INTRODUCTION

Background

• Clostridioides or Clostridium difficile (C.diff) is a bacterium that causes watery diarrhea, fever, nausea, abdominal pain, and loss of appetite. Most C. diff cases are caused by antibiotics. C. diff can easily spread from patient to caregiver to other caregivers and patients. If proper precautions are not taken, the germ literally can colonize almost everything it comes in contact with.
• C. diff bacteria can live outside the body; on clothes, counter tops, or any inanimate object for periods from months to years.

DECIDING WHETHER OR NOT TO PROCEED WITH HBOT 

The following approach may be used by hyperbaric medicine centers when deciding whether to treat a patient who has C. diff.

Evaluate if HBOT can be delayed

• The center should take into consideration the seriousness of the patient’s condition and necessity of urgent hyperbaric oxygen therapy (HBOT). 
• In an out-patient clinic, HBOT can be delayed until the infection/diarrhea has been appropriately treated and controlled. The patient may be removed from C. diff isolation when appropriate laboratory, cultures, and stool characteristics are met, generally 48 hours after again having formed stools.
• However, if the patient needs to be treated, then a committee-based decision must be made. We feel the following people should be part of that committee: the treating physician (and/or medical director), the hyperbaric technologists and nurses, and the hospital/clinic Infection Prevention Manager.  At the center of this discussion, we recommend reviewing the patient’s recent laboratory studies and any pertinent imaging/data showing necessity to treat or delay treatment. 

Ensure clinic has a robust policy for C. diff

If the decision is made to treat, the clinic should have a robust policy for C. diff infections and ensures the safety of the staff, patient, and other patients throughout the clinic and hyperbaric chambers. One must also consider any immunocompromised patients in the clinic as well as any at risk staff. The policy for C. diff infections should contemplate the elements described below:  

• In an outpatient monoplace facility, our staff would treat this patient as the last treatment of the day.  Whether or not other patients are treated simultaneously in other chambers is a discussion for the staff and medical director. Some clinics choose strict isolation.  We educate the patient about spread of C. diff and encourage each infected patient to shower with antibacterial soap prior to arrival. This helps wash spores from the body.  We also encourage the patient to wear a diaper into the chamber, hoping to isolate/prevent further soiling.
• After treatment, the hyperbaric chamber must be cleaned, as well as the chamber room and any horizontal surfaces.  Each chamber has an approved cleaning agent. Most of the time, the cleaning agent will include a chlorine bleach concentrate as part of its ingredients. This may be in the form of a liquid or a saturated disposable cloth.  It is imperative that the staff cleaning the chamber observe the appropriate ‘kill time’ for the particular cleaning fluid.
• After disinfecting the chamber, we pressurize the chamber to 2.0 ATA or greater, then set the ventilation rate on high for 15 – 20 minutes. The chamber is then rapidly surfaced in order to disperse the chlorine smell from the chamber. Not doing this may leave a lingering, strong odor in case the chamber is needed for another patient.  Unfortunately, all of the chlorine solutions leave a film residue on the chamber acrylic. Also recommended, is cleaning the chamber with approved soap and water to remove associated chemicals after the appropriate ‘kill time.’ See topic "Cleaning and Disinfection of Hyperbaric Oxygen Monoplace Chamber".

IN SUMMARY

• Pro:  The patient is able to be treated in urgent medical indications. 
• Con:  The patient and staff must follow the infectious disease guidelines in order to prevent others from becoming infected with C. diff.

Not an easy decision to make but one that must be made by a committee to ensure staff and patient safety.