Questions about how long to continue infection control precautions for patients with Clostridium difficile infection (CDI) generated a recent discussion on the EIN listserv.

A member from Pennsylvania described a patient with fulminant C. difficile colitis who required a subtotal colectomy with end ileostomy and is now doing well in the intensive care unit (ICU): “How long would others keep this type of patient in isolation precautions? For C. difficile patients in general, are others discontinuing isolation once diarrhea resolves or continuing it for the duration of hospital stay given the possibility of continued environmental contamination?”

Two respondents—one in Wisconsin, the other in Connecticut—described policies to continue isolating C. difficile patients for the duration of their stays. A member in Florida replied, “We discontinue isolation once diarrhea has resolved AND the patient is moved to another room, allowing decontamination of the patient’s room.”

In the case of a total colectomy, “I would stop isolation once the colon is out because ileal disease is quite rare,” a member in Texas wrote. “The patient’s prior room and belongings would require a ‘terminal clean.’ ” In the case of subtotal surgery, which is more problematic, “I suggest testing the stool for the presence of toxin or the organism to use as your guide to this question.”

An article from the January 2010 issue of Infection Control & Hospital Epidemiology, referenced by another EIN member in Florida, “found that skin contamination and shedding of C. difficile persisted even after diarrhea resolved and lasted for one to four weeks after therapy,” supporting the continued use of contact precautions until discharge. A respondent in Pennsylvania also cited research supporting a longer duration of carrier precautions, including an October 2007 article in Clinical Infectious Diseases.

“We struggle with patients with ileostomy because there is likely greater contamination of their environment than [for] an ambulatory, continent patient whose diarrhea has resolved,” a Utah member commented. “We are continuing isolation in these (rare) cases for duration of hospitalization. Contrary to what we have been taught, there is emerging evidence that small bowel disease occurs. Could this be related to the emergence of NAP1?”

The member cited several articles and case reports addressing small bowel disease, including a December 2009 article from The American Surgeon, a November 2009 article published in The British Journal of Radiology, and an article from the October 2009 issue of the Journal of Clinical Pathology.

There does not seem to be a uniform approach, “though duration of the hospital stay seems to be the slightly favored approach,” the Pennsylvania member wrote. The recently updated IDSA and Society for Healthcare Epidemiology of America (SHEA) practice guidelines for CDI recommend “maintain[ing] contact precautions for the duration of diarrhea (C-III).” The member noted, “As far as I can tell, this is not further addressed in the body of the guideline.”

“What is a clinician supposed to think when in one facility their patients are taken out of isolation when diarrhea resolves, and in another facility their patients remain in contact precautions for the duration of their hospital stay?”
An EIN member in Connecticut responded that “guidelines are just guidelines. Local conditions, outbreaks, trends, and changing epidemiology require different institutional responses to the same illness. Although we can probably agree on a core ‘bundle,’ I’m not sure how we can avoid some variation in practice for these reasons.”

The respondent from Utah also suggested a different approach to room cleaning: Daily wipe downs of high touch surfaces with bleach, which “have been evaluated and reduce surface contamination. We do this in the rooms of patients with C. difficile and recently initiated it in all rooms on our oncology/transplantation unit because of ongoing high rates. If daily bleach cleaning, as opposed to terminal cleaning, can be conducted, and the illness resolves, might that not be a good approach?”

An Indiana member agreed, citing a bone marrow/stem cell transplant unit, where all major surfaces were wiped down daily. Handwashing with soap and water, gloves, and gowns were required for entry. “In more than 10 years, there was nary a case of C. difficile despite prodigious use of antibiotics,” the member wrote. “In the same time period, C. difficile was quite common in the rest of our hospital.”

E-mail the Emerging Infections Network.

The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) with funding from the Centers for Disease Control and Prevention (CDC), EIN tracks emerging infectious diseases and keeps the public health community up to date with new disease trends, difficult cases, and other issues affecting members’ clinical practices. The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. Click here for more information or to join EIN.

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