Winnipeg Regional Health Authority Infection Prevention & Control Manual
DIARRHEA DISEASE SPECIFIC PROTOCOL FOR COMMUNITY HEALTH SERVICES
Worldwide, acute gastroenteritis is one of the most common diseases in humans. Many gastroenteritis cases are self-limiting, highly contagious and may be associated with an increased risk of outbreaks. Disease manifestations range from asymptomatic to severe, and, in some cases, fatal. Viruses, parasites, or bacteria are the infectious agents which may cause these episodes
The primary mode of transmission for most gastroenteritis agents is fecal-oral by ingestion of contaminated food or water
Acute diarrhea is often accompanied by other clinical signs and symptoms including vomiting, fever, dehydration and electrolyte disturbances.
In most cases in Community Health Services the cause of diarrhea will not be confirmed by laboratory testing. If a client has acute diarrheal stool Routine Practices should always be followed.
While Routine Practices are usually adequate for all patients with acute diarrheal stool, Contact Precautions should be considered for incontinent adults with poor hygiene who contaminate their environment.
I. Bacterial Diarrhea
Cause/Epidemiology
Many bacterial organisms cause infectious diarrhea illness in humans.
The most common and important are: Campylobacter Cholera Escherichia coli-Pathogenic strains (e.g., 0157: H7) Salmonella (including S. typhi) Shigella Yersinia
Clinical Presentation
Diarrhea is the passing of loose or watery stools and is often associated with vomiting and fever. Symptoms may be of variable severity.
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Winnipeg Regional Health Authority Infection Prevention & Control Manual
Incubation Period
Bacterial Microorganism Incubation Period Campylobacter 1-7 days Cholera 1-5 days Escherichia coli-Pathogenic strain (e.g., 0157: H7) 10 hours-8 days Salmonella (including S.typhi) Diarrhea: 6-72 hours Enteric Fever: 3-60 days Shigella 1-7 days Yersinia 1-14 days
Transmission
Transmission can occur: through direct contact via hands, indirectly through contaminated environmental surfaces and equipment, and/or by ingestion of contaminated food or water.
Fecal shedding may continue after symptoms have subsided.
Infection Prevention and Control Practices
Consider Contact Precautions: o For a patient under 6 years of age. o For a patient with non-contained fecal incontinence o For a patient with increased probability to contaminate the environment e.g.; poor cognition, unable to follow instructions, poor hygiene practices. Follow Routine Practices for all other patients 6 years of age and over with bacterial diarrhea, Refer to Routine Practices section and/or Routine Practices policy for specific information. If applicable refer to Contact Precautions in the Additional Precautions section. Refer to the Clinical Presentation/Microorganism/Infectious Disease Table for specific disease/microorganism information.
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Winnipeg Regional Health Authority Infection Prevention & Control Manual
Occupational Health Issues
Definitions of Occupational Exposure A healthcare worker who has had direct or indirect oral contact with infectious feces. Exposure may also occur with ingestion of contaminated food or water.
A Healthcare Worker Exposed to Bacterial Diarrhea No modifications to work practices or work restrictions
A Healthcare Worker Symptomatic or Infected with Bacterial Diarrhea Physician/Laboratory confirmed diagnosis Healthcare workers shall be referred to Occupational Health for clinical management Healthcare workers with diarrhea shall be excluded from work until stools are formed
II. Clostridium difficile Associated Diarrhea (CDAD)
Cause/Epidemiology
Clostridium difficile (C. difficile) is the most common cause of antibiotic associated diarrhea. It is a spore forming gram-positive bacillus which produces toxins causing the diarrhea. Clostridium difficile associated diarrhea (CDAD) is one of the most common and costly healthcare-associated infections.
Children 1year of age and under, are commonly asymptomatic carriers of Clostridium difficile bacteria. Previous antibiotic use increases the prevalence. In healthy children with antibiotic associated watery diarrhea, discontinuation of the antibiotic is usually sufficient to resolve the diarrhea. In this age category, it is not recommended to send a stool for C. diff culture/toxin.
CDAD can be minimized by the practice of good antimicrobial stewardship as part of the infection prevention & control effort.
Risk factors for acquiring CDAD include: A prolonged hospital stay Previous antibiotics Contact with someone with the disease Individuals who are very young or very old Chronic underlying disease or health condition Intestinal tube feeding Individuals who have had gastrointestinal surgery/manipulation Use of agents which alter normal intestinal motility
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Clinical Presentation
Signs and symptoms of CDAD include: Loose watery stools Abdominal pain and cramping Fever Mucous or blood in the stool and dehydration A characteristic odor to the stool
Pseudomembraneous colitis (PMC) is a more severe form of CDAD in which patients exhibit a colitis characterized by the presence of pseudomembranes on the colon surface.
