Isolation Precautions in LTCF for CDI
Clostridioides (Clostridium) difficile Toolkit for Long-term Care Facilities

In addition to MRSA, VRE and C. difficile, other infectious agents that are virtually resistant to all available classes of antibiotics such as Acinetobacter baumanii and carbapenem-resistant Klebsiella pneumonia (CRKP) may be thriving in LTCF and should be included in the category of epidemiologically important infectious agents. Therefore, when developing a room placement policy for new admissions, readmissions as well as permanent residents it is important to develop a policy that specifically defines conditions that facilitate transmission rather than on knowledge of a positive or negative test result.

Admission Assessment

• NO request for long-term care facility admission or readmission should be refused based on knowledge of a positive test for any MDRO (e.g., MRSA, VRE, C. difficile, etc.).
• NO request for negative tests prior to inter-facility transfer should be made. New or returning residents should be admitted based on the ability of the facility to provide supportive and restorative care.
• Obtain information about new or returning resident’s infection or colonization status prior to transfer from the hospital’s discharge coordinator or infection preventionist.
• Develop a resident care plan that takes into consideration the individual’s risks of transmission or acquisition of infectious agents.
• Prior to transfer, meet with an interdisciplinary team (e.g., infection prevention coordinator, charge nurse, director of nurses, medical director, social worker, treatment nurse, etc.) and discuss the advantages and disadvantages of placing the MDRO positive resident in a private room or with a compatible roommate.

Room Placement

• When single-resident rooms are available, assign priority for these rooms to residents with known or suspected CDI. Give highest priority to those residents who have conditions that may facilitate transmission (e.g., uncontained secretions or excretions).
• When single-resident rooms are not available, cohort patients with CDI in the same room.
• When cohorting is not possible, place CDI patients in rooms with patients who are at low risk for acquisition. This includes residents who:
  • Have intact skin and no significant open wounds
  • Have no invasive devices, indwelling vascular or urinary catheters or drainage devices
  • Is not immunocompromised due to chronic infection, steroids, chemotherapy or organ transplantation
• If cohorting is not possible, a personal commode should be dedicated to the resident with CDI. All commodes should have a commode liner with coagulant material to minimize the risk to health care workers.
• Balance infection risks with the need for more than one occupant per room, the presence of risk factors that increase the likelihood of transmission, and the potential for adverse psychological impact on the infected or colonized resident. Depending on the situation, options may include the following: a private room, cohorting or sharing a room with a roommate with limited risk factors.
• Use the least restrictive approach possible that adequately protect the infected resident and others.
• For infected residents without draining wounds, diarrhea, or uncontrolled secretions, establish ranges of permitted ambulation, socialization, and use of common areas based on their risk to other patients and on the ability of the colonized or infected patients to observe proper hand hygiene and other recommended precautions to contain secretions and excretions.
• Do not allow companion animals into isolation rooms.

Discontinuing Isolation Precautions

• Maintaining isolation longer than necessary may adversely affect psychosocial well-being. The facility should document in the medical record the rationale for selecting Transmission-based Precautions.
• Those residents preemptively placed in Isolation Precautions should be removed from Isolation Precautions listed if CDI test is negative and other infectious agents that require Isolation Precautions have been ruled out.
• Remove residents from Isolation Precautions when CDI symptoms resolve (e.g. resident has <3 unformed stools in a 24-hour period). Because an infected person may continue to shed bacteria even after symptoms resolve, facilities can consider extending Isolation Precautions (i.e. until 2 days after last unformed stool).

References

1. California Department of Health
2. Minnesota Department of Health Pink Book
3. Minnesota Hospital Association