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State of California—Health and Human Services Agency
California Department of Public Health

AFL 10-21
August 19, 2010

Skilled Nursing Facilities
General Acute Care Hospitals

Placement of Patients with Positive Clostridium difficile Tests in Skilled
Nursing Facilities

This is the only copy being sent to your facility. Please distribute copies to Infection Preventionists and Discharge Planning personnel.

This letter is being sent to provide information from the California Department of Public Health (CDPH) about Clostridium difficile (C. difficile) infection. Patients who are being discharged from General Acute Care Hospitals following the diagnosis of C. difficile are being denied placement in a skilled nursing facility until negative tests for C. difficile have been obtained (usually three consecutive negative tests), even if the patient is no longer symptomatic (e.g., no longer has diarrhea; that is, has formed stools). CDPH advises against following this practice as it is not an appropriate approach for mitigating the impact of C. difficile in skilled nursing facilities.

The following organizations recommend against this practice:

The SHEA position paper Clostridium difficile (C. difficile) in Long-Term Care Facilities for the Elderly states “There is no value to testing stools of asymptomatic individuals (including for “test of cure”), unless part of an outbreak investigation”.(1) As this paper from 2002 notes, as many as 20% of residents in skilled nursing facilities are colonized with C. difficile and will therefore test positive; this number is likely higher now as the incidence of CDI has been increasing. Therefore, a facility is not providing any increased degree of protection for its residents who are not colonized with C. difficile by
excluding those patients who are known to be colonized (that is, test positive) from admission.

The prevention of transmission of C. difficile is best achieved by using the following precautions for all residents with diarrhea, particularly if incontinent. When available, residents with diarrhea should be placed on contact precautions in a private room until symptoms have resolved. When private rooms are not available, symptomatic residents should be assigned a bedside commode which is thoroughly cleaned and disinfected with bleach immediately after each bowel movement. Gowns and gloves should be worn by healthcare workers and visitors when physical contact with the symptomatic resident or environmental surfaces in the room. All equipment and environmental surfaces including bedrails, tables and chairs should be cleaned and disinfected daily with a properly diluted bleach solution (1:10 dilution [1 part bleach to 9 parts water mixed daily]) and upon discharge or transfer. Healthcare workers should wash their hands with soap and water after each contact with the resident or environmental surfaces. Residents should wash their hands with soap and water after each bowel movement and frequently throughout the day. Since at least 1 out of every 5 skilled nursing home residents may be colonized with C. difficile and therefore shedding the organism in their stool, good resident and healthcare worker hygiene is important to prevent transmission, even from asymptomatic residents.

For questions about CDI, contact the Healthcare-Associated Infections Program at or by phone at (510) 412-6060. A revised guideline for infection control including the management of multi-drug resistant organisms in longterm healthcare facilities will be available soon. Hospitals and skilled nursing facilities can contact their Licensing and Certification Program District Office for information about regulations regarding admission and placement in skilled nursing facilities.



Original Signed by Kathleen Billingsley, R.N.

Kathleen Billingsley, R.N.
Deputy Director


California Hospital Association
California Association of Health Facilities
California Conference of Local Health Officers
CDPH Licensing and Certification Program
CDPH Division of Communicable Disease Control
HAI Advisory Committee

  1. SHEA - Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010
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