Guidance on prevention and control of Clostridioides difficile Infection (CDI) in community-based settings in Scotland
Scottish Health Protection Network Guidance

Version
1.0
Published
04 November 2024 (Latest release)
Type
Guidance
Author
Public Health Scotland
  • Conditions and diseases
  • Health protection

Overview

Intended audience

This guidance is for health protection professionals only and supports the community detection and management of Clostridioides difficile infection (CDI) in Scotland.

Community-based settings covered by this guidance include situations where care is provided to individuals at home or other-non secondary care settings.

Examples of community-based settings include:

  • care homes
  • rehabilitation services
  • hospices

The information provided in this document can also apply to prison settings.

Those seeking advice on prevention, diagnostics, and management of CDI in other settings should contact their local relevant teams. For example, local HPTs or infection prevention and control teams (IPCT). 

Scope of guidance

This guidance provides a standardised evidence-based approach to:

  • diagnosis
  • prevention and control
  • treatment of CDI

This is to enable staff to deliver safe care and support the reduction of CDI in their organisations.

This guidance links out to documents produced and maintained by partner organisations where appropriate.

The guidance aims to:

  • outline roles and responsibilities
  • aid the application of knowledge in preventing transmission of C. difficile, with a particular focus on community settings and where appropriate, direct the reader to partner organisations for other care settings
  • direct the reader to documentation for best practice on antimicrobial treatment of CDI from partner organisations
  • improve patient, resident and service user safety in relation to the acquisition of CDI and management of those with CDI
  • reduce morbidity, mortality, impact on services and public anxiety associated with CDI

The guidance should be used as a framework to:

  • ensure that relevant policies are in place locally
  • examine the currency of policy content where policies are already in place
  • inform local policy development where local policies are not in place

Roles and responsibilities

The recommendations set out in this guidance are based on the assumption that care settings have infection prevention and control (IPC) systems in place in line with existing national guidance.

All organisations and staff providing care have an important role in preventing and controlling CDI and other healthcare associated infections (HCAI).

Relavent organisations should ensure:

  • systems and resources are in place to facilitate implementation of national guidance and monitoring of compliance to support the reduction of CDI throughout the organisation
  • effective local surveillance systems are in place to detect increasing incidence (or frequency) and/or severity of CDI and prompt rapid investigations and implementation of prevention and control interventions

The duties of health protection teams (HPT) and infection, prevention and control teams (IPCT) will be dependent on local arrangements within boards.

These include:

  • providing expert advice on the application of CDI prevention and control measures:
    • in the care setting
    • on individual patient, resident or service user risk assessments as required
  • engaging with staff to support implementation of IPC precautions described in this guidance and in alignment, as required, with the:
  • engaging with staff to develop systems and processes that lead to sustainable and reliable improvements in relation to:
    • application of CDI prevention
    • control measures
  • if identified during the investigation of a case or cases of CDI, ensuring that senior managers are alerted to any issues including deficits in:
    • knowledge
    • resources
    • equipment
    • facilities
    • incidents that may result in transmission of infection or changes in the incidence and/or severity of disease
  • supporting further investigations when there is an increased number of cases of CDI in care homes and other relevant community-based care settings in collaboration with relevant staff including:
    • antimicrobial management teams (AMTs)
    • antimicrobial pharmacists
    • general practitioners
  • refering to health board antimicrobial pharmacists or AMTs when CDI clusters or exception reports occur
  • assisting in the investigation of any CDI cases that result in severe disease or death

Responsible medical officers (including GPs) should:

  • be aware of and follow local antimicrobial guidelines for primary care in the NHS board
  • be aware of major risk factors (see risk factors for CDI section of this guidance) and symptoms of CDI
  • use appropriate IPC measures as set out in this document when dealing with persons with diarrhoea
  • where indicated:
    • obtain stool specimens as early as possible from any person with otherwise unexplained diarrhoea in the community, aged 3 years and over
    • send the specimen to the local microbiology laboratory requesting the relevant testing for C. difficile
  • ensure that the HPT (or IPCT) is alerted within the NHS board when there is an increased number of cases of CDI within a community-based care setting
  • provide the patient, resident, service user or carer with information relating to CDI including the necessary IPC precautions to help prevent transmission
  • advise CDI patients, residents or service users that are being cared for at home to contact the GP if symptoms – including fever, rigors, and bowel movements – worsen while on treatment
  • seek advice on appropriate IPC precautions from the HPT or IPCT within the NHS board
  • follow the CDI treatment protocols outlined, and seek advice from the local infection specialist (for example consultant microbiologist or local health protection team) if unsure of appropriate steps
  • assist in the investigation of any community CDI cases that result in severe disease or death

Managers in community-based healthcare settings should ensure that staff:

  • are aware of and have access to IPC guidance documents
  • have had instruction and education about the clinical features and routes of transmission, and the epidemiology of CDI
  • ensure their staff are adequately trained and have a knowledge base on CDI as appropriate for their role
  • have adequate support and resources available to:
    • implement and monitor CDI prevention
    • control policies and procedures
  • take corrective action when there is non-compliance with CDI prevention and control policies and procedures

Staff providing care in community-based settings should ensure that they:

  • understand and apply the principles of IPC in relation to CDI, and antimicrobial stewardship as applicable to their role
  • maintain competence, skills and knowledge in IPC through attendance at education and training events as appropriate for their role
  • maintain competence, skills and knowledge on antimicrobial stewardship through attendance at education and training events where appropriate, for example:
    • prescribers
    • registered members of nursing staff
  • communicate the IPC practices to be undertaken by colleagues, persons, patients, residents, or service user, relatives and visitors without breaching confidentiality
  • report to line managers and document any deficits in knowledge, resources, equipment and facilities or incidents that may result in transmission of infection

Local responsible NHS board microbiology service should ensure: 

  • compliance with the protocol for the national mandatory CDI surveillance programme , including the submission of isolates to the reference laboratory as per protocol
  • compliance with the protocol for the C. difficile snapshot programme
  • diarrhoeal stool samples are tested and the results interpreted according to the national recommended protocol for testing for CDI
  • clinical staff are appropriately advised on testing, interpretation of results and treatment of CDI 
  • diarrhoeal stool samples from all CDI cases are stored at -20°C for a period of three months to enable further investigations
  • IPCTs and HPTs (as per local arrangements) are advised and supported in relation to specific CDI issues, e.g. increased number of cases/incidence, outbreaks and changes in practice
  • HPTs are advised and supported if there are any implications regarding CDI in care homes
  • senior managers are alerted to any concerns which may result in the transmission of CDI or changes in the incidence and/or severity of disease
  • they assist in the investigation of any CDI cases that result in severe disease or death

Antimicrobial management teams (AMTs) should:

  • be responsible for the development and maintenance of:
    • local antimicrobial policies
    • antimicrobial stewardship programmes
  • ensure implementation and support compliance monitoring of local antimicrobial prescribing policies that minimise the use of agents associated with CDI
  • support and advise clinical staff on antimicrobial prescribing and interpret local and national surveillance information on antimicrobial resistance and usage
  • respond to and investigate antibiotic prescribing in relation to CDI clusters and exception reports

Background to CDI

Summary

CDI is a major cause of infectious diarrhoea due to the anaerobic spore-forming bacterium, Clostridioides difficile.

There are strains of C. difficile which are non-toxin producing however CDI is caused by strains which produce toxins.

CDI is predominantly healthcare-associated but, transmission of C. difficile also happens out with healthcare settings in the community.

Treatment with antibiotics or invasive surgical procedures, which disturb the normal intestinal flora, may lead to overgrowth of C. difficile, resulting in either asymptomatic colonisation or infection.

CDI accounts for about 20% of cases of antibiotic-associated diarrhoea.

Those at a higher risk of developing CDI include:

  • elderly people
  • immunocompromised patients
  • individuals who have had recent exposure to antibiotics

Read a more detailed list of risk factors associated with developing CDI.

A small proportion of healthy adults may carry C. difficile as part of the normal gut flora.

