10
For further information refer to The Public Health Laboratory Network (PHLN) Clostridiodes
difficile infection (Clostridioides difficile) Laboratory case definition

4 Response
4.1 Care of patient with suspected/confirmed
C. difficile infection
Risk mitigation strategies include standard and contact precautions, environmental cleaning to
reduce horizontal transmission, and judicious antimicrobial stewardship.4

Management of a patient with confirmed C. difficile infection

Single room with unshared ensuite

Ensure appropriate precautions signage and PPE are available outside
of the room. Unnecessary stock should be removed from the room
before patient placement.
Patient
accommodation If there are a limited number of single rooms, it is recommended that
patients with faecal incontinence be prioritised to reduce the likelihood
of transmission to other patients, and the individual should not share a
room or bay with an immunocompromised individual and must have a
dedicated toilet/commode.

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 Management of a patient with confirmed C. difficile infection

Apply standard and contact precautions

PPE required: Apron/gown and gloves. Apply PPE on entry to patient
rooms and remove on exiting room. Change gloves and perform hand
hygiene as per the 5 Moments of Hand hygiene. These precautions
apply to all HCWs who enter the room and the patient, or the
Personal
environment has been touched.
protective
equipment Contact precautions should remain in place until at least 48 hours
after diarrhoea has ceased and the patient is passing formed stools.
Staff performing patient-care activities involving extensive patient
contact should wear a single-use long-sleeved gown. Contact
precautions should be re-instituted if diarrhoea reoccurs.

Hand hygiene with alcohol-based hand rub (ABHR) following glove

removal, or soap and water if hands are visibly soiled or when there is
a breach in glove integrity, should be carried out after each contact
with the patient/resident and the patient/resident’s environment as
per the 5 Moments of Hand hygiene.
Hand hygiene

HCW should be bare below the elbows.

Wearing gloves to reduce hand contamination remains important to

prevent C. difficile transmission via the hands of HCW.4,6

Confirmed cases (based on microbiological results) may cohort with

other C. difficile infection patients. If cohorting is necessary,
Cohorting
consideration should be given to whether the patient has any other
isolation requirements (for example multi-resistant organism alerts).

Dedicated patient equipment.

Single-use items are encouraged as much as possible. If equipment is
returning to communal use, clean it with combined
Patient
detergent/disinfectant or sporicidal wipes. Bedpans should be single-
equipment
use or reprocessed in a pan sanitiser using thermal disinfection if
reusable. Refer to section 4.4 Cleaning of patient equipment and
4.5 Bedpans

Product selection: suitable detergent and disinfectant (e.g., 1000ppm

Cleaning chlorine. Refer to 4.2 Environmental cleaning
(environmental) Frequency: Daily cleaning of the patient environment. Discharge clean:
Refer to section 4.3 Discharge cleaning

Alerts (if used) may be placed in the ieMR and HBCIS. Given C. difficile
infection is a transitory condition, the notation of organism with
Infection control precautions in clinical notes is sufficient. It should be
Alerts
identified whether the C. difficile infection is hospital or community-
acquired for coding purposes. Please ensure receiving areas are
notified of confirmed C. difficile infection status.

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 Management of a patient with confirmed C. difficile infection

Hospitals and Health Services should follow their current waste and
linen management policies as for any other multi-resistant organism.
Waste and linen Linen should be placed into a skip at the point of use, and not carried
against the uniform. Heavily soiled or wet linen should be placed into a
red alginate bag within the linen skip.

Ceasing antibiotics which may be associated with the onset of

C. difficile infection can be an important management strategy. The
mainstay of C. difficile infection treatment is to provide the patient with
Antimicrobial another type of antibiotic which specifically targets the C. difficile
stewardship
infection. The treating team or Infectious Diseases physician should
follow Antimicrobial Stewardship guidelines for prudent antibiotic
prescribing to ensure the appropriate use of antibiotics is adhered to.

PPE: Visitors of patients under contact precautions are not required to

wear PPE providing they are not directly involved in patient care.
Where there is prolonged contact or likely contact with faeces, gloves
as a minimum are recommended in conjunction with strict adherence
to hand hygiene. Visitors should be educated by nursing staff on the
use of PPE if required.12
Visitors
HH: Educate visitors on the importance of hand hygiene. Visitors
should be instructed not to use the patient’s ensuite/toilet facilities.
Other: Visitors should not visit other areas of the hospital after
visiting a person with C. difficile infection. Family members and
visitors of residents should not visit if they are unwell or displaying
symptoms of fever, diarrhoea or vomiting.

