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

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).

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.

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:

• NIPCM for Healthcare settings
• Care Home IPCM for (CHIPCM) Care Home settings

Both the NIPCM and CHIPCM have information on:

• standard infection control precautions (SICPs) – for example, hand hygiene and patient placement
• additional measures for cases and outbreak management including transmission-based precautions (TBPs)
• decontamination of the environment and equipment

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.

Additional resources

Useful links

Learning resources for staff

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.

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.