Good hand hygiene and environmental decontamination is important for controlling onward spread.

View more information and resources on control measures.

Vale of Leven Incident

The Vale of Leven Inquiry occurred between 2007 and 2008.

It was set up by Scottish Ministers to investigate the occurrence of C. difficile infection from 2007 onwards in the Vale of Leven Hospital.

A report was published in 2014, highlighting the serious outcomes which can happen during a CDI outbreak and the need for clear, consistent CDI guidance covering:

  • surveillance
  • diagnosis
  • treatment
  • management

More recently, the importance of strong guidance for CDI has been reiterated by the emergence of new C. difficile ribotypes, some of which are associated with antibiotic resistance.

Symptoms of CDI

Symptoms of CDI include:

  • watery diarrhoea
  • fever
  • nausea
  • abdominal pain

CDI may lead to serious complications including:

  • pseudomembranous colitis
  • toxic megacolon
  • death

Risk factors for developing CDI

The possibility of CDI should be considered in all persons with otherwise unexplained diarrhoea.

Following a search of contemporary literature, risk factors which may increase index of clinical suspicion for CDI include:

  • current or recent (within the last three months) use of antimicrobial agents (especially, but not restricted to, those with a high risk for CDI), for example:
    • cephalosporins
    • broad spectrum penicillins
    • fluoroquinolones
    • clindamycin
  • increased age (over 65 years old)
  • a previous diagnosis of CDI
  • a recent or prolonged hospital stay
  • serious underlying diseases or comorbidities
  • surgical procedures (in particular bowel procedures)
  • immunosuppression
  • use of proton pump inhibitors (PPI) or H2 antagonists (drugs which reduce the production of stomach acid)

Epidemiology

A detailed overview of the epidemiology of Clostridioides difficile infection (CDI) in Scotland is available in the CDI section of the Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) Scotland website.

This includes:

  • quarterly and annual surveillance reports
  • the case definition of CDI used for the purpose of national surveillance 

View the ARHAI Scotland information on Clostridioides difficile Infection (CDI) in Scotland.

Testing for CDI

Best practice recommendations

The possibility of CDI should be considered in all persons with otherwise unexplained diarrhoea.

Early diagnosis of CDI is important for:

  • treating individual patients, residents and service users
  • preventing further spread of C. difficile

Refer to risk factors for developing CDI for further information on factors which may increase clinical suspicion.

Best practice recommendations for investigating potential CDI are available on the Scottish Microbiology and Virology Network (SMVN) website.

Positive isolates suspected of being part of an outbreak or where CDI is deemed 'severe' should be referred to the Enteric Bacterial Infections Service (EBIS), part of the Scottish Microbiology Reference Laboratory (SMiRL) to undergo further investigations.

Information on sample types and criteria for further investigation are available in the SMiRL user manual.

No single test or combination of tests should be considered infallible in establishing or excluding a diagnosis of CDI.

The clinical condition of the patient, resident or service user should always be considered when making management or treatment decisions.

Control measures for CDI

Under the Public Health etc (Scotland) Act 2008, C. difficile is a notifiable organism and is included in the national minimum list of alert organisms and conditions in appendix 13 of the NIPCM.

Mandatory national surveillance of CDI is conducted by ARHAI Scotland as per the protocol for the Scottish surveillance eprogramme for Clostridioides difficile infection.

Management of CDI in a community-based setting

CDI should be considered in all persons with otherwise unexplained diarrhoea with testing conducted where indicated.

This includes where persons have risk factors which may increase index of clinical suspicion as highlighted within this guidance.

The following actions should be taken in the event of a laboratory-confirmed CDI case or where there is a strong clinical suspicion of CDI.