Educate patients on the importance of hand hygiene. Patients and

Patient their significant others should be provided with information about
Education testing, diagnosis and treatment of C. difficile infection. The factsheet is
available from the ACSQHC Infection prevention and control resources
for consumers. 1,2,4–7,7,9–11,13

4.2 Environmental cleaning

The healthcare environment is a high-risk reservoir for the C. difficile organism. C. difficile forms
spores that can remain viable on surfaces for months. Frequently touched objects in the patient
environment such as toilets, bedrails and door handles can be heavily contaminated.
Clean and disinfect rooms and patient care equipment of suspected and confirmed cases using:

• a physical clean using an ARTG-listed combined detergent and 1000 ppm available chlorine
solution or sporicidal-impregnated wipe that makes specific claims for use against C. difficile
(2-in-1 clean),
or
• a physical clean using detergent, then clean with ARTG-listed disinfectant such as 1000 ppm
available chlorine solution or sporicidal impregnated wipe that makes specific claims for use
against C. difficile (2-step clean).3,4,9

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Sporicidal agent contact times recommended by the manufacturer/supplier need to be practical
for healthcare settings. Long contact times (the time the surface needs to remain wet) of 10–30
min may become a work health and safety hazard when used in patient care areas and are
unlikely to be achieved or complied with. A risk assessment should be made to ensure the
sporicidal agent’s practical use.4
Cleaning products containing quaternary ammonium compounds have poor activity against
C. difficile spores and therefore are not indicated for use in C. difficile infection.14
All patient surrounds and frequently touched surfaces (such as bedrails, trolleys, bedside
commodes, doorknobs, light switches, tap handles, and ensuite facilities) should be cleaned
daily as a minimum.4,5,9,13
After the floor of the room has been mopped, the mop head should be changed, and the bucket
cleaned and disinfected before use in any other area as per local processes. Equipment that is
unable to be dedicated to single patient use should be cleaned and disinfected after use,
allowed to dry, and stored clean.3,4,9
Daily cleaning of patient’s room minimum frequencies for routine cleaning are outlined in the
Queensland Health—Cleaning Services Operational Guidelines

4.3 Discharge cleaning

Thorough cleaning and disinfection of the entire patient care environment upon discharge is
required as per Queensland Health guideline: Queensland Health—Cleaning Services Operational
Guidelines. Prior to commencing cleaning, ensure disposal of stocks of single-use items in the
immediate patient environment that are difficult to clean or disinfect. All furniture, patient
equipment items, horizontal surfaces, frequently touched surfaces (for example, light switches
and call buttons), and bathroom/toilet/shower area should be thoroughly cleaned and
disinfected with chlorine solution.
Disposable privacy curtains should be changed, and reusable privacy curtains changed and
laundered after each patient is discharged. Refer to the manufacturer’s instructions if
antimicrobial curtains are used and change as per advice for pathogens such as C. difficile. If
blinds are in place clean as per manufacturer’s instructions. Cleaning should be monitored and
audited regularly to ensure standards are maintained.4,5,9

4.4 Cleaning of patient equipment

It is recommended that all cleaning and disinfection of rooms and equipment (for example,
electronic thermometers, sphygmomanometers, glucometers, hoists, pat slides) of patients with
C. difficile is undertaken using detergent/disinfectant wipes, or 1000 ppm available chlorine
solution or impregnated sporicidal wipe. 4,6,9 Please refer to the manufacturer’s instructions on
cleaning to ensure they are compatible with the cleaning product.
All consumables that are unable to be cleaned should be discarded.

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4.5 Bedpans
Facilities should select one of the following options for the management of bed pans based on
risk assessment and available resources:
1. Single-use bed pans can be utilised. If a macerator is not available in the clinical area, the
bedpan and contents should be disposed of into an appropriate waste receptacle.
2. Re-useable bed pans should be reprocessed in the ward washer/disinfector* between uses
and loaded as per the manufacturer’s instructions. Items should not be loaded with items from
other patients.
*NB: washer disinfector must have manufacturer claims of efficacy against C. difficile.

