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Clostridium difficile (C. diff) — Epidemiological Management

Clostridium difficile (C. difficile / CDI) management protocol for Georgian healthcare facilities. Case definition, contact precautions, environmental disinfection with sodium hypochlorite, hand hygiene with soap and water, antibiotic stewardship.

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Document type
Epidemiological Management Protocol
Scope
All Georgian inpatient healthcare facilities
Evidence basis
ECDC C. difficile infection guidance; IDSA/SHEA CDI clinical practice guidelines 2021
Published by
Public Health Institute of Georgia (PHIG)
Last updated
2025

Clostridioides difficile infection (CDI) is the leading cause of healthcare-associated diarrhoea[3] in Georgian and European hospitals. C. difficile spores are highly resistant to alcohol — standard ABHR is insufficient. This protocol defines the evidence-based management approach for Georgian facilities.

Case definition

  • Confirmed CDI — Diarrhoea (≥3 loose stools in 24 hours) AND positive toxin test (GDH + toxin A/B EIA, or PCR for toxin gene) OR endoscopic/histological evidence of pseudomembranous colitis
  • Healthcare-associated CDI — Symptom onset more than 48 hours after admission to a healthcare facility OR within 4 weeks after discharge
  • Community-associated CDI — Symptom onset in the community or within 48 hours of admission with no recent (12 weeks) healthcare exposure
  • Recurrent CDI — New CDI episode occurring within 8 weeks of a previous episode resolving

Critical IPC requirements for CDI

Key requirementCRITICAL: Alcohol-based hand rub (ABHR) is NOT effective against C. difficile spores.[4] For all contact with confirmed or suspected CDI patients and their environment, healthcare workers MUST wash hands with soap and water. This is the single most important departure from routine IPC practice for CDI. ABHR may be used in addition to soap and water but not instead of it.

Contact precautions for CDI

  • Isolation — Single room with dedicated toilet; if unavailable, cohort CDI patients
  • Gloves and gown — Mandatory for all room entry, not only patient contact
  • Hand hygiene — Soap and water on exit from room; ABHR alone is insufficient
  • Environmental cleaning — 0.5% sodium hypochlorite (5,000 ppm) for all environmental surfaces twice daily and after each patient use of toilet; alcohol-based disinfectants do not kill spores
  • Equipment — Dedicated commode or toilet; disposable bedpan liners; dedicated measurement equipment
  • Duration — Contact precautions must be maintained for minimum 48 hours after the last loose stool; some guidelines recommend until discharge
  • Terminal cleaning — On discharge, deep clean with 0.5% sodium hypochlorite including mattress covers, curtains, call bells and all high-touch surfaces

Antibiotic stewardship and CDI prevention

The single most modifiable CDI risk factor is prior antibiotic use.[1] CDI risk is highest with fluoroquinolones, clindamycin, broad-spectrum cephalosporins and carbapenems. Facilities must restrict unnecessary antibiotic prescribing through antimicrobial stewardship programmes. Proton pump inhibitor (PPI) use should also be reviewed as it is an independent CDI risk factor. CDI incidence rate is a key stewardship metric — target below 1 case per 10,000 patient-days.

Georgian original source / ქართული წყარო

C. difficile Management — Georgian IPC Documents

References

  1. [1] McDonald LC, Gerding DN, Johnson S, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66(7):e1–e48. doi:10.1093/cid/cix1085
  2. [2] Crobach MJT, Planche T, Eckert C, et al. European Society of Clinical Microbiology and Infectious Diseases: update of the diagnostic guidance document for Clostridioides difficile infection. Clin Microbiol Infect. 2016;22 Suppl 4:S63–81. doi:10.1016/j.cmi.2016.03.010
  3. [3] ECDC. Clostridium difficile infections — Annual Epidemiological Report. European Centre for Disease Prevention and Control. 2022;—:—. Available at: https://www.ecdc.europa.eu/en/clostridium-difficile-infections
  4. [4] Jabbar U, Leischner J, Kasper D, et al. Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands. Infect Control Hosp Epidemiol. 2010;31(6):565–570. doi:10.1086/652772
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In plain language

Clostridioides difficile causes diarrhoea and colitis, especially after antibiotic use. Its spores survive on surfaces and are not killed by alcohol hand rub, so control relies on early isolation, soap-and-water hand washing, sporicidal cleaning and careful antibiotic use.

Why it matters

4.3Mpatients a year in EU/EEA hospitals acquire at least one healthcare-associated infectionSource: ECDC PPS 2022–2023
9.5%of healthcare-associated infections in EU/EEA hospitals were gastrointestinal, a group in which C. difficile is prominentSource: ECDC PPS 2022–2023, via CIDRAP
Types of healthcare-associated infection, EU/EEA acute care hospitals 2022–2023 (% of all HAIs)
Respiratory tract29.3%
Urinary tract19.2%
Surgical site16.1%
Bloodstream11.9%
Gastrointestinal9.5%
Source: ECDC point prevalence survey 2022–2023, via CIDRAP

Key actions checklist

  • Test promptly when diarrhoea is unexplained
  • Isolate with contact precautions and a dedicated toilet
  • Wash hands with soap and water — alcohol rub does not kill spores
  • Clean with a sporicidal agent
  • Review and reduce high-risk antibiotics

International guidance

Questions and answers

Why not alcohol hand rub?

C. difficile spores are resistant to alcohol; mechanical removal with soap and water is needed.

What prevents recurrence?

Stopping unnecessary antibiotics and following the treatment protocol.