Three Clostridioides difficile Cases in Seven Days on One Ward
On a 32-bed medical unit, three patients have developed Clostridioides difficile infection within seven days; all three have received antibiotics in the past month. The unit uses alcohol-based hand rub at every doorway, and there are two shared blood pressure cuffs and two stethoscopes for the whole floor. Patient 5 has had six unformed stools in 12 hours, a white cell count of 19 × 10⁹/L, a temperature of 38.1 °C, and is continent of stool; she is prescribed oral vancomycin. An agency nurse covering the next shift says, 'I'll use the alcohol gel - it kills everything, and we don't have enough gowns anyway.' Two of the three cases are in adjacent bays and share a bathroom.
1. Explain why alcohol hand rub alone is inadequate here, and set out the isolation and equipment measures this cluster requires.
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The organism drives the answer: C. difficile produces spores, and alcohol does not reliably kill spores. Mechanical removal with soap and water is what clears them from hands. Alcohol rub is appropriate for many organisms but is the wrong tool for this one.
Hand hygiene:
- Soap and water for all staff and visitors after contact with the patient or their environment, and before leaving the room. Alcohol rub may follow but cannot replace it.
- Ensure a working sink inside or immediately outside each affected bay - this is a facilities issue to escalate, not a reason to accept gel alone.
Isolation and cohorting:
- Contact precautions: single room with ensuite if possible; if not, cohort the confirmed cases together with dedicated toilet/bathroom and close the shared bathroom to non-cohorted patients.
- Gown and gloves for every entry, removed inside the room before leaving.
- Dedicated equipment: thermometer, BP cuff, stethoscope, commode. Leaving two shared cuffs and stethoscopes on the floor is the single most likely transmission route in this cluster.
- Environmental cleaning with a chlorine-releasing sporicidal agent, especially the bathroom, commode, bed rails and door handles; increased frequency during the outbreak.
- Stop unnecessary antibiotics and proton-pump inhibitors where possible; review all three patients' prescriptions with the prescriber.
Name the system failures: insufficient PPE stock, alcohol-only hand hygiene stations, shared equipment, shared bathroom, and no screening of the cluster by the infection prevention team. Report all three cases to infection prevention and control and the ward manager as a suspected outbreak - individual nurses cannot solve a supply problem alone.
2. Which patient do you assess first and what are you looking for, given the whole unit's workload?
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See Patient 5 first - but triage by deterioration risk, not by diagnosis.
Why her:
- Six unformed stools in 12 hours in a continent adult is a large ongoing fluid and electrolyte loss; she is at risk of hypovolaemia, acute kidney injury and hypokalaemia.
- WBC 19 × 10⁹/L and temperature 38.1 °C suggest significant inflammation and possible progression to severe or fulminant colitis.
- Her continence means she is contaminating her own environment and staff hands repeatedly - the highest transmission risk on the unit.
Assess specifically for severe/fulminant disease (the findings that mandate urgent medical review):
- Abdominal distension, tenderness, absent bowel sounds, guarding - ileus or megacolon.
- Haemodynamic status: BP, HR, postural change, capillary refill, mucous membranes; strict fluid balance and hourly urine output.
- Electrolytes and renal function; WBC trend, lactate, albumin.
- Number and character of stools (record a stool chart), any blood.
Actions: start oral vancomycin as prescribed (oral is required - IV vancomycin does not reach the colonic lumen), review whether any other antibiotics can stop, contain stool with a bedpan/commode and prompt cleaning, ensure the call bell is answered quickly so she does not wait.
Then: check the other two cohorted patients for the same red flags, and verify that the shared bathroom has been taken out of use. The remaining patients on the unit do not need review, but they do need the equipment controls in place.
3. What do you say to the agency nurse about the alcohol gel and the missing gowns, and what do you do about the supply problem?
Read the worked answer
Address the practice directly, privately, and with the reason - then fix the obstacle she named.
What to say:
- 'For this patient, gel alone will not work - C. difficile spores survive alcohol. It has to be soap and water, every time you leave the room.'
- 'The gown is not optional either: your uniform and forearms will carry spores to the next patient and to the shared BP cuff. I would rather we both stop and find a gown than skip it.'
- Offer the practical route: where the stock is kept, who to call, and what to do if it genuinely runs out (stop and escalate - do not proceed with the task unprotected).
Tone matters: she has named a real resource problem. Acknowledge it ('you're right that we're short') and separate it from the practice standard ('and we still can't carry spores between patients'). Blaming an agency nurse for a stock failure produces concealment, not compliance.
What you do about the supply:
- Check and restock the PPE trolley and the affected bays immediately; put a soap-and-water sign at each sink and at the doorway.
- Escalate to the nurse in charge and infection prevention: PPE stock-out, alcohol-only hand hygiene at doorways, shared equipment, shared bathroom.
- Document the shortage and the escalation - if the outbreak continues, the record shows the system failure was reported in real time.
- Debrief or flag the event through the incident reporting system, and ensure agency staff receive the unit's isolation instruction at orientation, not mid-shift.