4.6 Considerations for rehabilitation and

outpatient settings
If residents with C. difficile infection receive allied health services or diversional therapy (for
example, physio/occupational therapy equipment, recreational resources), staff should work
with the patient individually and contact precautions should be maintained for the duration of
the therapy. Gym or therapy equipment should be cleaned in between patient use as per
4.2 Environmental Cleaning and 4.4 Cleaning of patient equipment and manufacturer
instructions. Hydrotherapy should be ceased for duration of precautions.

4.7 Considerations for paediatric settings

There is no difference in management for confirmed paediatric cases of C. difficile infection
parents should be encouraged to perform hand hygiene. PPE is not generally necessary for
parents within these settings. Where there is prolonged contact or likely contact with faeces,
gloves as a minimum are recommended in conjunction with strict adherence to hand hygiene.
Visitors should be educated by nursing staff on the use of PPE if required.

4.8 Considerations for residential long-term care

facilities
People living in a long-term care facility or residential aged care facility are at high risk of
C. difficile infection due to chronic disease, increased age, and co-morbidities. Additionally,
higher rates of antibiotic usage in long-term care facilities increase the risk for residents to
acquire C. difficile infection.
Residents with suspected or confirmed C. difficile infection should be isolated in a single room
and placed on contact precautions. If a single room is not available, the individual should not
share a room or bay with an immunocompromised individual and should have a dedicated
toilet/commode.

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Contact precautions should remain in place until at least 48 hours after diarrhoea has ceased
and the patient is passing formed stools. Communal activities should be ceased while the
patient is symptomatic and may resume when the resident has passed formed stools for
48 hours.
If residents with C. difficile infection receive allied health services or diversional therapy (for
example, physio/occupational therapy equipment, recreational resources), staff should work
with the patient individually and contact precautions should be maintained for the duration of
the therapy. Gym or therapy equipment should be cleaned in between patient use as per
4.2 Environmental Cleaning and 4.4 Cleaning of patient equipment and manufacturer
instructions. Family members and visitors of residents should not visit if they are unwell or
displaying symptoms of fever, diarrhoea or vomiting.
Residents who have been asymptomatic and passing formed stools in the last 48 hours can be
managed without any additional infection control precautions.

4.9 Surveillance
Healthcare facilities should have a reliable surveillance program in place to detect/identify
patients with suspected or confirmed C. difficile infection. Surveillance will allow for outbreak
identification, trend monitoring, and evaluation of actions to reduce incidence and spread.2,8
Surveillance of C. difficile infection in facilities should be undertaken as per the Australian
Commission on Safety and Quality in Healthcare: Implementation Guide for Surveillance of
C. difficile. It is recommended that all hospitals review surveillance data regularly to monitor for
an increase in newly diagnosed cases of C. difficile infection or if any transmission has occurred
between cases.
Smaller facilities where C. difficile infection is uncommon should consider one case significant. It
is recommended that a clinical response plan be developed to review surveillance and identify
investigation processes when there is an increase in cases (including smaller facilities who find a
single case where this is deemed to be a significant finding) and implement appropriate
interventions to ensure patient safety. An assessment of the risk should be performed. For
additional information refer to Queensland Health Guideline Health Facilities Communicable
Disease Outbreak Preparedness, Readiness, Response and Recovery for guidance on the
management of transmission of C. difficile infection.

4.10 Antimicrobial stewardship

C. difficile infection and colonisation are almost always associated with the use of antibiotics,
especially excessive or prolonged. However, cases have been associated with the appropriate
use of a single perioperative antibiotic dose for surgical prophylaxis.
Antimicrobial stewardship guidelines for prudent antibiotic prescribing to ensure appropriate
use of antibiotics should be adhered to. In general, beta-lactams (for example, cephalosporins
or amoxicillin), lincosamides (clindamycin or lincomycin), and fluoroquinolones are regarded as
antibiotics that provide the highest risk for C. difficile infection. However, all antibiotic types
have been implicated.1

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5 Recovery
5.1 Outbreak cessation
There is little information pertaining to when an outbreak should be declared over. An outbreak
should be declared over when there is no further transmission, and there has been a return to
the organisation's baseline C. difficile infection rate.4

5.2 Debrief and evaluation

Evaluation of the effectiveness of management of cases and outbreaks provides important
opportunities to improve practices. Please refer to Health Facilities Communicable Disease
Outbreak Preparedness, Readiness, Response and Recovery Guideline for information about
outbreak evaluation.

