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Clostridium Difficile

On the last day of each month all Ontario hospitals are required to publicly report:

  • Rates of new hospital-acquired C. difficile cases associated with the hospital, separately for each hospital site; and
  • The number of new hospital-acquired C. difficile cases associated with the reporting facility (count) separately for each hospital site.

To ensure patient confidentiality in smaller cities, the Ministry of Health and Long-Term Care has advised hospitals that have between one and four cases in a month to report the number of cases as "less than 5".  
Reports for all Ontario hospitals, including the four Quinte Health hospitals are posted on the Health Quality Ontario website.

Questions and Answers about C. Difficile

What is Clostridium difficile (or C. difficile)?

C. difficile is one of the many types of bacteria that can be found in feces (bowel movement), and has been a known cause of health care-associated diarrhea for about 30 years.

Its proper name is Clostridium difficile that is often abbreviated to C. difficile. Some people call it "C. diff" for short.

Where does C. difficile come from?

C. difficile is not new. Although people may associate it with health care settings, it doesn't come from hospitals, long-term care homes or laboratories. It is found in the intestine, occurring naturally in 3-5% of adults (more commonly in the elderly) without causing symptoms.

What causes C. Difficile?

C. difficile can be picked up on the hands from exposure in the environment and can get into the stomach once the mouth is touched, or if food is handled and then swallowed. Once in the stomach, the bacteria usually will not cause any problems unless the other bowel bacteria are disturbed, which can happen when antibiotics are taken. The use of antibiotics increases the chances of developing C. difficile diarrhea as it alters the normal level of good bacteria found in the intestines and colon.

What does it mean to a person who gets C. difficile?

If you pick up the C. difficile germ you most often do not develop any symptoms of diarrhea at all. But some people, especially those taking antibiotics, may get diarrhea. The diarrhea can be mild or severe with many bowel movements in a day with stomach pains and cramps.

How does someone get C. difficile?

You can pick up the C. difficile germ anywhere. But the C. difficile germ is especially common on hospitals. This is because hospitals have many sick people in one place and many people in the hospital are on antibiotics. The chances for the C. difficile germ to spread from person to person is much higher in a hospital than it is in someone's own home for example.

The C. difficile germ enters your body by you placing your contaminated (dirty) hands in your mouth. This is why cleaning your hands is so important to preventing yourself from picking up C. difficile and other germs.

What are the risk factors for C. difficile diarrhea?

Certain people are at increased risk for developing diarrhea from C. difficile. These risk factors include:

  • History of antibiotic use
  • Bowel surgery
  • Chemotherapy
  • Prolonged hospitalization
  • Being elderly
  • Serious underlying illness or debilitation

What is the treatment for C. difficile diarrhea?

If a person has diarrhea due to C. difficile the doctor will prescribe a type of antibiotic that kills the C. difficile germs. The two most commonly used antibiotics to treat C. difficile diarrhea are metronidazole and vancomycin.

How is C. difficile diarrhea detected or diagnosed?

If C. difficile diarrhea is suspected, a stool (bowel movement) sample is tested in a laboratory for the germ or the poison (toxin) it makes. The test takes several hours to perform and most hospitals do this test in their own laboratory. Those hospitals that do not do this test themselves will send the stool sample to another laboratory to do the test.

Sometimes a doctor will do a test to actually look into the bowel directly with a special instrument (called a sigmoidoscope or colonoscope, or "scope" for short). The purpose of this is to look for abnormal changes in the lining of the bowel that mean that C. difficile is causing the diarrhea.

Can a person die from C. difficile diarrhea?

Yes, in severe cases of C. difficile diarrhea death can occur. This is uncommon and tends to occur in those people with other severe health problems. The vast majority of people recover from C. difficile diarrhea.

Is C. difficile only seen in hospitals?

No. It is true that C. difficile is commonest in hospitals. But you can pick up C. difficile germs anywhere and not know it. It is the combination of antibiotics and C. difficile germs that leads to the diarrhea and other symptoms in most cases.

What can I do to protect myself from C. difficile?

It is not possible to prevent every case of C. difficile diarrhea yet. But each of us can protect ourselves and others by cleaning our hands often. Health care providers in hospitals must clean their hands according the Ontario Ministry of Health and Long-Term Care Hand Hygiene Guidelines. If you are receiving care in a hospital it is okay to ask any one providing care to you if they have cleaned their hands.

Cleaning your own hands after using the toilet, before you eat, after blowing your nose and any time they are dirty is a basic and important step to preventing the spread of all infections including C. difficile germs. Taking antibiotics only as needed and prescribed by your doctor or Nurse Practitioner and watching out for diarrhea are also important.

What does the hospital do if there is an outbreak of C. difficile?

If a hospital determines that is has an outbreak of C. difficile diarrhea then it must report this to the Ontario Ministry of Health and Long-Term Care and to the local Public Health Unit. But reporting the high rates is not enough. The hospital and its Infection Prevention and Control professionals must take the necessary steps to stop the spread of the C. difficile germ.

There are many actions a hospital takes to combat the spread of C. difficile diarrhea. Briefly, a few of these include placing cases of C. difficile diarrhea in a private room, all persons entering that room at any time clean their hands carefully, put on gloves and a long sleeved gown before they enter the room, extra cleaning of the room and other affected areas is carried out, a careful search for other cases of diarrhea that might be caused by the C. difficile germ occurs, education of patients, staff and visitors occurs on how to prevent the spread of the C. difficile germ.