Managers in community-based healthcare settings:

  • log any cases of CDI (as part of local surveillance)
  • contact local HPT/IPCT for advice on the management of CDI cases
  • contact local HPT/IPCT if:
    • a CDI patient, resident or service user dies
    • CDI is on patient, resident or service user's death certificate
  • ensure transmission-based precautions remain in place when there is a case of CDI until cases are free from diarrheal symptoms for 48hrs and bowel motions have returned to normal
  • regularly review IPC measures

Responsible Medical officers:

  • clinically assess every CDI case (including a review of current medication) to determine:
    • severity of infection
    • if hospitalisation/onward referral is needed
  • follow relevant IPC measures when assessing CDI cases
  • follow CDI treatment protocols as applicable for the GP or community-based care setting
  • for CDI cases receiving care at home, advise patient to contact their healthcare provider if symptoms (including fever, rigors or bowel movements worsen whilst on treatment)
  • support the investigations of all severe community cases and deaths due to CDI

HPT/IPCT should:

  • give advice on management and IPC measures for cases of CDI
  • monitor for further cases of CDI in the community
  • review all severe cases of CDI and deaths attributed to CDI in the community
  • use the HIIAT tool to assess impact where appropriate
  • report any observed exceedance of CDI cases in the community to relevant people/organisations
    • HPTs should report exceedance to PHS
    • IPCTs should report exceedance to ARHAI Scotland
  • review and report any lessons learned following a case/cases of CDI in the community

Duration of precautions

As detailed in the NIPCM, those with CDI should be considered infectious whilst exhibiting symptoms.

Most people are deemed non-infectious after 48 hours of being 'symptom-free'.

Transmission-based precautions may be discontinued when the patient, resident or service user:

  • has been symptom-free for 48 hours
  • bowel movements have returned to normal for the individual

Avoiding vulnerable groups

For non-hospital settings, symptomatic individuals may be asked to avoid contact with vulnerable groups until 48 hours symptom-free.

This would be an individual case by case risk assessment based on the environment and needs of the patient, resident or service user.

Discharge from hospital

An individual risk assessment should be undertaken if a patient with CDI is to be discharged from hospital to a community-based care setting.

There should be communication between facilities to ensure precautions are in place.

Negative impacts on health and wellbeing

The guidance reminds staff to be alert to any negative impacts on patient, resident or service users' physical health, mental health, and general wellbeing that may arise as a consequence of any IPC measures in place.

Resources for IPC advice for managing a case or cases of CDI

IPC information is available in the:

Both the NIPCM and CHIPCM have information on:

The HIIAT tool

NIPCM also includes the Healthcare Infection Incident Assessment Tool (HIIAT).

This should be used by the IPCT or HPT, depending on local processes for reporting, to assess healthcare outbreaks or incidents. 

View the NIPCM appendix 14: Healthcare Infection Incident Assessment Tool (HIIAT).

Clinical management of CDI

For the most up-to-date treatment guidelines for Clostridioides difficile infection, refer to the CDI information on the Scottish Antimicrobial Prescribing Group (SAPG) website.

Following a clinical review, where possible and if safe to do:

  • stop or rationalise non-anti-clostridial antibiotics
  • stop laxatives
  • stop anti-motility agents (e.g. loperamide, opiates)
  • stop gastric acid suppression, for example:
    • PPIs
    • H2 antagonists
    • antacids

Ensure the patient, resident or service user is well hydrated.​

General advice

Generic SHPN guidance on managing public health incidents can be found on the Public Health Scotland website which health boards and local authorities can refer to when preparing for or responding to an incident.

This guidance also details the roles and responsibilities for incident management teams.

View the SHPN guidance on managing public health incidents.

Guidance development methods

Guidance development process

Method

This guidance was developed in line with the approach for reviewing and updating existing guidance documents within the context of the Scottish Health Protection Network (SHPN).

View the guidance review and update methodology.

Guidance Development Group

A multidisciplinary Guidance Development Group (GDG) was convened to produce this guidance.

The GDG had representation from:

  • ARHAI Scotland
  • NHS board microbiology services
  • NHS Education for Scotland (NES)
  • NHS health protection teams
  • NHS infection prevention control teams
  • Public Health Scotland
  • Scottish Antimicrobial Prescribing Group (SAPG)
  • Scottish Health Protection Network (SHPN)
  • Scottish Microbiology Reference Laboratory (SMiRL)
  • Scottish Microbiology and Virology Network (SMVN)

Each GDG member returned a conflict-of-interest (COI) form. No competing interests were declared by GDG members.