The overall mortality is usually low in patients with CDAD because of effective treatment. Recurrence of CDAD after treatment occurs in 15 - 25% of patients.
Incubation Period
Variable
Transmission
Transmission occurs: through direct contact via hands, or indirectly through contaminated environmental surfaces and equipment. C. difficile has the ability to produce spores, enabling it to survive for months in the environment, with ongoing transmission.
Infection Prevention and Control Practices Perform hand hygiene at the point of care using soap and water. If a sink is not available at the point-of-care use alcohol-based hand rub. Perform hand hygiene with soap and water as soon as a sink is available Routine Practices are usually adequate for all patients with acute diarrheal stool, Contact Precautions should be considered for incontinent adults with poor hygiene who contaminate their environment. If applicable refer to Contact Precautions in the Additional Precautions section Refer to the Clinical Presentation/Microorganism/Infectious Disease Table for specific disease/microorganism information If using Contact Precautions discontinue them when the patient has had at least 48 hours without diarrhea (e.g., formed or normal stool for the individual) Re-testing to test for cure or determine discontinuation of Additional Precautions is not recommended
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Winnipeg Regional Health Authority Infection Prevention & Control Manual
Occupational Health Issues
Definitions of Occupational Exposure A healthcare worker who has had direct or indirect oral contact with infectious feces. Exposure may also occur with ingestion of contaminated food or water.
A Healthcare Worker Exposed to C. difficile No modifications to work practices or work restrictions
A Healthcare Worker Symptomatic or Infected with C. difficile Physician/Laboratory confirmed diagnosis Healthcare workers shall be referred to Occupational Health for clinical management Healthcare workers with diarrhea shall be excluded from work until stools are formed
III. Diarrhea: Other Infectious Microorganisms
Cause/Epidemiology
Protozoa are microscopic, one-celled organisms that can be free-living or parasitic in nature. They are able to multiply in humans, leading to serious infections. The following protozoan infections are most common to humans:
Amebiasis, caused by Entamoeba species Giardiasis, caused by Giardia lamblia species Crytosporidiosis, caused by Cryptosporidium
Clinical Presentation
The symptoms vary according to the specific microorganism. Some infections do not have symptoms while others can cause diarrhea, nausea, vomiting and abdominal pain as well as bloody stools.
Incubation Period
Microorganism Incubation Period Entamoeba species Days to weeks Giardia lamblia species 2-14 days Cryptosporidium parvum 1-4 weeks
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Winnipeg Regional Health Authority Infection Prevention & Control Manual
Transmission Transmission occurs: through direct contact via hands, or indirect contact through contaminated food, water, environmental surfaces and equipment.
Shedding of these microorganisms can continue even after symptoms have subsided.
Infection Prevention and Control Practices
Consider Contact Precautions: o For a patient under 6 years of age. o For a patient with non-contained fecal incontinence o For a patient with increased probability to contaminate the environment e.g.; poor cognition, unable to follow instructions, poor hygiene practices. Follow Routine Practices for all other patients 6 years of age and over with diarrhea. Refer to Routine Practices section and/or Routine Practices policy for specific information. If applicable refer to Contact Precautions in the Additional Precautions section. Refer to the Clinical Presentation/Microorganism/Infectious Disease Table for specific disease/microorganism information.
Occupational Health Issues
Definitions of Occupational Exposure A healthcare worker who has had direct or indirect oral contact with infectious feces. Exposure may also occur with ingestion of contaminated food or water.
A Healthcare Worker Exposed to Infectious Diarrhea No modifications to work practices or work restrictions
A Healthcare Worker Symptomatic or Infected with Infectious Diarrhea Physician/Laboratory confirmed diagnosis Healthcare workers shall be referred to Occupational Health for clinical management Healthcare workers with diarrhea shall be excluded from work until stools are formed
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Winnipeg Regional Health Authority Infection Prevention & Control Manual
IV. Viral Diarrhea
Cause/Epidemiology Viruses are recognized as a leading cause of acute gastroenteritis. Many different viruses can cause gastroenteritis. Norovirus, also known as Norwalk-like virus or small round enteric virus (SREV) is part of a larger family of human viruses called caliciviridae that can cause gastroenteritis. Norovirus has been associated with outbreaks on cruise ships, as well as hospitals and nursing homes. Rotavirus, adenovirus, astrovirus and coxsackievirus are other viruses and are more common in children under the age of four.