The Ontario Provincial Infectious Diseases Advisory Committee (PIDAC) has developed detailed best practice recommendations for hospitals and all health care facilities on the prevention of the spread of C. difficile.

However, the C. difficile germ is very hardy and can survive for a long time on the many surfaces in a hospital. Outbreaks of C. difficile diarrhea have been difficult to control in some situations and require a prolonged effort by the hospital to control.

It is fair to say that we do not have all of the answers to preventing and treating C. difficile diarrhea. But we do know that keeping a close eye out for this infection by surveillance is very important. By combining all of this information from all of Ontario's hospitals, we can learn a great deal about the best ways to control C. difficile.

Questions and Answers about Public Reporting of Infectious Diseases

How are the rates calculated?

The C. difficile rate is calculated as follows: Number of new hospital-acquired cases of C. difficile associated disease (CDAD) associated with the reporting facility divided by the number of patient days X 1000.

This rate represents the incidence rate of hospital-acquired CDAD associated with the reporting facility per 1000 patient days. The exclusion criteria for the data (excluded from the numerator and denominator) are children under one year. All other patients (e.g. mental health and rehab) are included.

What is a "rate"?

A rate is the way we measure how many new cases of C. difficile diarrhea are happening in the hospital.

Hospitals report important things like C. difficile cases as a number "per 1000 patient-days". A "patient-day" means one patient in the hospital for one day. 1000 patient-days means one patient is in the hospital for 1000 days or 1000 patients were in the hospital for one day, or anything in between. The number of patients in the hospital for a month is multiplied by the number of days each patient spent in the hospital for that month. Some people are in and out of the hospital in one day, others stay seven days, and some stay even longer. So if 100 people each spend 10 days in the hospital, that equals 100 people x 10 days = 1000 patient days.

This is the required way to report C. difficile infection data so that hospitals, both large and small, can compare their rates of C. difficile over time.

What does the rate of C. difficile mean?

Over the last few years C. difficile has become more common in many hospitals. This can be because hospitals are using more modern ways to detect C. difficile cases and so they find more cases. C. difficile is being found in hospitals around the world. The rates vary a lot between hospitals over time.

If the rate of C. difficile in a hospital goes up within a short period of time, this could mean that there is an outbreak that the hospital must look into and take action to prevent any further spread. Hospitals that provide care to the patients with the most complex health problems such as large referral and teaching hospitals tend to have higher rates of C. difficile diarrhea than smaller hospitals. However, C. difficile is of concern in all hospitals and this is why measuring the rate of C. difficile diarrhea is important. This rate lets the hospital know if there is a C. difficile problem and that they need to take steps to prevent spread of this germ.

Where are these rates of C. difficile reported to?

Hospitals are required to report their rates of C. difficile diarrhea to the Ontario Ministry of Health and Long-Term Care and on their hospital's public web site.

If a hospital is experiencing an outbreak of C. difficile diarrhea they must report this to the Ontario Ministry of Health and Long-Term Care and to the local Public Health Unit.

What does "nosocomial" or "hospital acquired" mean?

"Nosocomial" is a latin word that means the disease or infection happened while you were under treatment in a hospital or other health care facility.

"Hospital acquired" means that the disease or infection was picked up in the hospital.

What is "surveillance"?

Surveillance is looking for a disease or infection in an organized way. For C. difficile and other hospital acquired infections this means hospital staff members search for people who have diarrhea caused by C. difficile and keep careful records of all cases. The hospital staff responsible for infection prevention and control keep close watch on the numbers of C. difficile cases and use this information to decide on what to do to stop any spread of C. difficile within the hospital.

What is an outbreak?

An outbreak of C. difficile diarrhea exists when a hospital has more cases of C. difficile diarrhea that are normally seen indicating that the germ is spreading in a part of or the entire hospital.

Why will you not be reporting on deaths caused by C. Difficile?

This is a very complicated issue and one that requires further thought and discussion. We understand that this is an issue that Dr. Michael Baker (Expert Lead - Patient Safety with the Ministry of Health and Long-Term Care) will be looking at in the time ahead, and will seek advice into prior to submitting his recommendations to the government. Our priority right now is to prepare for and implement the government-mandated public patient safety reporting regime that is rolling out over the coming months.

What conclusions should patients draw from the reported C. difficile rates?

Patients should know that this hospital is safe, that the care you receive here is top-notch, and that every effort - on behalf of every one of us - is to ensure you receive the highest quality of care possible.

Public reporting of C. difficile rates is another, helpful measure to ensure the care provided to you is even safer, and improves over time. It provides a snapshot of what has happened with respect to one infection - C. difficile - in a hospital over a certain period of time.

A high number of C. difficile cases in a one-month period does not necessarily mean that a hospital is "unsafe"; a lower number of cases in a one-month period does not necessarily mean that a hospital is "safe". That is why it is vital that C. difficile rates be viewed in the context of other performance indicators.

The public reporting of C. difficile rates is not intended to serve as a measure for hospitals to compare themselves against other organizations, or for the public to use as a measure of where to seek care.

Rates can vary from hospital to hospital, month to month. Some hospitals may experience higher rates of C. difficile due to their type (i.e. acute care) and patient population (i.e. elderly).

That said, the analysis of our C. difficile rates over time will certainly provide us with helpful information that we can use to make quality improvements in our organization. We look forward to working with our health professionals to make those improvements in the time ahead.

Source: South Eastern Ontario Infection Control Network