6 Further information
The C. difficile organism can exist, and persist, in various environmental reservoirs such as water
courses, swimming pools, soil, and in a range of animals including dogs, sheep and pigs.
C. difficile has been found on culture from items and inert surfaces in patients’ rooms. The risk
of colonisation for inpatients increases with hospitalisation and the median time from exposure
to C. difficile to infection is short (2–3 days) which supports the importance of rapid isolation of
patients with C. difficile infection. 5 Asymptomatic colonisation is possible, with healthy adult
studies demonstrating carriage rates of up to 18% of hospitalised patients colonized. These
patients will still shed C. difficile in stool, and therefore potentially contaminate their
surroundings, but do not have diarrhoea. A small number of C. difficile clinical isolates are also
non-toxigenic.6
Transmission of C. difficile to other patients in the environment can occur from those with active
C. difficile infection and those with asymptomatic colonization.6
Since 2000, there has been an increase in the rates of C. difficile infection in some overseas
healthcare facilities associated with an epidemic strain of C. difficile known as BI/NAP1/027,
toxin type III or PCR ribotype 027. Other types of C. difficile that have been imported from
overseas, and considered hypervirulent, are the 078 and 023 strains. The most common types in
Australia include the 014/020, 002, 056 and 070 strains. Small numbers of virulent ribotypes 078
and 244 have been found. Few isolates of ribotype 027 have been identified in some Australian
states.6
Risk factors for community-acquired C. difficile infection (CA- C. difficile infection) include
antimicrobial exposure, with the strongest associations found with prior use of clindamycin,
fluoroquinolones and cephalosporins. 4 The available evidence regarding CA- C. difficile infection
transmission suggests close contacts (including children <2 years old), the environment, animals
(particularly production animals), and food are potential sources of infection in the community.
C. difficile infection can occur in younger patients without any evidence of recent hospitalisation
or antibiotic use.1,4,6

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Guidance on best practices in regard to whether alcohol-based hand rub (ABHR) or soap and
water is preferred varies throughout the literature. Limitations of disinfection hand with ABHR
are well described, as they are non–sporicidal and do not remove C. difficile spores from
contaminated hands. It is therefore important to raise awareness about the limitations of
ABHRs. Additional studies are necessary to further clarify the effects of the use of ABHR on
C. difficile infection and make a more robust conclusion.15
Evidence suggests that modern washer-disinfectors can be used for disinfection of reusable
bedpans in between use, however staff must be trained in their use, and manufacturers'
specifications correctly followed.16,17

7 References
1. Trubiano JA, Cheng AC, Korman TM, Roder C, Campbell A, May MLA, et al. Australasian Society of
Infectious Diseases updated guidelines for the management of Clostridium difficile infection in
adults and children in Australia and New Zealand. Intern Med J. 2016 Apr 1;46(4):479–93.
2. Australian Commission on Safety and Quality in Healthcare. Implementation Guide for the
Surveillance of Clostridioides difficile Infection [Internet]. ACSQHC; 2023 [cited 2024 Jan 3].
Available from: https://www.safetyandquality.gov.au/publications-and-resources/resource-
library/C. difficile infection-surveillance-guide
3. Kociolek LK, Gerding DN, Carrico R, Carling P, Donskey CJ, Dumyati G, et al. Strategies to prevent
Clostridioides difficile infections in acute-care hospitals: 2022 Update. Infect Control Hosp
Epidemiol. 2023/04/12 ed. 2023;44(4):527–49.
4. Stuart RL, Marshall C, Harrington G, Sasko L, McLaws ML, Ferguson J. ASID/ACIPC position
statement – Infection control for patients with Clostridium difficile infection in healthcare
facilities. Infect Dis Health. 2019;24(1):32–43.
5. National Health and Medical Research Council. Australian guidelines for the prevention and
control of infection in healthcare [Internet]. ACSQHC; 2010 [cited 2024 Jan 3]. Available from:
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Appendix 1 – Clostridioides difficile
Quick Reference Guide
Term Definition
C. difficile Gram-positive, anaerobic, spore-forming, potentially toxigenic bacterium that is
basics the most common infectious cause of diarrhoea.

Clostridioides difficile infection - A patient who has clinical features suggestive of

C. difficile C. difficile infection (diarrhoea, ileus, toxic megacolon), plus Microbiological
infection evidence of toxin (A and/or B) producing C. difficile or Pseudomembranous colitis
demonstrated on colonoscopy.