Clinical Presentation
Viral gastroenteritis can vary from asymptomatic to severe disease leading to dehydration and death. Symptoms include sudden onset of vomiting and non bloody, watery diarrhea, with abdominal cramps and nausea. Low grade fever may also occur. Diarrhea is more common in children than vomiting. Symptoms usually last anywhere from 48 to 72 hours; dehydration is the most common complication. People of all ages may be infected but the greatest severity is at extreme ages such as young children and the elderly.
Incubation Period
Viral Agent Incubation Period Norovirus, Calcivirus (SREV) 12-48 hours Rotavirus 1-3 days Coxsackievirus 3-6 days Adenovirus 3-10 days Astrovirus 1-4 days
Transmission
Transmission occurs through direct contact of fecal microorganisms via hands, or indirect contact through contaminated food, water, environmental surfaces and equipment.
Shedding of these microorganisms can still occur after symptoms have subsided.
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Winnipeg Regional Health Authority Infection Prevention & Control Manual
Infection Prevention and Control Practices
Consider Contact Precautions: o For a patient under 6 years of age. o For a patient with non-contained fecal incontinence o For a patient with increased probability to contaminate the environment e.g.; poor cognition, unable to follow instructions, poor hygiene practices. Follow Routine Practices for all other patients 6 years of age and over with viral diarrhea, Refer to Routine Practices section and/or Routine Practices policy for specific information. If applicable refer to Contact Precautions in the Additional Precautions section. Refer to the Clinical Presentation/Microorganism/Infectious Disease Table for specific disease/microorganism information.
Occupational Health Issues
Definitions of Occupational Exposure A healthcare worker who has had direct or indirect oral contact with infectious feces. Exposure may also occur with ingestion of contaminated food or water.
A Healthcare Worker Exposed to Viral Diarrhea No modifications to work practices or work restrictions
A Healthcare Worker Symptomatic or Infected with Viral Diarrhea Physician/laboratory confirmed diagnosis Healthcare workers shall be referred to Occupational Health for clinical management Healthcare workers with diarrhea shall be excluded from work until stools are formed
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Winnipeg Regional Health Authority Infection Prevention & Control Manual
References
1. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, Appendix A-Gastroenteritis. CDC. Retrieved March 19, 2010 from: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf
2. Communicable Disease Management Protocol, Clostridium difficile Associated Diseases (CDAD). (September, 2006). Winnipeg, Manitoba: Manitoba Health, Communicable Disease Branch. Retrieved March 19, 2010 from: http://www.gov.mb.ca/health/publichealth/cdc/protocol/cdifficile.pdf
3. Enteric Illness Protocol. (March, 2008). Winnipeg, Manitoba: Manitoba Health, Communicable Disease Branch. Retrieved March 19, 2010 from http://www.gov.mb.ca/health/publichealth/cdc/protocol/enteric.pdf
4. Gerding, D. (ed) Clostridium Difficile Infection and Pseudomembranous Colitis: in APIC Text of Infection Control and Epidemiology. 3rd edn. (2009). Chapter 76, p.76-1 to 76-6. Washington, DC. APIC.
5. Summaries of Infectious Diseases, Section 3, pp 204-206, 225. (2009). Retrieved March 19, 2010 from: American Academy of Pediatrics Red Book Online Red Book® Online -- Table of Contents (2009)
6. Best Practices for Hand Hygiene in All Health Care Settings (2010) Provincial Infectious Disease Committee (PIDAC). Available at: http://www.publichealthontario.ca/en/eRepository/2010- 12%20BP%20Hand%20Hygiene.pdf
7. Public Health Agency of Canada (2011) Fact Sheet - Clostridium difficile (C. difficile). Available at: Fact Sheet – Clostridium difficile (C. difficile) - Public Health Agency of Canada
8. Routine Practices and Additional Precautions: Preventing the Transmission of Infection in Healthcare (2012) Manitoba Health. Available at http://www.gov.mb.ca/health/publichealth/cdc/docs/ipc/rpap.pdf
9. Guide to Preventing Clostridium difficile Infections (2013) Association for Professionals in Infection Control (APIC) available at: http://apic.org/Resource_/EliminationGuideForm/e3a85b7e-7ad8-4ab6-9892- 54aef516cf10/File/2013CDiffFinal.pdf
10. Clostridium difficile Infection-Infection Prevention and Control Guidance for Management in Acute Settings (2013) Public Health Agency of Canada (PHAC) available at http://www.phac-aspc.gc.ca/nois-sinp/guide/c-dif-acs-esa/index-eng.php
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