Evidence base

This guidance update focused on streamlining the existing guidance and referring to partner agencies for more detailed guidance on their respective areas of expertise. It was agreed that a review of the full evidence base underpinning the 2017 CDI guidance was not required.

Instead, guidance produced by partner agencies was reviewed to identify areas of duplication.

However, as the advice on risk factors associated with developing CDI was being retained in this updated guidance, the GDG agreed that a review of the evidence should be undertaken.

Review of partner agency guidance

Relevant guidance on the management of CDI in Scotland was identified through a discussion with the GDG. Once relevant documents were identified, an exercise was undertaken to detect areas of duplication between the partner agency guidance and the existing SHPN CDI guidance from 2017.

Areas of duplication were recorded in a draft of the guidance. The GDG then considered this and agreed whether to retain or remove advice from the draft guidance. Where advice was removed, weblinks to the relevant partner agency guidance were added to ensure the advice was still accessible from within the CDI guidance.

Evidence review

A review of the evidence on the risk factors associated with developing CDI was undertaken.

Key questions

Key questions were agreed by the GDG in order to focus the literature search.

  1. What demographic factors (age, gender) are associated with an increased risk of C. difficile infection?
  2. Are there specific comorbidities or underlying health conditions that predispose individuals to C. difficile infection?
  3. What role do antibiotic use and previous antibiotic exposure play in the development of C. difficile infection?
  4. Are there particular types or classes of antibiotics that pose a higher risk for C. difficile infection
  5. How does the duration and frequency of antibiotic use influence the risk of C. difficile infection?
  6. What impact do healthcare settings (hospitalization, long-term care facilities) have on the risk of C. difficile infection?
  7. How does the use of proton pump inhibitors (PPIs) and other gastric acid-suppressing medications affect the risk of C. difficile infection?
  8. What role does immunosuppression or compromised immune function play in susceptibility to C. difficile infection?
Search strategy

Three databases (Medline, Embase and Scopus) were searched by PHS Knowledge Services for terms related to CDI and risk.

Due to the publication date of the last version of the CDI guidance, the time period for the literature search was from 2017 onwards, restricting the area to global north and included human studies only. For completeness, grey literature was also included in the search.

Review of literature

Each title and abstract, as well as the full text, were screened by a single reviewer. However, the extraction process was conducted by a team of two people.

This was undertaken using Sciwheel, and extraction data was added to a table.

Critical appraisal of included studies was not completed due to time limitations.

Evidence identified

The search returned 276 articles after duplicates were removed. Full text screening and extraction was undertaken on 42 articles.

A narrative summary of the evidence review was produced and shared with the GDG.

Evidence to recommendation

The GDG met to consider the draft guidance that highlighted areas of duplication with other guidance, and also the narrative summary of the risk factors from the evidence review.

Expert opinion on particular areas of the guidance was also sought during GDG meetings or via email.
Agreement on the final recommendations was achieved through informal consensus.

Based on the evidence identified all recommendations are considered to be good practice recommendations, as they are primarily based on expert opinion.

Consultation

The guidance was circulated for consultation with a wide range of stakeholders.

The consultation took place in May 2023 and was open for approximately 3 weeks.

The consultation responses were reviewed by the GDG and the guidance was updated accordingly.

Approval and review

This guidance has been approved by the SHPN and PHS.

In line with the SHPN method the guidance will be reviewed at least every three years.

Feedback on this guidance can be shared with phs.guidance@phs.scot

Equality impact assessment (EQIA)

An EQIA was undertaken to consider any unintended or differential impact or risks arising from implementing the recommendations in the guidance.

It evaluated the variable impact of the guidance on different groups in society.

For example:

  • children versus adults
  • deprived versus wealthy
  • by gender

Where variable impacts were identified, this was discussed and adapted the guidance to minimise impacts.

View a printable version of the whole publication

Last updated: 04 November 2024
04 November 2024 - Version 1.0

First publication

29 September 2017
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