Factors associated with people at high risk of C. difficile infection include

hospitalisation, extensive antibiotic use, multiple co-morbidities, including
primary or secondary immunodeficiency, Hirschsprung disease, solid organ
Risk groups
transplantation, inflammatory bowel disease, cystic fibrosis proton inhibitor use,
presence of a gastrostomy tube and structural or postoperative intestinal
disorders.

Person-to-person spread through the faecal–oral route. Direct and indirect

C. difficile
contact where hands, devices, fomites, or the environment may become
transmission
contaminated also serve as a reservoir for C. difficile spores.

C. difficile infection is usually treated as per therapeutic guidelines, such as oral

C. difficile
metronidazole or oral vancomycin. Alternative treatments are also available for
treatment
recurrent infection and for children.

C. difficile Collection of stool specimen which meets the criteria of diarrhoea and takes the
testing shape of the container. Refrigerate if left out for >2.

PREPARE
C. difficile IPC
• Have OMP and convene outbreak control team in an outbreak.

READINESS
• SIGHT protocol on immediate suspicion
S Suspect C. difficile infection for any adult patient who develops diarrhoea
with no clear cause, particularly in those who have been prescribed
antibiotic or immunosuppressive therapy in the last 12 weeks
I Isolate the patient/resident. Consult with the infection prevention and
control team where available while determining the cause of the
diarrhoea
G Apply standard and contact precautions
Gloves and aprons must be used for all contacts with the patient/resident
and their environment
H Hand hygiene with alcohol-based hand rub (ABHR) following glove
removal, or soap and water if hands are visibly soiled or when there is a
breach in glove integrity, should be carried out as per the Hygiene.
HCW should be bare below the elbows.
T Test the stool for Clostridium difficile toxin, by sending a specimen
immediately

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 Term Definition
RESPONSE
• isolation of cases in a single room with an unshared ensuite
• cohort with other C. difficile infection patients based on microbiological
confirmation of the cause of diarrhoea
• continue standard and contact precautions with strict adherence to the
5 moments of hand hygiene until diarrhoea has ceased for 48 hours
• dedicated patient equipment or clean and disinfect equipment and
environment between each patient use or encounter
• enhanced environmental cleaning and disinfection (daily and on discharge
from any clinical zone)
• undertake thorough discharge cleaning and disinfection
• use ARTG-listed combined detergent and disinfectant products (2-in-1 clean),
or ARTG-listed chemical disinfectant that makes specific claims for use
against C. difficile (as part of a 2-step clean)
• single-use bed pans can be utilised where possible
• patient dedicated re-useable bed pans should be reprocessed in the ward
washer/disinfector between uses by themselves and cannot be washed with
items from other patients.
• waste should be discarded as per local procedures
• provide information to patients ACSQHC Infection prevention and control
resources for consumers
• visitors do not need to wear gown and gloves but must perform hand
hygiene. Where there is prolonged contact or likely contact with faeces,
gloves as a minimum are recommended in conjunction with strict adherence
to hand hygiene. Visitors should not visit anyone else in the facility
immediately after visiting someone with C. difficile.
• alerts will be placed in the ieMR and HBCIS.
• surveillance of C. difficile infection in facilities should be undertaken as per
the Australian Commission on Safety and Quality in Healthcare:
Implementation Guide for Surveillance of C. difficile and the Queensland
Health Guideline for Surveillance of Healthcare Associated Infection.
Investigate and manage any outbreaks.

RECOVERY
• an outbreak should be declared over when there is no further transmission,
and there has been a return to the organisation's baseline C. difficile infection
rate
• debrief and evaluate the effectiveness of measures in the event of an
outbreak or case of C. difficile infection

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Document approval details
Document custodian
Queensland Infection Prevention and Control Unit (QIPCU), Communicable Diseases Branch,
Queensland Public Health and Scientific Services.

Approval officer
Belinda Henderson, Chief Infection Control Nurse QIPCU

Version control
Version Date Prepared by Comments / Reason for update
1.0 23/01/2014 CHRISP
2.0 05/11/2014 CDMU Full revision
3.0 21/05/2019 CDMU Full revision
4.0 30/04/2024 QIPCU Prepared by QIPCU
A major review of the evidence base and
restructure of guidelines, key changes include:
- NEW: Key Messages section
- NEW: Quick reference guide for clinicians
Restructured according to Outbreak
Preparedness, Readiness, Response and Recovery
model

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